Integrating Behavioral Health into Primary Care (IBH-PC...

Integrating Behavioral Health into Primary Care (IBH-PC) University of Vermont

Patient Centered Outcomes Research Institute Award PCORI

B E N J A M I N L I T T E N B E R G , M D - P I

R O D G E R K E S S L E R , P H D , A B P P – C o - P I

C O N N I E V A N E E G H E N , D R P H – C o - I n v e s t i g a t o r

Does increased integration of evidence-supported behavioral health and primary

care services, compared to simple co-location of providers, improve patient-

centered outcomes in patients with multiple morbidities?

Research Question

A I M 1 : C o m p a r e c o - l o c a t i o n a n d I B H t o s e e w h i c h o n e h a s b e t t e r o u t c o m e s f o r p a t i e n t s . A I M 2 : S e e i f a s t r u c t u r e d p r o c e s s t o h e l p p r a c t i c e s o f f e r I N H h e l p s t h e m s u c c e e d . A I M 3 : E x p l o r e h o w t h e t y p e o f p r a c t i c e a n d t h e h e a l t h c a r e s y s t e m i n f l u e n c e h o w w e l l i n t e g r a t i o n w o r k s .

Aims

Co-Investigators

Dan Mullin , PsyD University of Massachusetts Behavioral Health Integration

Chet Fox, MD SUNY Buffalo Family Medicine

Roger G. Kathol, MD Cartesian Solutions Theory of IBH

Wilson Pace, MD University of Colorado Data access

Patient Investigator Patient Viewpoint

Patient Investigator Patient Viewpoint

Sarah Scholle, DRPH NCQA Quality Measurement

Kurt Stange, MD CWRU Family Medicine

Consultants

Dan Mullin, Psy. D. University of Massachusetts Professional Education

C.R. Macchi, PhD Arizona State University Professional Education

Deborah Cohen, PhD Oregon Health Sciences University Mixed Methods

Frank deGruy, MD University of Colorado, Denver Family Medicine

Advisory Board

Patient Investigator Patient


Farifteh F. Duffy, PhD American Psychiatric Association Mental Health

Seth Ginsberg Global Healthy Living Foundation Patient Advocacy

James Hester, PhD , Payer viewpoint


Gene A. Kallenberg, MD UCSD ,Collaborative Family Health Association Family Medicine

Mara Laderman IHI Quality Improvement


Susan H. McDaniel University of Rochester, American Psychological Associa(on

Psychiatry/Family Medicine, Integration

John Muench, PhD OHSU Family Medicine,integration


Betty Ramber, PhD, RN UVM Green Mountain Care Board Health Policy, Nursing

Andrea Auxier, PhD NBDH Psychology Managed Behavioral Health

Practice Inclusion Criteria (40 practices)

�  Score on Practice Integration Profile < 75 �  Minimum .5 BH clinician for practice duration

�  Willingness to accept randomization

�  Willingness to participate in training and improvement components of intervention

�  If in control, during that time commit to not engaging in a similar intensity integration project

�  Willingness to execute relevant Data use Agreements for sharing or extracting data from DARTNet

�  Willingness to be supervised by a cluster PI

Subject Inclusion Criteria

�  At least one target chronic medical condition (arthritis, asthma, chronic obstructive lung disease (COPD), diabetes, heart failure (HF), or hypertension) and evidence of a behavioral problem or need

�  Specific diagnosis (anxiety, chronic pain including headache, depression,

fibromyalgia, insomnia, irritable bowel syndrome, problem drinking, or substance use disorder)

�  persistent use of certain medications used for behavioral concerns (antidepressants, anxiolytics, opioids, antineuropathy agents, etc.)

�  Persistent failure to attain physiologic control of a medical problem (blood pressure>165 while on 3 or more medications, A1C > 9% for 6 months)

�  Unscheduled care (in the clinic, hospital or emergency room) for a medical or behavioral problem within 6 months

�  Presence of 3 or more of the target chronic medical conditions.

