American Psychiatric Nurses Association25th Annual ConferenceDisneyland Hotel, Anaheim CA

Primary Care Behavioral Health Consultation Services:

What it is and How to Make it Happen in Your Organization

Saturday October 22, 2011

Block 2: 10:25 – 11:15 AMIntegrated Physical/Mental Health Track

Michael Terry, DNP, APRN-PMH/FNP

THE SPEAKER HAS NO CONFLICTS OF INTEREST TO DISCLOSE

Effect of the ACA on Practice

• general medical sites deliver exclusively over half of all formal mental health care, making primary care the de facto mental health care system in the United States today. (Narrow et al., 2002; Narrow et al., 1993; Reiger et al,. 1993)

• 70 percent of all healthcare visits have primarily a psychosocial basis, (Fries et al., 2003)

• More than 25 percent of all healthcare recipients have a diagnosable mental disorder, yet more than half of mental disorders go undiagnosed in primary care. (U.S. Dept. of Health and Human Services, 2001)

Effect of the ACA on Practice

• One-third of all patients with chronic illnesses have co-existing depression that when left untreated amplifies physical symptoms, increases functional impairment, and interferes with self-care and adherence to medical treatment. (Unützer et al., 2006)

• In large cities, behavioral health disorders may account for 69 percent of hospitalizations among homeless adults, compared with 10 percent of non-homeless adults (New York City Depts. of Health and Mental Hygiene and Homeless Services, 2005)

Effect of the ACA on Practice

• Services for medical problems and for mental health problems operate on separate tracks today; causing illnesses to be misdiagnosed or missed entirely. This healthcare system is providing effective treatment to only a few of the patients who need it

Effect of the ACA on DNP Practice

• As 32 million more patients become eligible for primary care in 2014 under the Affordable Care Act, the need to better integrate behavioral health services into primary care settings has never been greater

The ACA is Coming!

The ACA is Coming!

Spectrum of Options for Mental Health Services in Primary Care

Practice Model 1: Improving Collaboration between Separate Providers

Spectrum of Options for Mental Health Services in Primary Care

Practice Model 2:

Medical-Provided Behavioral Health Care

Spectrum of Options for Mental Health Services in Primary Care

Practice Model 3:

Co-location

Spectrum of Options for Mental Health Services in Primary Care

Practice Model 4: Disease Management

Spectrum of Options for Mental Health Services in Primary Care

Practice Model 5: Reverse Co-location

Spectrum of Options for Mental Health Services in Primary Care

Practice Model 6: Unified Primary Care and Behavioral Health

Spectrum of Options for Mental Health Services in Primary Care

Practice Model 7: Primary Care Behavioral Health

Spectrum of Options for Mental Health Services in Primary Care

Practice Model 8: Collaborative System of Care

Spectrum of Options for Mental Health Services in Primary Care

Primary Care Behavioral Health Specialty Mental Healthpopulation-based client-based; specific requirements for

service acceptance often informal client inflow(PCP:BHC ratio is 1:3-4 optimally)

formal acceptance process; requires intake assessment, treatment planning

treatment usually limited; 1-3 visits20-30 min. per client

often long-term treatment; number variable, related to client condition

treatment afforded to persons with mild impairments, those coping with situational stress and sometimes stabilized persons with serious mental disorders

treatment restricted to persons experiencing or at risk of serious mental disorders

informal counseling session, vulnerable to frequent interruptions (8-12 pts/day)

more formal, private interchange

Spectrum of Options for Mental Health Services in Primary Care

Primary Care Behavioral Health Specialty Mental Healthbehavioral records often integrated with the medical treatment chart

mental health records stand-alone

therapist workday often involves jumping from one activity to another

therapist can focus on one-to-one client interaction

care responsibility returned to medical provider once behavioral treatment is concluded

therapist remains contact point if needed

frequent consultation with medical provider for clients with co-occurring health and mental health condition

often little or no interaction with medical provider regarding medical condition

clients often seen, at least briefly, on same day as referral

often substantial wait-time for services in non-emergency cases

Spectrum of Options for Mental Health Services in Primary Care

• How will clients be identified?

• Who will prescribe psychotropic medication?

• Who will provide counseling/psychotherapy?

• Who will provide mental health back-up?

• Who will track clinical outcomes and how?

• How will treatment changes be initiated?

Questions for Preparation

• How will team members communicate?

• What is the overall implementation strategy?

• Who will lead/coordinate the effort?

• What kind of provider/staff training is needed?

• What structural/program changes are needed?

• What are anticipated barriers and challenges?

Questions for Preparation

• How will we measure success?

• How can the model be sustained?

