Patient perspectives of integrated primary and behavioral health care

Melinda M. Davis, PhD, Assistant ProfessorRose Gunn, MA, Research Associate

Collaborative Family Healthcare Association 17th Annual ConferenceOctober 15-17, 2015 Portland, Oregon U.S.A.

Session # E1bOctober 16, 2015

Acknowledgements• Many thanks to the patients and staff that

participated in this work• To our co-authors and collaborators:

– Kris Gowen, PhD– Deborah Cohen, PhD– Jennifer Hall, MPH – David Cameron, BA– Brianna Muller, MD/MPH Candidate – Maribel Cifuentes, RN, MSN– Bijal Balasubramanian, PhD, MBBS

Presentation Purpose / Overview

• Purpose: Describe patients’ experiences in integrated clinics and discuss implications for practice.

• Overview1. Business (disclosure, objectives, etc.)2. Background3. Advancing Care Together

a) Overviewb) Qualitative Study – Patient Experience

4. Audience Discussion (Q&A)

Faculty Disclosure

The presenters of this session have NOT had any relevant financial relationships during the past 12 months.

Learning Objectives

• At the conclusion of this session, the participant will be able to:

– Describe the effect that integrated care team relationships have on patients.

– Reflect on how the patient experience can be used to refine the model of care in your setting.

– Identify significant contributing factors to patients accepting behavioral health care.

Learning Assessment

• A learning assessment is required for CE credit.

• A question and answer period will be conducted at the end of this presentation.

• Discussion interspersed throughout the presentation

References1. Aysola J, Werner RM, Keddem, S, et al. Asking Patient About

Patient-Centered Medical Homes: A Qualitative Analysis. J Gen Intern Med (10) 2015.

2. Ludecke D. Patient centredness in integrated care: results of a qualitative study based on a systems theoretical framework. International journal of integrated care 2014;14:e031.

3. Pinfold V, Sweet D, Porter I, et al. Health Services and Delivery Research. Improving community health networks for people with severe mental illness: a case study investigation. Southampton (UK): NIHR Journals Library; 2015.

4. Hildebrandt H, Pimperl A, Schulte T, et al. Pursuing the triple aim: evaluation of the integrated care system Gesundes Kinzigtal: population health, patient experience and cost-effectiveness. Bundesgesundheitsblatt, Gesundheitsforschung, Gesundheitsschutz 2015.

5. Vilhelmsson A, Svensson T, Meeuwisse A. A Pill for the Ill? Patients' Reports of Their Experience of the Medical Encounter in the Treatment of Depression. PloS one 2013;8:e66338.

JABFM September-October 2015; 28 (Supplement) highlights findings from two projects: Advancing Care Together and the Integration Workforce Study.

Table of Contents Available at: www.jabfm.org/content/28/Supplement 1.toc

HOT OFF THE PRESS!!!!

Background

• Integrated care: care rendered by a practice team of primary care and behavioral health clinicians, working together with patients and families and using a systematic and cost-effective approach to provide patient-centered care.

• Integrated care is associated with improved experience of care, better quality, and controlled costs

• Few studies explore patient perspective of integrated care using qualitative methods

Patrick

https://www.youtube.com/watch?v=7CObVLYUORc

Advancing Care Together (ACT)

• ACT was a 4-year program to “change practice” and enable “whole person care”– funded by The Colorado Health Foundation– 11 ACT practices– Program office, technical assistance, evaluation

• 5 ACT practices selected for patient interviews

Practice Characteristics  A B C D E

Type Mental health Mental health Primary care Primary care Primary care

Ownership Private, not for profit

Private, not for profit

Private, not for profit Clinician Clinician

Setting  Rural Suburban Suburban Urban Suburban

PCP FTE 2 0.5 11 14 5BHC FTE 8 23 2 1 0.5

Annual Visits 7,904 4,732 14,924 47,476 15,600

Care type PC in BH PC in BH BH in PC BH in PC BH in PC

Identification of problem

Systematic screening

Clinician discretion

Systematic screening

Clinician discretion

Systematic screening

Transition approach Referral Referral Warm hand

offWarm hand

off Referral

Patient Sample

• Eligible patients identified from clinic tracking sheet– Evaluation team purposively identified 18-21 patients at

each clinic– Clinic champion approached patients to obtain permission

to share contact information

• 47 patients agreed to be contacted by the evaluation team

• Interview participants received a $25 gift card.