Subject Inclusion Criteria

A. Community Pa.ent Panel

A. Community Pa.ent Panel

C. Study Subject Panel

D. Iden.fied and treated pa.ents

Co-‐loca.on All pa.ents in the prac.ce

(Group B not shown)

Integra.on

Subject Identification by Phase

C. Study Subject Panel

D. Iden.fied and treated pa.ents

●  T r a i n i n g o f t h e e n t i r e o f f i c e i n t e a m b a s e d i n t e g r a t e d b e h a v i o r a l h e a l t h

●  I m p l e m e n t a t i o n o f t h e I n t e g r a t i o n T o o l k i t

Intervention

T h e i n t e r v e n t i o n c o n s i s t s o f t r a i n i n g f o r p r a c t i c e l e a d e r s , B H C s , P C P s , a n d o f f i c e s t a f f , a s t r u c t u r e d

i m p r o v e m e n t p r o c e s s s u p p o r t f o r p r a c t i c e r e d e s i g n , a n d a t o o l k i t o f s u g g e s t e d t a c t i c s f o r i m p l e m e n t a t i o n .

The Practice Integration Model

Tactics

Protocolized Process

Skills

Institutional Support

A. Identification

B. Assessment

C. Treatment

D. Surveillance

Environmental and Organizational Context

Clinical Tasks Care

Structure Leadership

Medical Services

Behavioral Health Services

Integrated Care

Things that matter to patients and families

Patient-Centered Outcomes

PCORI Project Training Modules

October 12, 2015

Project Structure and Delivery u  Media and delivery

u  Asynchronous, online modules

u  Flipped classroom approach employing monthly coaching/consultation via AdobeConnect webinars – discuss module topics and related skills and practice-related examples

u  Program-specific website portal

u  Registration tool

u  Online learning community (webinars and interactive blog)

u  Continuing Education (CE)/Continuing Medical Education (CME) records/archive

u  Training process, evaluations, and participant performance targets

u  Established competencies

u  APA Competencies for Psychology Practice in Primary Care [McDaniel, et al. 2014]

u  Core Competencies for Interprofessional Collaborative Practice, Association of American Medical Colleges (2011)

u  Behavioral health integration into primary care - Primary Cary Behavioral Health Model (PCBH), Robinson & Reiter (in press)

u  Primary Care Toolkit-medical provider competencies, Runyan (2009)

u  National Integration Academy Council, Agency for Healthcare Research & Quality (AHRQ)

u  CE management

u  PCPs Continuing Medical Education Units (CMEs) – provided by Center for Integrated Primary Care

u  BHC Continuing Education Units (CEUs) – provided by Arizona Psychological Association

Interprofessional

u  Principles of integrated behavioral healthcare

u  Why should we go to all the trouble? - BH integration aimed at facilitating practice changes to provide better care, improve patient satisfaction, and reduce costs (Triple Aim)

u  IBH is best thought of an expansion and enriching of primary care rather than as a changing of venue for mental health or substance abuse services

u  Population Health Management - Population health-focused care delivery

u  Team-based approach to healthcare delivery

u  Cost and outcome evidence related to integrated delivery models compared to coordinated and co-located models

Interprofessional

u  Team-based approaches to patient care

u  The interaction of patient activation and shared decision-making

u  Addressing and improving health literacy

u  Scripts for patient engagement

u  Scripts for patient activation

u  Team transparency and patient engagement

u  The role of the Patient Centered Care Plan (PCCP)

u  Making goal-setting a brief and regular part of care

Interprofessional

u  Team role distinctions, overlaps, and complementarity u  From “physician-led team” to “team-supported physician"

u  The advantages of leveraging screening into a new workflow

u  Role clarity and task flexibility in successful teams

u  How team members learn to pass a relationship with the patient to other team members

u  Integrating roles of BHC, Care Manager (CM) and Care Coordinator (CC) on the team, especially where there is not a different person for each role

u  Behavioral health and population health management u  The population care model

u  Screening

u  Registries

Interprofessional

u  Protocolized process - Overview

u  Including patients in redesign

u  What do patients have to offer?

u  Respect, trust and transparency among the team

u  Suggested “ground rules” for behavior in the team

u  DIAMOND Team Audit

Behavioral Health Clinicians

u  Clinical and practice management skills for IBH

u  Developing/implementing/evaluating IBH within primary care clinics

u  Warm handoffs (PCP & BHC)

u  Primary focus on brief interventions (adaptation to < 30 minute hour, brief treatment across the lifespan)

u  Common BH treatment strategies (i.e. CBT, MI, fACT)

u  Productivity expectations of each provider

u  Examples of a medical team’s typical day

Behavioral Health Clinicians u  Common co-morbidities and needs

u  Symptoms, mechanisms and treatments

u  Asthma

u  Diabetes

u  Heart disease

u  Chronic pain

u  Obesity

u  COPD

u  Hypertension

u  BH needs

u  Behavioral assessment

u  Functional assessment

u  Validated measures appropriate for use in primary care

u  Innovative delivery models (e.g., Group Medical Visits, web-based apps, etc.)


