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A Project of the Tides Center

Initiative Overview and Evaluation Findings

Gary Bess, PhD and Jim Myers, MSW

Collaborative Family Healthcare Association October 23, 2009

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About Us….About Us….

Launched in March 2006 as a project of

to accelerate integration of behavioral health services into primary care settings (CCHs)

Sunsets in 2010 - 2011 Focus is on providers in California

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Our goals …Our goals … Increase access to behavioral health

services

Reduce stigma associated with seeking treatment

Improve treatment outcomes

Strengthen linkages between mental health and primary care

by….

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Our goals …Our goals … Identifying, studying and

disseminating promising practices and models

Establishing a learning community

Sponsoring training opportunities

Designing a resource website (www.ibhp.org)

Advocating for policy and system changes

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Conducted developmental assessment of IBH practice levels in CCHCs

Selected seven primary care clinics and two clinic consortia to receive grants and serve as vanguard demonstration sites

Build IBH capacity Study operations & mine data Evaluate approaches

Identified policy and system barriers to integration

Phase IPhase I

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Data Collected

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Patient DescriptionPatient Description(N = 5,000+)(N = 5,000+)

Female - 70.9%; Male – 29.1% Nearly 90% either Hispanic/ Latino (40.8%) or

White (48.6%); other ethnic/racial groups comprised no more than two percent of population.

Average age approximately 41 years; range from 18 to 94.

Average number of visits for either primary care or behavioral health (or both) during study period was 2.63.

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First Clinic Visit and the First Clinic Visit and the

“Warm Hand-Off”“Warm Hand-Off” One-third (33.3%) of patients tracked for the study* had the same date for their initial visit with the clinic AND entry into the clinic’s integrated behavioral health program (N=1162).

Greater than one-half of patients (52.5%) tracked for the study* were referred to the clinic’s integrated behavioral health program within six months of their initial visit to the clinic (N=1162).

*Includes patients that were referred for behavioral health services in the 12 months prior to commencement of grant award AND those patients that were referred for behavioral health services after the commencement of the grant.`

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Duke Health ProfileDuke Health Profile

17 Item patient self report6 Health measures—physical,

mental, social, general, perceived, self-esteem

4 Dysfunction measures—anxiety, depression, pain, disability

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Duke FindingsDuke FindingsDuring the Study Period…

Health scores increased (the desired clinical outcome) for each of the six health measures from baseline to most recent follow-up assessment. Statistically significant changes occurred in physical health, mental health, and general health.

Each health score at the time of the most recent assessment, however, was lower (p < .05) than the normative sample from which the Duke was developed.

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Duke FindingsDuke FindingsDuring the Study Period…

Dysfunction scores decreased (the desired clinical outcome) in each of the four health measures from baseline to most recent follow-up. Statistically significant decreases occurred in anxiety and depression.

Each dysfunction score at the time of the most recent assessment, however, were significantly (statistically) was greater (p < .05) than the normative sample from which the Duke was developed.

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PHQ-9PHQ-9

9 Item depression scale

The PHQ-9 is based directly on the diagnostic criteria for major depressive disorder in the Diagnostic and Statistical Manual Fourth Edition (DSM-IV)

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PHQ-9PHQ-9

During the study period…

The average depression score decreased (p < .05)(the desired clinical outcome) from baseline to most recent assessment follow-up.

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Patient Satisfaction Patient Satisfaction SurveySurvey

High patient satisfaction in every dimension measured during study period.

Treatment and language of provided information

Comfortable at clinicTreated the same as other patientsStaff consideration of person’s well-beingPatients are more likely to follow through with

an outside referral for mental health services after engagement in the behavioral health program

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Phase IIPhase II

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Launched in summer 2008 One-year grants ranged from $10,000 to

$75,000 to 27 CCHCs and consortia Funds support IBH continued development, and

innovative projects that met grant objectives♦ Special populations / provider education /

new technologies Continue advocacy for policy and system

changes ♦ Reducing barriers that inhibit integration

efforts♦ Gaining support for the basic tenets of

integrated care

Phase IIPhase II

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Develop a Learning Community of providers through educational activities, trainings, and sharing of information on the IBHP website

Establish a “mentor”/ T.A. consultation component using Phase I grantees as “experts” to introduce best practices to new grantees

Phase II Phase II ContinuedContinued

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Current StudyCurrent Study

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BASIS OF STUDYBASIS OF STUDYA survey based upon Conceptualizing

and Measuring Dimensions of Integration in Service Models Delivering Mental Health Care to Primary Care Patients by Miles, K., Linkins, K., et al.,[1]

Proposed a continuum of integration with respect to five dimensions

[1]Miles, K., Linkins, K., Chen, H., Zubritsky, C., Kirchner, J., Coakley, E., Quijano, L., & Bartels, S.

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Dimension of Integration

1. Physical Proximity – physical proximity of primary care providers and mental health counselors

2. Temporal Proximity (Timing) – the degree of delay or time separation between the delivery of primary care services and scheduling of mental health services

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Dimensions of Integration

3. Communication – primary care and mental health clinicians share information about patient diagnosis and treatment

4. Mental Health Expertise and Services Available – the level of integrated with respect to mental health expertise, thus minimizing necessity of referrals

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Dimensions of Integration

5. Institutional Stigma – where mental health care is provided in a setting not explicitly recognized as a mental health setting (e.g., primary care clinic), there may be less stigma associated with receiving services

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Methodology

IBHP required grantees to complete the Dimensions of Integration Tool

Uploaded for Asynchronous Responses During Window of Three Weeks

Completed only by staffs involved in IBH services

86 BH staff and 195 PCPs

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PCPs and BHS staff were asked to assess communication regarding the provision of behavioral healthcare using a scale of zero (0) to 20