Data Collection and Analysis

• 25 semi-structured patient interviews • Interviews were conducted in person in (N=8) and by

phone (N=17).• Interviews lasted 25 minutes on average• A multi-disciplinary team analyzed interview data by

reading and reviewing transcripts, discussing larger patterns as a team, and uncovering themes

Results: Patient Characteristics• Demographics• 67% were female• Age range: 20-82 (mean age = 50)• 17% Hispanic/Latino

• 11 patients from community mental health settings integrating primary care

• 13 patients from primary care clinics integrating behavioral health

Results: Thematic Overview

1. Mind, body, life are connected2. Access to integrated care3. Benefit to self and others4. Develop/relearn coping skills5. Pros: Service co-location, problem-focused

encounters, ability to seek additional care6. Challenges: Payment barriers, staff turn-over,

redundancy

Mind, Body, Life Are Connected

• Patients spoke about their lives

• Well-being included both body and mind

• Physical, emotional, and life conditions discussed with primary care teams

[Wellbeing includes] Not just our physical body but what kind of life we have. Before [Clinic], we really didn't have a functional life. Things were just crazy and sporadic and emotional and none of us could live a happy, normal life. With a lot of therapy, some medication…for some of us, a lifestyle change, we actually are a family.

-Elizabeth

Mind, Body, Life Are Connected

Access to Integrated Care

• Patients were connected to integrated care through multiple avenues– Warm hand off through clinical screening or

routine encounters– Family members received BH care at clinic– Encouragement by employers, practice staff, or

from ER visits• No mention/stories of stigma in the data

Access to Integrated Care

Well, the [BHC staff] just come in and introduce themselves and ask you how you are doing and then they ask all the questions, and if I say, "Oh, I'm feeling a little sad," they'll just ask "Oh, why are you feeling sad?" Once you explain, that's pretty much it. They just tell you, "Well, if you need anything, you can call me or make an appointment.“

- Angela

Benefit to self and others

• Patients shared stories of how integrated care helped them work through challenging physical and emotional circumstances

• Patients described sharing the skills learned with close others, or referred family members for additional care

• [Seeing the counselor] was a fabulous experience... I came in one day and I was totally beside myself. Just in tears and just ranting and raving. By the time I had seen her three weeks I was fine….I took a lot away from my meetings with her….I'd go home and I'd call [my friend] and say, "This is what she said. I did this and I did that." …

- Alice

Benefit to Self and Others

Develop/Relearn Coping Skills

• Patients told stories of learning to recognize their emotions, value their worth and set boundaries with coworkers, children, and partners

• Patients described a range of tools that they used to help cope with emotions

Develop/Relearn Coping Skills

I have started to feel a lot better. Finally someone said it’s okay to feel what you're feeling instead of telling me everything you're doing is wrong. So that has helped a lot. I joined their DBT group...[they tell me] it's okay to have feelings. It's okay to be angry. It has provided alternative ways of coping with the anger and letting go of baggage that's better let go of.

-Shelly

Katie

https://www.youtube.com/watch?v=XassBKsuko8

Pro: Service Co-location, Problem-Focused, Additional Care

• Patients appreciated that their clinic offered multiple services at one location– Ease of access– Clustering personal and family appointments– Improved communication between providers

• Encounters were solution focused• Clinicians available if additional care was

needed

Pro: Service Co-location

I went into the [clinic name] because it has everything. It has your mental health, and it has your doctors and I think that's very important because, for me, I don't like to run back and forth all over the place. I like to have everything just done right there....

-Maria

Pro: Problem Focused EncountersI had been in therapy years and years ago…I hesitated about coming back to therapy [because] I didn't want to drag up all the old stuff…it's like, "Okay, I've dealt with all that ..." Obviously I'm still dealing with some of it, but I didn't want to bring up all that stuff again. The doctor and BHC said, "We don't do that…we don't dredge back into all that stuff…”

- Janet

Challenges: Payment Barriers, Turnover, Redundancy

• Insurance limited the type of visits and/or the provider a patient could see (referral out not always pursued)

• Staff absence, turnover, or leave prohibited access

• Integrated care viewed as redundant

Challenges: Payment Barriers

Me and her really, really hit it off, but then when my insurance wouldn't cover it, it really took a toll on me because I like to keep the same counselor. It's really hard to switch…you start trusting them and then all of a sudden they pull the plug on you, it's really, really hard to open up to somebody new.

-June

Challenges: Redundancy

Then the [counselor] came in and we had, basically, the same conversation twice…..I didn’t find the counselor super helpful, but it was nice to talk to someone.

-Tom

Summary / Limitations

• Patients reported benefit – Mind, body, life– Multiple pathways– Benefit – coping skills– Challenges focused on process/system factors:

payment/insurance, turnover, redundancy

• Limitations: – Data from single state and program– Relatively small sample.

Question & Answers

• Questions for us?• Question for you:

1) What aspect of this presentation resonated with your experience providing integrated care?

2) How might what you heard impact the way you care for patients?

3) We heard about policy earlier, how might policies be altered to improve patient experience of integrated care?

4) Where should research in this area go next?

Session Evaluation

Please complete and return theevaluation form to the classroom

monitor before leaving this session.

Thank you!