Change and Transformation: Adapting to a Primary Care

Culture

Laura O. Wray, PhDAndrew Pomerantz, MD

Primary Care Culture Then

And Now…

Health Care Realities Primary Care has become the nexus

of our outpatient health care delivery system

Up to 70% of PC medical appts have psychosocial component (Fries, Koop, & Beadle, 1993) Psychiatric disorders – full spectrum Behavioral issues (IBS, tension headaches, insomnia,

nonspecific pains, vague somatic systems- most pts view as medical

Unhealthy lifestyles (smoking, diet, etc..) Life stressors

Health Care Realities Most psychotropic medications are

written by PCPs (SSRI factor) Distressed patients use twice the

healthcare services PCPs lack time and training to

address the large number of pts with behavioral health concerns

Primary Care Realities

“For primary care physicians…there is too much to do- too many patients, too many demands, too much information flowing through, too little time to do a good job.”

Avg US (Non-VA) panel: 2300 patients. “To do chronic and preventive care would take 18 hours/day to do it right”NEJM, Perspective Roundtable 11-19-08

Typical PC Clinic Day: Our Survey Said

• 14-16 appointments, with 30 min. • Clinical reminders: 4-10/pt, for 5-15

min• Health problems: 3-8 active, 1-2

complex• Admin Task: 100 view alerts qd (2

hours work), e-mails, phone calls, orders, scripts, notes etc. etc.

The result:

Population-Based Integrated Care

• Preventative care, access to acute care, effective chronic disease management • Emphasizes early identification/prevention• De-emphasizes traditional MH Dx • Screening, provide educational info

• Provides triage and treatment in stepped care fashion

• Supports, rather than replaces specialty care

Conceptual Shift Needed

“We must move beyond the narrow conception of ourselves as mental health professionals and begin to see ourselves as comprehensive health professionals.”

Russ NewmanMay 2005 APA Monitor

Population-Based Behavioral Health Care

Integration - BHC as team member- to help PCP manage psychological needs

PCP maintains control of pt. care Easy, quick access (brief visits: 15-30

min) Focus on functional assessment

Includes impact of MH functioning and Health behavior factors (smoking,

weight, stress, adherence…) Distinct from specialty care

• Traditionally trained MH staff face a radical culture shift

• “But that can’t be done in 30 minutes”

• However, within and outside the VA system, it is being done…

Population-Based Behavioral Health Care