integrating behavioral health into primary care innovation ... · integrating bh into pc setting...
TRANSCRIPT
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Integrating Behavioral Health Into Primary Care
Innovation Community
Webinar #2
January 20, 2015
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Slides for today’s webinar are
available on the CIHS website at: www.Integration.samhsa.gov
under About Us/Innovation Communities
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Structure
Short comments from experts
Specifics from their point of view
Polling You
Every 20-minutes
Finding the “temperature” of the group
Asking Questions
Watching for your written questions
Follow-up and Evaluation
Ask for what YOU want or expect
Ideas and examples added to the AOS Resource Center
3
Our format…
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How to ask a question during the webinar
If you dialed in to this
webinar on your phone
please use the “raise
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question to the group.
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please type your
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question box and we
will address your
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Today’s Presenter
Pam Pietruszewski, MA
Integrated Health Consultant,
National Council for Behavioral Health
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Today’s Agenda
• Welcome
• Integration Levels Summary
• Screening, Intervention, Measures
& Leading Change
• Next Steps
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5 Innovation Communities
Overall goals:
1. Provide topic-specific foundational information
and best practices
2. Conduct innovative implementation planning
3. Work toward adoption of the innovation and
sustainability
December
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Integrating BH
into PC Setting
Core Competencies Focus:
1. Screening & Assessment
2. Intervention
3. Cultural Competence & Adaptation
4. Practice-Based Learning and Quality Improvement
Jan – Feb • Deeper dive into 4 Core Components
• Subject matter experts describe integration experience
• IPAT Tool
• Coaching call following January webinar
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Integrated Practice
Assessment Tool
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2
0
1
5
3 3
0
Level 0 Level 1 Level 2 Level 3 Level 4 Level 5 Level 6
IPAT Results
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BH has a communications plan for shared clients. Need to formalize
and implement so it includes the patient and all providers involved in
the process and evaluation. Depts need to communicate more
effectively – the pt needs to be the priority. (L3)
We started with one fulltime LCSW and have expanded to 4 fulltime BH
specialists. We currently provide services to four clinic locations. (L5)
PC and BH share an EHR. Ability to share a treatment plan but not yet
used by all care team members. Starting to monitor BH population for
lab work, screenings and symptom improvement. (L5)
Pre-identified preliminary steps to advance to level 6: EHR, billing
system, establish outcome measurements. (L5)
We were surprised with how integrated we actually are already. We are
looking forward to even more integration and achieving level 6. (L5)
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• How to hand-off screening results to bx health; how to build
workflows that are realistic for a PC setting.
• The actual integration of the intervention, what intervention in an
integrated setting looks like.
• Interventions that are most appropriate and efficient in the PCP
offices/medical outpatient.
• Determining intervention goals and developing plans to treat to those
goals
• Difference between integration of departments within one agency vs.
integration of services offered by two or more agencies
• Efficient and meaningful metrics and evaluation processes
December
comments
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Screening
Intervention
Measures &
(Bonus!) Leading Change
Spotlight on…
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Screening
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Poll Question
As part of your behavioral health integration plan, which
of the following are you planning to screen for by the time
this IC finishes in August? (Choose all that apply)
• Depression
• Anxiety
• Bipolar
• Alcohol misuse
• Drug use
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Screening
29% of adults with medical conditions have
mental disorders
68% of adults with mental disorders have
medical conditions
National Comorbidity Survey Replication, 2001–2003
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Screening:
Healthy Lifestyle
17
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The ACE Study
"Major Findings," Centers for Disease Control and Prevention (CDC)
Major links identified between early childhood trauma and long term health outcomes, including increased risk of many chronic illnesses and early death
Felitti, et. al. Am J Prev Med 1998
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Why ACE is
• Exposure to stressors weakens immune system and
increases inflammatory response (linked to injury and
infection) = increased risk for medical disorders.
• Depression is linked to altered immune function.
• People impacted by adverse child events may be more
likely to engage in unhealthy behaviors.
• Mental illness can complicate ability to manage medical
condition including self-care regimens and expectations.
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Assessment
• What does this mean to your various team members?
• What does it mean from a regulatory perspective?