0 Very Low – PCP and BHS very rarely communicate beyond initial referral; includes little feedback about progress and almost no communication about missed appointments

5 Low – PCP and BHS staff may communicate occasionally about diagnosis in rare selected cases; feedback is infrequent; communication about missed appointments is irregular and only in special circumstances

10 Moderate – PCP and BHS staff sometimes communicate about diagnosis and occasionally about treatment, but not in most cases; may be some feedback about progress and missed appointments

15 High – PCP and BHS staff often communicate about diagnosis and treatment choices; information is often shared about progress and outcomes; missed appointments are reported in most cases

20 Very High – PCP and BHS staff almost always communicate about diagnosis; communication about treatment in most if not all cases; constant feedback about treatment and progress; missed appointments are almost always shared

CommunicationCommunication

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PCPs (M = 13.47) and BH staff (M = 13.64) assessed their communication

as moderate

Moderate: PCP and BHS staff sometimes communicate about diagnosis and occasionally about treatment, but not in most cases; may be some

feedback about progress and missed appointments.

Communication

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PCPs and BHS staff were asked to assess the level of behavioral health expertise in their clinic utilizing a scale of zero (0) to 20:

0 Very Low – No specialty BHS expertise within clinic; occasional pharmacological interventions may be provided; patients referred off-site for specialty BH care.

5 Low – Very limited BHS expertise available in clinic; usually provide standard pharmacological interventions; patients with modestly complex problems almost always referred off-site

10 Moderate – Some limited BHS expertise available in clinic; trained BHS counselor or psychiatrist consultation available by phone; some short-term counseling for routine BH issues provided by PCP; more complex usually referred off-site

15 High – Trained BHS counselor or psychiatrist on site for face-to-face consultation; all pharmacological and many counseling services for BH issues are available in clinic setting; only complex problems or treatment resistance usually referred to specialty care

20 Very High – Wide range of specialty BH expertise available in clinic setting; most basic services are provided by fully qualified BH clinicians; minimal need to use outside specialty expertise

Behavioral Health Expertise Behavioral Health Expertise Within Primary Care Within Primary Care

SettingSetting

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PCPs assessed behavioral health expertise as high – M = 15.77

BH staff assessed behavioral health expertise as high to very high – M= 17.90

Variance in mean scores was statistically significant (p < .005)

Behavioral Health Behavioral Health Expertise Within Primary Expertise Within Primary

Care SettingCare Setting

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PCPs and BHS staff were asked to assess temporal proximity regarding the provision of behavioral healthcare using a scale

of zero (0) to 20:

0 Very Low – Primary care referral and initial BH services are scheduled at distinctly different times, separated by on average by more than 21 days

5 Low – Primary care referral and initial BH services are provided at different times, separated by an average of 15 to 21 days

10 Moderate – Primary care referral and initial BH services are usually provided within an average of 8 to 10 days of each other

15 High – Primary care referral and initial BH services are provided within 7 days, but not on the same day

20 Very High – Primary care referral and initial BH services are provided during the same visit, on the same day

Temporal Proximity of Temporal Proximity of Primary and Behavioral Primary and Behavioral

Health CareHealth Care

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Temporal Proximity of Temporal Proximity of Primary and Behavioral Primary and Behavioral

Health CareHealth CarePCPs assessed Temporal Proximity as moderate –

M = 11.54

BH staff assessed Temporal Proximity as nearing high–

M = 14.94

Variance in mean scores was statistically significant (p < .001)

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PCPs and BHS staff were asked to assess physical proximity regarding the provision of behavioral healthcare using a scale

of zero (0) to 20:

0 Very Low – Primary care and BH services are separated by more than four blocks

5 Low – Primary care and BH services are located within four blocks but not within the same complex or campus

10 Moderate – Primary care and BH services are in different buildings but within the same campus or complex

15 High – Primary care and BH services are in the same building but in different practice areas

20 Very High – Primary care services are co-located with BH services, in the same practice area

Physical Proximity of Physical Proximity of Primary Care and Primary Care and Behavioral HealthBehavioral Health

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Physical Proximity of Physical Proximity of Primary Care and Primary Care and Behavioral HealthBehavioral Health

PCPs assessed physical proximity as moderate – M = 13.79

BH staff assessed physical proximity as high – M= 15.99

Variance in mean scores was statistically significant (p < .001)

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PCPs and BH staff were asked to assess the level of institutional stigma in their clinic utilizing a scale of zero (0) to 20:

0 Very High – BH services are referred to as a separate entity; staff makes no attempt to treat it as other than a program just for those in need of BH services

5 High – May have a name that is indirectly related to BH service, but staff makes little attempt to avoid treating it as a separate program for those in need of BH services

10 Moderate – Program has a distinct separate name not directly related to BH treatment; staff makes some efforts to avoid referring to it as a separate program

15 Low – Minimal distinction is made between PC and BH settings; staff attempts to avoid treating it as a separate program

20 Very Low – No distinction is made between PC and BH settings in name or setting; staff does not treat as a separate program

Institutional StigmaInstitutional Stigma

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Institutional StigmaInstitutional Stigma

PCPs (M = 13.52) and BH staff (M = 13.77) assessed institutional stigma

as moderate

Moderate – Program has a distinct separate name not directly related to BH treatment; staff makes some efforts to avoid

referring to it as a separate program

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Overall Integration Overall Integration ScoreScore

PCPs, M = 68.31 and BH staff, M = 75.79

A overall integration score of greater than equal to 75 suggests an integrated program

Variance in mean scores was statistically significant (p < .005)

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Thank you!!