u  Common behavioral patterns related to specific medical conditions

u  Obesity

u  Nutrition and dietary issues

u  Physical inactivity

u  Smoking cessation

u  Sleep disorders

u  Anxiety

u  Depression

u  Substance misuse/abuse

u  Problem drinking


u  Evidence-supported approaches to health behavior change

u  Health behavior change strategies

u  Building the doctor/patient relationship for better health

u  Stages of Change model

u  Motivational interviewing

u  Matching approaches to stages of change

u  Treating the Patient with Medically Unexplained Symptoms (MUS)

u  Teamwork in engaging patients with MUS in behavioral care

u  Language that engages the patient

u  Use of uncertainty in uncertain situations

u  Case examples


u  Behavioral Medicine Skills

u  Relaxation response therapies

u  Sleep promotion

u  Progressive relaxation and autogenics

u  Hypnotic methods (without trance)

Primary Care Physicians

u  Screening and referrals to BH u  Indications

u  Team roles

u  Workflows

u  Monitoring

u  Team approaches to address patient BH co-morbidities

u  What does a BHC do?

u  Evidence-supported approaches to behavioral issues

u  Wise prescribing for behavioral problems

u  Referral to specialty mental health

u  Dual appointments with BHCs

u  Shared records

Other Staff

u  Impact of workflow on patient experiences

u  How workflow affects patients

u  Development, implementation, and refinement of workflow

u  Team collaboration and feedback

u  Communication skills

u  Documentation practices

Project Facilitator

u  Protocolized process u  Implementation Pathway

u  The Model for Improvement

u  Rapid improvement cycles

u  Describe the Current State

u  Define the Future State

u  Test and Measure

u  Stage I: Preparation u  Assess practice readiness, challenges, and opportunities

u  Measure baseline

u  Prepare and select team

u  Outcome: team objectives and schedule

Project Facilitator

u  Stage 2: Design

u  Current State

u  Future State

u  Outcome: implementation plan

u  Stage 3: Implementation

u  Rapid improvement cycles

u  Measure

u  Outcome: evaluation and maintenance plan

u  Managing change and including patients

u  The dynamics of change

u  Lessons learned

u  Tips for getting started

u  Including patients in the process

Care Manager

u  Core content u  Care Management in PCMH

u  Networking in the Medical Neighborhood

u  High Risk Registries for Population Management

u  Effective Patient Centered Care plans

u  Electives u  Heart Disease 101

u  Caring for Patients with SMI

u  Geriatric Patients and Their Families

u  Diabetes Care

u  EBP for Depression Care Management

u  Shared Decision Making

Care Manager

u  Electives u  Smoking Cessation

u  Managing Weight

u  Trauma Informed Care

u  Crisis Intervention

u  Caring for the Homeless

u  Unhealthy Substance Use

u  Chronic Pain

u  Patient Experience

u  An Introduction to MI

u  Fostering Patient Activation

u  Mind-Body connection and Stress Response

u  Behavior chain analysis and solution focused

Practice Manager u  Principles of IBH management

u  Registries and data-driven practice management

u  Transforming systems of care

u  Tactics for changing care

u  Algorithms for care – electronic or manual

u  Workflows for team-based approaches

u  Staff roles

u  Financial dimensions of treatment and billing practices

u  Costs and outcomes of IBH

u  Reimbursement options

u  Documentation standards

u  Personnel and administrative procedures

u  Quality assurance and documentation

u  Productivity and access to care

T h e t o o l k i t p r o v i d e s o v e r t w o d o z e n c l i n i c a l , o p e r a t i o n a l , a n d f i n a n c i a l t a c t i c s t h a t s u p p o r t t h e p r e p a r a t i o n a n d d e s i g n a c t i v i t i e s o f t h e s t r u c t u r e d

i m p r o v e m e n t p r o c e s s .

Behavioral Health Integration Toolkit

The IBH Implementation Toolkit

●  Project Preparation

●  Selection of Tactics Clinical Operational Financial

●  Workflow Design

●  Implementation

●  Measures & Follow Up

Toolkit continued…

P R A C T I C E S W I L L B E E N C O U R A G E D T O :

●  A d d r e s s t h e n e e d t o s c r e e n p a t i e n t s ●  U s e b r i e f B H v i s i t s

(rather than traditional 50 minute psychotherapy visit) ●  S u p p o r t B H C a n d P C P c o l l a b o r a t i o n

(joint meetings, case reviews, educational sessions, etc.) ●  E n h a n c e c o m m u n i c a t i o n b e t w e e n B H C s a n d P C P s a b o u t

s p e c i f i c c a s e s (shared records, standardized forms, case conferences, etc.)

