integration of a behavioral health curriculum into four different primary care practices nyann...
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Integration of a Behavioral Health Curriculum into Four
Different Primary Care PracticesNyann Biery, MS, Research Coordinator
Teresa A. Duda, MS, MSS, LCSW, BCD, Behavioral Health Scientist Joanne L. Cohen Katz, PhD, Clinical Associate Professor of‐
Family Medicine/Family Systems Associate
Collaborative Family Healthcare Association 13th Annual ConferenceOctober 27-29, 2011 Philadelphia, Pennsylvania U.S.A.
Session #B3AOctober 28, 20113:30 PM
Faculty Disclosure
We have not had any relevant financial relationships during the past 12 months.
Need/Practice Gap & Supporting Resources
In a 2004 report, there was a called for action to change how Family Medicine residents are educated to support the needs
of the future. LVHNFMRP answered that call by participating in a national
demonstration project called p4 (Preparing the Personal Physician for Practice.)
A major feature of the innovation is the decentralization of the outpatient clinic into different continuity care sites (CCS), so
that residents can be educated in a variety of practice models.Our teaching of behavioral medicine has been decentralized and
occurs at these CCS sites as well.
Objectives
Participants will be able to describe a training model that incorporates intensive training in primary care counseling and collaborative care into a primary care residency training program in 4 different sites
Participants will be able to identify 2-3 common barriers to implementing such a program in multiple settings
Participants will be able to describe at least one solution to each of these barriers
Participants will be able to identify 2-3 benefits (to patients, trainees, and practices) of a collaborative training program in a primary care setting across multiple sites
Expected Outcome
Promote integration of Behavioral Health within Family Medicine Practices
Identify & Problem solve common barriers to integration in different types of practices
Discuss how integration can be adapted in different sitesDiscuss the benefits to patients, trainees, and practices of an
integrated model
Learning Assessment
Please feel free to ask questions during the presentation.
A brief Question & Answer period will be available at the conclusion of this presentation also.
Background
Family Medicine Residency ProgramDe-centralized Family Medicine Center into 3
additional practice sites for a total of 4 Each new site has residents of each post-
graduate yearCurriculum discussed last year at CFHAFocus today on implementation and adaptation
to different sites
Behavioral Medicine Clinics
• Weekly half day sessions longitudinal, through PGY2 & PGY3 years
• Staffed by residents & Family Doc/Behavioral health preceptors
• Patients referred from primary care with any behavioral/mental health issue
• Patients co-interviewed by Family Medicine residents & behavioral health specialists, then precepted with Family Doc
Behavioral Medicine Clinics
• Behavioral Health specialists include Ph.D./LCSW (every week) and Psychiatrist 1-2x/month
• Sessions live-observed by remainder of treatment team (resident/faculty) through video feed
• Residents see maximum of 3 patients/session• BMC sees 3-12 patients overall
Format of BMC• Resident–led session with behavioral health co-interviewing • Sessions are live observed by team when pts. allow• Debriefing includes team discussions with medical and
behavioral health faculty • Case discussions often followed by relevant didactic topic,
e.g.:– Parenting issues– Psychopharmacology– Smoking cessation– Child Behavioral problems– Marital stress
Clinic – Lehigh Valley Family Health Center
• Original Family Medicine Clinic• Network owned• Urban, large Spanish speaking population• 7 residents• Faculty:– 2 behavioral health (PhD, LCSW), weekly– 1 family physician (MD), weekly– 1 psychiatrist, 1x/month
Clinic – Lehigh Valley Family Practice Associates
• Private Practice owned by two family physicians– not within hospital network
• Suburban location, close to both rural and city population
• Prior to BMC – all patients referred out for counseling
• 2 residents• Faculty:– 1 Psychologist (PhD), weekly– 1 Family Physician (MD), weekly– 1 Psychiatrist, 1x/month
Clinic – The Caring Place
• Network affiliated• Federally Qualified Health Center – look alike status• Inner-City• Large percentage of patients/providers are Spanish
speaking• 2 residents• Faculty Members (both Spanish speaking):– Psychiatrist, 1x/month– LCSW, weekly
Clinic - Pleasant Valley Family Practice
• Network owned• Rural setting (Primary Care & Mental Health
HPSA)• LCSW already embedded within practice• 1 resident – July 2010 implementation• Faculty– 1 behavioral health (LCSW), weekly– 1 family physician (DO), weekly– (1 psychiatrist), 1x/month**
Statistics for AY 2011Location # Patients # visits per
patient (range)
% Anxiety % Depression % referred out long-term therapy
# Residents
FHC 65 1 - 7 20 53 23 7
TCP 2