Questions for Preparation

Goals

1. Design a new integration project PCBHCS according to the tenets of the PCBH model.

2. Improve patient care by effective integration of medical care and behavioral health strategies in primary care services.

3. Foster intra-professional and inter-professional collaboration by primary care providers and behavioral health providers through a successful phased implementation of the PCBHCS project.

4. Assure adherence to the PCBH model and standards by the training of (organization) staff and Behavioral Health Consultants (BHCs) through on-going evaluation.

Timeframe

http://www.integratedprimarycare.com/Air Force Manual/primary care practice manual.pdf

Adapted from: Air Force Manual - Primary Behavioral Health Services Practice Manual

Timeframe

Timeframe

Objectives & Activities

1. The Project Director will complete the design and implementation strategy so that training may begin. This will be demonstrated by a formal presentation to clinic management and (organization) administrators on (date).

1a. Conduct a site assessment of (organization) using the Worksheet for Assessing Organizational Climate (Air Force Manual) or based on questions listed above

1b. Modify or adapt the clinical forms and evaluation tools to be used in the project implementation

1c. Complete the training materials and orientation package for primary care providers and (organization) staff

1d. Complete the orientation package for the Behavioral Health Consultants

Objectives & Activities

2. The Project Director will conduct 3 staff orientation sessions, offer 2 primary care provider orientation sessions and complete BHCs orientation. The Project Director will present results at the clinic management meeting on (date).

2a. Conduct 3 weekly orientation sessions for reception staff and medical assistants, introducing service goals, methods, flow and paperwork/forms to be used

2b. Offer two 30-minute orientation services to PCPs and follow-up with weekly lunch hour Q&A sessions for 4 weeks

2c. Orient and organize Psychiatric Mental Health Nurse Practitioners or BHCs to initially provide services at BHC I level, as measured by the Training Core Competency

Objectives & Activities

3. The PCBHCS project will have initiated services to (number) selected patients; with each BHCs providing at least 5 visits each week. This reach will be monitored by the Project Director reviewing the Referral Log of each BHC weekly. The adoption of skills by BHCs will be evaluated by the Project Director using the Training Core Competency Tool Part I by (date).

3a. Using vertical integration strategies, select appropriate patients to offer preventive care (weight management and smoking cessation) and mental health brief counseling (depression and anxiety)

3b. BHCs provide basic level skill (above) plus triage and crisis intervention services as needed

3c. Project Director mentors the BHCs and monitors productivity and compliance with skills using the Training Core Competency Tool Part I and the PCBHCS Chart Audit form with each BHC weekly

Objectives & Activities

4. PCBHCS project will expand to the full range of services; with BHCs providing at least 15 visits each week. This reach will be monitored by the Project Director reviewing the Referral Log of each BHC weekly. The adoption of skills by BHCs will be evaluated by the Project Director using the Training Core Competency Tool Part II by (date).

4a. During the month of (date), increase Psychiatric Mental Health Nurse Practitioner services to the level of BHC II as measured by the Training Core Competency – Part II

4b. Beginning in (date), BHCs provide the full range services

4c. Project Director mentors BHCs and monitors productivity and compliance with skills using the Training Core Competency Tool Part II and the PCBHCS Chart Audit form with each BHC weekly

Objectives & Activities

5. The Project Director will complete the summative evaluation portion of the formal evaluation to evaluate reach, adoption and maintenance of the PCBHCS. This will be demonstrated in a formal presentation to clinic management and Glide Foundation administrators on (date).

5a. Collect all BHC Provider Referral logs and compare utilization to national averages to determine project reach

5b. Evaluate initial to subsequent Behavior Health Questionnaire-36 questionnaires for change in symptoms to determine project efficacy

5c. Summarize findings of the on-going evaluation of PCBHCS Audit Forms to determine final project adherence to project standards and their maintenance

5d. Project Director will administer a PCP Satisfaction Survey Form quarterly for evidence of progress and maintenance of the project implementation. Front desk staff will collect the Patient Satisfaction Survey Form at each visit for the Project Director to use for on-going feedback to BHCs and to evaluate maintenance in the final report

Project Evaluation

Based the RE-AIM format. See: http://www.re-aim.org/2003/defined2.html

Forms referenced are from the Air Force Manual, Appendices: http://www.thenationalcouncil.org/galleries/business-practice%20files/2011%20BHOP%20Appendices,%207.28%20updates.pdf

Providers of PCBH Focus & SkillsLicensed Clinical Social Worker Case management, community liaison

Clinical Psychologist In-depth counseling, specialty connections

Psychiatrist psychopharm, specialty connections, medical background

Health Psychologist Chronic illness counselingPrimary Care Psychologist Risk reduction & behavior change

PMHNP Psychopharm, medical bkgrnd, pt. ed., risk reduction

What’s different with a PMHNP prepared specifically to work in Primary Care?