●  D e v e l o p s u p p o r t f o r r e f e r r a l t o s p e c i a l t y m e n t a l h e a l t h o r c o m m u n i t y r e s o u r c e s o u t s i d e t h e p r a c t i c e …

(alcoholics anonymous, pastoral care, medication assistance, etc.) ●  … a n d B H s e r v i c e s i n s i d e t h e p r a c t i c e

(streamlined referral and appointment-making , same day visits, warm hand-offs, maintaining a directory of community assistance, etc.)

Measurement

●  P r a c t i c e I n t e g r a t i o n P r o f i l e ( P I P ) ●  P R O M I S

●  B a s e d u p o n C J P e e k ’ s L e x i c o n (Describes Common Dimensions of Collaborative Care)

●  C o m p a r e s m o d e l s o n s i x c o m m o n d i m e n s i o n s

30 items,1o minute electronic, soon to be web based

Generates domain scores and total score

●  P r o v i d e s d e t a i l e d d e s c r i p t i o n s a n d e x a m p l e s f o r o p e r a t i o n a l i z i n g e a c h d i m e n s i o n

●  P r o v i d e s a w a y t o q u a n t i f y d e g r e e o f i n t e g r a t i o n f o r e a c h d i m e n s i o n

●  C o m p o s i t e d i m e n s i o n s c o r e s p r o v i d e a n o v e r a l l r a t i n g f o r c l i n i c - l e v e l o f i n t e g r a t i o n

Measuring the Degree of Integration: The Practice Integration Profile (PIP)

●  M O D E L T Y P E Professional consensus and extrapolation of current conceptual models

●  T H E O R Y B A S E / R E F E R E N C E – A H R Q Lexicon for BH and PC Integration National Agenda for Research in Collaborative Care

●  U S E O F M O D E L F O R I N T E G R A T I O N L E V E L Measures multiple dimensions of integration Provides composite rating for clinic-level integrated medical/BH care

●  P S Y C H O M E T R I C S Operationalizes BH components related to each dimension

●  V A L I D A T I O N Initial beta testing with clinicians and healthcare managers Follow up beta test related to scenarios of four different sites Distribution to multiple sites, contacts, and time points

●  S T O R I N G D A T A Electronic distribution Respondent online access to data entry Online data management

Measuring the Degree of Integration: The Practice Integration Profile (PIP)

Patient Reported Measures Patient-Reported Outcome Measures Domain Instrument Number of

Questions

Aim 1a) Primary Outcomes – all patients Emotional Distress – Anxiety PROMIS-29 v2 [Cella 2010] 4 Emotional Distress – Depression PROMIS-29 v2 4 Fatigue PROMIS-29 v2 4 Pain – Interference & Intensity PROMIS-29 v2 5 Physical Function PROMIS-29 v2 4 Sleep Disturbance PROMIS-29 v2 6 Social Participation PROMIS-29 v2 4 Aim 1b) Secondary Outcomes – all patients Communication CAHPS 12-Month PCMH Adult Questionnaire 2.0 [AHRQ 2014] 6

Empathy Consultation and Relational Empathy measure [Mercer 2004] 10 Self-management Patient Activation Measure-13 [Hibbard 2005] 13 Adherence Modified Self-reported Medication-taking Scale [Morisky 1986] 4 Utilization Patient Report of Utilization [MacLean 2004] 6 Time lost due to disability Restricted Activity Days [Adams 1999] 1 Physical Function Duke Activity Status Index [Hlatky 1989] 12 Aim 1c) Disease Control - administered only to subjects with the specific condition noted Depression, Anxiety, Pain, Insomnia PROMIS-29 v2 4* Diabetes Hgb A1C † Substance Use disorder & Problem Drinking 30-day use [Snodgrass 2007]; Global Appraisal of Individual Needs – Short

Screener [Dennis 2006] 25

Hypertension Systolic blood pressure † Asthma Asthma Symptom Utility Index [Revicki 1998; Bime 2012] 10 COPD, CKD, CAD, HF Duke Activity Status Index 12*

Timeline

[email protected]

Questions

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