LVFPA 38 1 - 8 57.9 57.9 18 2
PV 21 0 - 2 61.9 42.9 24 1
Barriers
• High No show rate – PV 67% rural network– TCP urban FQHC– FHC 10% urban network*– LVFPA 1% suburban private
• Insurance issues• Unmet clinical need revealed by BMC• Residents’ concern that model is unrealistic
for primary care
Barriers & Solutions: FHC
• Insurance– Help patients apply for network’s reduced cost care
• High No show rate – Fill open slots with medical sick visits, but cap the
number of sick visits
• Inability of BMC to meet clinical need– Search for full-time behavioral health specialist
with bilingual, multicultural skills
Barriers & Solutions: FHC
• Concerns by residents that BMC is unrealistic model for PC– Faculty retreat to clarify how to keep teaching
primary care-friendly • “What would you do in a 15 minute session in this
case?”• Encourage patients with lifestyle change needs• Uniform implementation of “teaching pearls”
Barriers & Solutions: TCP
• Spanish speaking population– Recruited a bi-lingual behavioral health faculty
and psychiatrist
• No show rate– Creating alternative models of treatment• Group visits for Depression• Citizens’ Healthcare Project focusing on how to best
use the BMC time
Barriers & Solutions: TCP
• No insurance– Sliding fee scale
• Awareness of unmet clinical need magnified by BMC– Hired psychiatric nurse specialist
• Reviewing other models of care such as proactively scheduling all patients to have initial interview with social worker
– With FQHC look alike status, pursuing contract with independent mental health group (on-site)
– Creation of Citizens’ Health Project
Barriers & Solutions: LVFPA
• Presence of BMC created high demand by patients & practice staff for more services – Physicians decided among several models for
expanding services, chose a co-training model– Fall, 2011: Psychology practicum student added• Co-trains in BMC with Family Medicine residents,
producing rich interactions
Barriers & Solutions: LVFPA
• Since BMC, residents treating more complex psychiatric problems than previously treated in practice– Residents may have different comfort levels than
preceptors– Solution:• Ongoing discussions, supporting residents having a
good rationale for their plans• Involving preceptors in discussions with psychiatrist &
psychologist to help their comfort level
Culture Change: LVFPA
• Presence of behavioral health specialists revealed a need within the practice for more time to focus on providers’ stress– “Difficult patient” session held for entire practice
by behavioral science faculty– Plans to develop meetings that allow for more
team building, care of providers, etc.
Barriers & Solutions: PV
• No show due to lack of transportation & inclement weather (rural area)– Co-interview for acute medical visits, but cap
number of visits
• Insurance– Help patients apply for network’s reduced cost
care
Barriers & Solutions: PV
• Due to presence of embedded provider, clinical needs were not a significant barrier– Outside of BMC, behavioral health scientist co-
interviews patients identified by resident or faculty
• Embedded provider also provides help with difficult doctor-patient relationships
Overall Feedback: Benefits of Integration to Patients
• Staying in the medical home where they are comfortable
• Reduced overutilization & ED visits• Better medication control, increased access to
psychiatry for some patients• Addressing of biopsychosocial issues by team
of care providers working together• Providers more aware of available community
resources
Overall Feedback: Benefits of Integration to the Resident
• Learn how to treat whole person; mind, body, and spirit, in a site that better matches their future practice goals
• Recognize the full range of biopsychosocial factors contributing to illness
• Comfort in management of psychotropic medication• More in-depth exposure to other forms of biopsychosocial
treatment• Develop comfort level assessing how and when to refer to a
behavioral health specialist• Learn how to co-manage patients with behavioral health
scientist
Overall Feedback: Benefits of Integration to the Practice
• Doctors feel they can offer better access to mental health care for their patients
• Potential increase in practice morale, as providers feel they are taking care of their patients better
• Potential increase in practice morale, as presence of behavioral health providers opens up new options for provider self-care
Take Home
• An educational intervention promoting behavioral health integration often faces similar challenges regardless of the primary care setting – Each setting may find unique solutions to
addressing these barriers– These solutions can enhance the resident, patient
and practice experience
Take Home
• An educational program such as this can result in unexpected transformation within the practices where they live.– Educators and clinicians working on these
programs need to stay open to these possibilities…
Session Evaluation
Please complete and return theevaluation form to the classroom monitor
before leaving this session.
Thank you!