• What fits best within your organization and how to be
most efficient
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Sequential Teams
• Work flows from one to another, usually in 1 direction
• Interdependence to meet goals
• Agreed upon process
• Accountable to each other
Intensive Teams
• Need to understand, create and implement solutions to solve a new problem
• Highly complex and variable
• Constantly changing systems
• High need for relationship
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Intervention
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Poll Question
As part of your behavioral health integration plan, which
of the following are you planning to use / implement?
(Choose all that apply)
• IMPACT stepped care for depression
• Motivational Interviewing
• SBIRT for risky substance use
• CALM for anxiety
• Other interventions
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Intervention: Stepped Care
Treatment
adjustments as
needed using
evidence-based
clinical outcomes
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STAR*D Trials - Rush, 2006
Treatment Step Remission Rate Weeks to
Remission
1. Antidepressant 36.8% 6.5
2.Switch or augment
(meds/therapy)
30.6% 5.4
3.Switch or augment again 13.7% 5.6
4.Switch or augment again 13.0% 7.4
Total 70%
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Motivational interviewing is a
collaborative, person-centered, guiding method designed to elicit and strengthen
motivation for change.
Miller & Rollnick, 2012
Motivational Interviewing
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• MI improves treatment retention, adherence, and
outcomes across a range of behaviors – but without
training, coaching and feedback, outcomes can vary
widely
• MI skill is reliably measurable and predicts better
outcomes
• MI generalizes fairly well across cultures
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Open-ended inquiry
How are you taking your medication?
Affirmations
You’re creative when it comes to finding time to exercise.
Reflections
Depression is not something you’ve talked about in your
family… and you’re looking for support.
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Measures
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Measurable
Clinical Outcomes
Blood Pressure
Lipids
Hemoglobin A1c
Tobacco Use / Breath CO
Depression: PHQ-9
Anxiety: GAD-7
BMI
Pain: Brief Pain Inventory
Alcohol/Drug Use: AUDIT, DAST, CRAFFT
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Other Outcome Measures
• Patient Activation
• Patient Satisfaction
• Functioning: DLA-20
• No show rates
• Rx fills
• ER visits
• Hospital admissions/readmissions
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Questions?
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Leading
Adaptive vs Technical
Change
Ronald Heifetz, MD, Harvard Medical School
Founder, Center for Public Leadership
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Adaptive Change
• Challenge is complex
• Need to address deeply
held beliefs & values
• Loss is inherent part of
the process
• Organic = Grow
Technical Change
• Problem is well defined
• Answer can be found
within present structure
• Implementation is clear
• Mechanic = Fix
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EHR, tools,
staff memos,
process & workflow
Leadership support &
clinical champions
Staff engagement, values, beliefs
Allowing staff to work up to training capabilities & testing expanded roles
Shared vision & accountability
The most
common cause
of leadership
failure
is treating an
adaptive
problem with a
technical fix.
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Clinical Example
• Technical: Diabetes diagnosis, medication prescription
• Adaptive: Identifying as someone with diabetes, loss of
“the way things were before”, how to fit medication
into daily routine.
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Process Example
• Technical:
New screening tool, workflow algorithm
• Adaptive:
Values and beliefs about screening for X, being the
new member of the team, loss of independence
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Theory U Otto Sharmer, PhD, MIT, 2007
Problem Solution
Focus
Deepening Creativity,
new thinking
Creativity,
New processes
Creativity,
New structures
Broadening
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Questions?
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Cherokee Health Systems mission:
“To improve the quality of life for our patients
through the integration of primary care,
behavioral health and substance abuse treatment
and prevention programs.”
https://www.youtube.com/watch?v=OtqMPhDH5TU&feature=channel_video_title
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Next Steps
• Open Office Hours: Fri, Jan 23, 12-3pm Eastern
Pam Pietruszewski 1-202-684-7466 x253
• Next Webinar: Tues Feb 17, 3-4pm Eastern
Maureen Neal, CFRE & David Pullen, MS, CRC, LMHP-E
The Daily Planet Healthcare Center, Virginia
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For More Information
Pam Pietruszewski
Integrated Health Consultant
202-684-7457, ext. 253
Hannah Mason
Senior Associate
202-684-7457, ext. 255
Questions? SAMHSA-HRSA Center for Integrated Health Solutions
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