pathways in primary care - safe communities madison-dane · – team consultation and collaboration...

Pathways in Primary Care

Victoria Egizio, PhDProgram DirectorPrimary Care Behavioral HealthUnityPoint Health-Meriter

Learning Objectives

• Be able to explain the rationale for integrating behavioral health services in primary care

• Be able to describe different models of integration

• Be able to identify options that may work at your organization

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Agenda• What Does the Research Tell Us?

• Models of Integrating Behavioral Health Services in Primary Care

• Steps You Can Take Back to Your Organization

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What Does the Research Tell Us?

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What Does the Research Tell Us?Disorder/Risk Factor Patients with at least 1

psychiatric diagnosisPatients with no psychiatric history

Hypertension 21.9% 18.8%Smoking 36% 21%Heart Disease 5.9% 4.2%Diabetes 7.9% 6.6%Obesity 42% 35%Asthma 15.7% 10.6%

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Data excerpted from www.samhsa.gov

What Does the Research Tell Us?

• 70% of all health care visits are generated by psychosocial factors, if not by frank psychiatric symptoms (Fries et al., 1993)

• Per a national survey-32% of undiagnosed, asymptomatic adults would likely turn to their primary care physician to help with mental health issues while only 4% would see a mental health provider (National Mental Health Association, 2000)

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What Does the Research Tell Us?

• A study of patients treated at 56 integrated care clinics showed greater improvement in hemoglobin A1c, cholesterol levels, and hypertension compared to patients treated at control clinics (Scharf et al., 2014)

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What Does the Research Tell Us?• The addition of psychological interventions

for Kaiser Permanente patients with serious medical conditions resulted in: – 77.9% reduction in their average length of

hospitalization – 66.7% reduction in hospitalization frequency – 48.6% decrease in number of prescriptions

written– 48.6% decrease in office visits– 45.3% decrease in emergency room visits– 31.2% decrease in telephone contacts

9Data excerpted from www.samhsa.gov

Models of Integrating Behavioral Health Services in Primary Care

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Excerpted from:Heath B, Wise Romero P, and Reynolds K. A Review and Proposed Standard Framework for Levels of Integrated Healthcare. Washington, D.C.SAMHSA-HRSA Center for Integrated Health Solutions. March 2013

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Models of Integration

• What does it look like clinically?– Team consultation and collaboration– Timely access to services– Generalist approach– Brief, empirically-based interventions

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Models of Integration• Collaborative Care

– Patients screened for depression in primary care (usually using PHQ-9)

– Patients with positive screenings (usually PHQ-9 scores of 10+) are assigned a care manager

– Care managers can be• Bachelor’s level providers • Psychiatric RNs• Master’s prepared therapists• Psychologists

• Further reading: UW AIMS (Advancing Integrated MH Solutions) Center at www.aims.uw.edu

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Models of Integration

• Care managers– Manage about 90-120 patients– Offer additional behavioral health screenings– Provide solution-focused interventions:

motivational interviewing, problem-solving, goal-setting, behavioral activation

– Offer triage to specialty behavioral health services

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Models of Integration

• Care managers support medication management– Have close communication with PCP and

Psychiatric Consultant• Enforce psychotropic medication compliance,

monitor for side effects, re-administer screening tools to assess symptom progression, etc.

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Models of Integration

• Behavioral Health Consultant– Embedded behavioral health providers in primary

care– See patients same-day and for scheduled

appointments– Visits are brief and solution-focused– Consultation resource

• Further Reading: Robinson, P. J., & Reiter, J. T. (2007). Behavioral Consultation and Primary Care. New York, NY: Springer.

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Models of Integration• Behavioral health consultant can be

– Psychologist – Master’s prepared therapist

• Behavioral health consultant workflow– Patient seen by PCP for psychiatric symptoms– “Warm handoff” to onsite behavioral health

consultant on same day as PCP visit• About 15-30 min encounters

• Initial interview• Solution-focused, evidence-based treatment

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Models of Integration

• Behavioral health consultants offer– 3-6 follow-ups (often linked to PCP visits)―Focal coping skills training aimed at referral

question NOT comprehensive psychotherapy―Bridge connection to specialty behavioral

health

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Steps You Can Take Back to Your Organization• Screen primary care patients for

behavioral health symptoms– PHQ-9, GAD-7 demonstration

• Administer PHQ-9 and GAD-7 at med checks to measure treatment response

• Discuss results with the patient to refine treatment plan

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Steps You Can Take Back to Your Organization• Assessing lethality risk

– In response to elevated scores on PHQ-9 item 9, administer C-SSRS

• C-SSRS demonstration– Helps determine thoughts vs plans vs intent– Use as treatment planning tool– Use to determine need for calling 911

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Steps You Can Take Back to Your Organization• Collaborative Safety Planning• https://suicideprevention-icrc-

s.org/sites/default/files/sites/default/files/events/17_7_26_icrc-sslides.pdf

• https://www.mirecc.va.gov/VISN16/docs/Safety_Planning_for_Older_Adults_Manual.pdf

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Steps You Can Take Back to Your Organization• Counseling on Access to Lethal Means

(CALM) – Online Training• http://training.sprc.org/• http://training.sprc.org/enrol/index.php?id=

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Questions?

Thank You!

Victoria Egizio, PhDVictoria.Egizio@unitypoint.org

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