Clinical Skills• Brief focused counseling using motivational interviewing & behavioral activation methods• Performs patient-centered narrative interviewing to compliment and augment medical interviews• Coordinates and incorporates care for acute & chronic medical conditions• Conducts supportive & psychoeducational group therapy sessions• Provides brief cognitive-behavioral psychotherapy sessions for patients with chronic illness• Offers risk-reduction behavioral change sessions for tobacco cessation, weight loss, physical activity, etc.

What’s different with a PMHNP prepared specifically to work in Primary Care?

Practice Management Skills• Conducts practice analysis and plan for implementation of PCBHCS • Employs population-based approach for case-finding of pts. needing behavioral health services via screening practices, chart review, database & tickler file use• Trains MAs, RNs, IT, billing and reception staffs in pt. identification, referral, support, and billing for behavioral health services• Trains MD/NP/PA staff on use PCBHCS• Develops EHR or chart forms, and sets up referral & liaison interface with mental health specialty services• Establishes and maintains behavioral health registries for appropriate conditions

What’s different with a PMHNP prepared specifically to work in Primary Care?

Other Management Skills• Develops grant proposals for new or improved services• Crafts policy analysis documents for Board of Directors, community agencies, and legislators r/t practice issues• Performs evaluations of services (e.g., PDSA, formative, summative, etc.)• Precepts PMHNP students in DNP programs, serves on their doctoral committees, advises on practice project design and implementation

What’s different with a PMHNP prepared specifically to work in Primary Care?

Educational Preparation

New PCBH Roles for APRNs

• PNCB certification for PNPs & FNPs• Dually-certified FNP/PMHNP• PMHNP with PCBH

experience/rotation• Primary Care Behavioral Health NP

Educational Preparation

How could a DNP program prepare APRNs for PCBH roles?

1. What are the different types of roles in PCBH of NPs?

2. What would a PCBHCS educational program look like?

Educational Preparation

• PCBH focus in core DNP courses- Integrated care emphasis in Health Policy- Grant writing/publication in PCBH - project planning, development, evaluation- pathophysiology of stress

• 500 additional hours: - in PCBH consultation services sites, incl. coding & billing- with emphasis on CNS role preparation

• Final project in PCBH site• Additional coursework in PCBH

- Health psychology, behavioral medicine- Clinical Nurse Specialist role/skills- Motivational Interviewing- Positive psychology & coaching

Questions?

Integrated Behavioral Health Project (California)www.ibhp.org

Bureau of Primary Care (HRSA)http://bphc.hrsa.gov

California Department of Health Care ServicesOffice of HIPAA Compliance www.dhcs.ca.gov/formsandpubs/laws/hipaa/Pages/default.aspx

CalMENDhttp://www.calmend.org

Collaborative Family Healthcare Associationwww.cfha.net

Hogg Foundation for Mental Health (Texas)www.utexas.edu/programs_ihc.html

ICARE Partnership (North Carolina)www.icarenc.org

IMPACT Model for Treating Depression in PrimaryCare www.impact-uw.org

Integrated Primary Carewww.integratedprimarycare.org

MacArthur Initiative on Depression in Primary Carewww.depression-primarycare.org

Additional Resources

Mountainview Consulting Groupwww.behavioral-health-integration.com

National Guideline Clearinghousewww.guideline.gov

National Council for Community Behavioral Healthcarewww.thenationalcouncil.org

Rand Partners in Care Initiativewww.rand.org/health/projects/pic

Robert Wood Johnson Foundation Depression in Primary Care Initiativewww.wpic.edu/dppc

The Reach Institute Guidelines for Adolescent Depression inPrimary Carewww.thereachinstitute.org/guidelines-foradolescent-depression-in-primary-care-gladpc.Html

Washtenaw County Health Organization (Michigan)www.ewashtenaw.org/government/departments/wcho/ch_behealthcarepresentation.pdf (Powerpoint of their integrated program)

References

Agency for Healthcare Research and Quality (AHRQ). (2002). A Step-by-Step Guide to Delivering clinical preventive services: A systems approach. Washington, DC: Author. 123-144.

Blount, A. (2003). Integrated primary care: Organizing the evidence. Families, Systems & Health, 21, 121-134.

Bower, P. (2002). Primary care mental health workers: models of working and evidence of effectiveness. British Journal of General Practice, 52: 926-933.

Burt, M. R., Aron, L.Y. & Douglas, T. (1999). Homelessness: Programs and the people they serve. Washington, DC: Interagency Council on the Homeless.

Fries, J., Koop, C., & Beadle, C. (1993). Reducing health care costs by reducing the need and demand for medical services. The New England Journal of Medicine,329, 321–325.

Haas, L., (ed). (2004). Handbook of Primary Care Psychology. New York: Oxford University Press. Available at http://www.amazon.com/Handbook-Primary-Care-Psychology-Leonard/dp/0195149394.

Hunter, C., J. Goodie, M. Oordt, and A. Dobmeyer. (2009). Integrated Behavioral Health in Primary Care: Step-by-Step Guidance for Assessment and Intervention. Washington, DC: American Psychological Association. Available at http://www.amazon.com/Integrated-Behavioral-Health-Primary-Step/dp/143380428X.

Glasgow, R. E., Ockene, J., Pronk, N., & Goldstein, M.G. (2003). Translating what we have learned into practice: principles and hypotheses for addressing multiple behaviors in primary care. American Journal of Preventive Medicine. Aug;27(2 Suppl):88-101.

Institute of Medicine. (2005). Improving the quality of health care for mental and substance-use conditions: Quality chasm series. Washington, DC: National Academy Press.

References

Jilcott, S., Ammerman, A., Sommers, J., & Glasgow, R. E. (2007). Applying the RE-AIM framework to assess the public health impact of policy change. Annals Behavioral Medicine, 34, 105-114.

Mauer, B. (2003). Background Paper: Behavioral Health/Primary Care Integration Models, Competencies, and Infrastructure. Rockville, MD: National Council for Community Behavioral Healthcare. Available at www.thenationalcouncil.org/galleries/business-practice%20files/PC-BH%20Models-Competencies.pdf.

Narrow, W. E., Rae, D. S., Robins, L. N., & Regier, D. A. (2002). Revised prevalence estimates of mental disorders in the United States: Using a clinical significance criterion to reconcile 2 surveys' estimates. Archives of General Psychiatry, 59, 115–123.

Narrow, W. E., Reiger, D., Rae, D. S., Manderscheid, R., & Locke, B. (1993). Use of services by persons with mental and addictive disorders: Findings from the National Institute of Mental Health Epidemiological Catchment Area Program. Archives of General Psychiatry, 50, 95-107.

Office for Prevention and Health Services Assessment (2002). Primary Behavioral Health Care Services Practice Manual Version 2.0. Brooks AFB, TX: U.S. Air Force. Retrieved 4/28/2008, from http://www.integratedprimarycare.com/Air%20Force%20Manual/primary%20care%20practice%20manual.pdf.

Parthasarathy, S., Mertens, J., Moore, C., & Weisner, C. (2003). Utilization and cost impact of integrating substance abuse treatment and primary care. Medical Care 41, 357–367.

Regier, D., Narrow, W., Rae, D., Manderscheid, R., Locke, B., & Goodwin, F. (1993). The de facto mental health and addictive disorders service system. Archives of General Psychiatry, 50, 85-94.

References

Robinson, P. J. & Reiter, J. T. (2007). Behavioral consultation and primary care: A guide to integrating services. New York, NY: Springer Science+Business Media, LLC.

Schoenbaum, M., Unützer, J., Sherbourne, C., Duan, N., Rubenstein, L., Miranda, J., & Meredith, L. S. (2001). Cost-effectiveness of practice-initiated quality improvement for depression. Journal of American Medicine Association, 286, 1325–1330.

Tyler, D. O. & Horner, S. D. (2008). Family-centered collaborative negotiation: A model for facilitating behavior change in primary care. Journal of the American Academy of Nurse Practitioners. 20:4, 194 – 203.

Unützer, J., Schoenbaum, M., Druss, B., & Katon, W. (2006). Transforming mental healthcare at the interface with general medicine: Report of the President’s New Freedom Commission on Mental Health. Psychiatric Services, 57, 37-47.

U.S. Air Force. (2002). Primary Behavioral Health Care Services: Practice Manual. Brooks AFB, TX: U.S. Air Force. Available athttp://www.integratedprimarycare.com/Air%20Force%20Manual/primary%20care%20practice%20manual.pdf.

U. S. Department of Health and Human Services. (2001). Report of a Surgeon General’s working meeting on the integration of mental health services and primary health care. Rockville, MD: Author. Retrieved 4/28/2008, from www.surgeongeneral.gov/library/mentalhealthservices/mentalhealthservices.PDF

Whitlock, E., C. Orleans, N. Pender, and J. Allan. (2002). Evaluating Primary Care Behavioral Counseling Interventions: An Evidence-Based Approach.American Journal of Preventive Medicine 22(4):267–84. doi:10.1016/S0749-3797(02)00415-4. Available at http://dx.doi.org/doi:10.1016/S0749- 3797(02)00415-4.