Mapping New Territory: Implementing the Primary Care Behavioral Health (PCBH)

Model in Homeless Shelter Clinics

Stacy Ogbeide, PsyD, MS

David S Buck, MD, MPH

Jeff Reiter, PhD, ABPP

Collaborative Family Healthcare Association 16th Annual ConferenceOctober 16-18, 2014 Washington, DC U.S.A.

Session #B2bFriday, October 17, 2014

Faculty Disclosure

• I/We have not had any relevant financial relationships during the past 12 months.

Learning Objectives

At the conclusion of this session, the participant will be able to:

• 1): Gain knowledge regarding the unique needs of homeless clinics and strategies for tailoring the PCBH model to this population with co-morbid health conditions;

• 2): Gain an understanding of the clinical and systems challenges to implementing the PCBH model in a homeless clinic; and

• 3): Understand the basic descriptive data for a new PCBH service in a homeless clinic, including preliminary clinical outcomes, descriptive patient data, most common conditions treated, and others.

References• 1. Mauer, B. J., & Druss, B. G. (2010). Mind and body reunited: Improving care at the

behavioral and primary healthcare interface. Journal of Behavioral Health Services & Research, 37(4), 529-542.

• 2. Miller, B. F., Brown-Levey, S. M., Payne-Murphy, J. C., & Kwan, B. M. (2014). Outlining the scope of behavioral health practice in integrated primary care: Dispelling the myth of the one-trick mental health pony. Families, Systems, & Health. Advance online publication. http://dx.doi.org/10.1037/fsh0000070

• 3. Robinson, P. J., & Strosahl, K. D. (2009). Behavioral health consultation and primary care: Lesson learned. Journal of Clinical Psychology in Medical Settings, 16, 58-71. doi: 10.1007/s10880-009-9145-z

• 4. Vogel, M. E., Malcore, S. A., Illes, R. C., & Kirkpatrick, H. A. (2014). Integrated primary care: Why you should care and how to get started. Journal of Mental Health Counseling, 36(2), 130-144.

• 5. Weinstein, L. C., LaNoue, M., Collins, E., Henwood, B., & Drake, R. E., (2013). Health care integration for formerly homeless people with serious mental illness. Journal of Dual Diagnosis, 9(1), 72-77. doi: 10.1080/15504263.2012.750089

Learning Assessment

• A question and answer period will be conducted at the end of this presentation.

Introduction

• The mission of Healthcare for the Homeless – Houston (HHH): – to promote health, hope, and dignity for

Houston's homeless through accessible and comprehensive care.

• Eligibility: homelessness– Services sliding scale

• Services are offered 7 days a week

Introduction

• Services offered:– Primary Care and

Behavioral Healthcare– Case Management– Dental Services (full-

service)– Jail Inreach Project– Project Access

– The HOMES Clinic– Women’s Clinic– Volunteer-run podiatry

services– Medical Street

Outreach– Bi-annual Vision Fairs

Utilization Data

Data Type 2008 2009 2010 2011 2012 2013

# Unduplicated Patients 8,674 8,810 10,170 9,634 10,202 9,343

# Patient Visits 14,240 19,268 21,995 19,619 21,400 21,765

# Units of Service 56,700 71,471 71,010 80,055 81,169 90,466

8

Gender

9

61%

39%

Male Female

Race/Ethnicity

10

59%

1%

33%

5% 2%

Black Asian/Pacific Islander White

Hispanic Other Multiracial / Unreported or Unknown

Age Distribution

11

<15 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60+0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

Age

Introduction

• Most common diagnoses in 2013:– Severe Mental Illness– Hypertension– Addiction– Obesity– Diabetes– Asthma– Heart Disease– Hepatitis C

Introduction

• In 2013: – 4,879 PC patients for medical services, 4,285 (88%) have behavioral

health issues

• 722 behavioral health patient visits out of 8,834 medical visits or 8%– Specialty behavioral health providers (psychiatry, LCSW, LPC)

Introduction• Individuals with severe mental illness (SMI)2, 5:

– Higher rates of mortality– Higher prevalence of chronic disease compared to the general

population• Weinstein, LaNoue, Collins, Henwood, and Drake (2014)5:

– Individuals with experiences of homelessness and SMI also have serious medical/chronic illnesses

– Integrated behavioral health care programs can improve access to care and offer regular health screenings

Introduction• Miller, Brown-Levey, Payne-Murphy, & Kwan (2014)2: Behavioral Health

Consultants (BHCs) can address needs of persons with SMI by:– Behavioral interventions for physical health diagnoses– Monitoring medications and side effects– Lower no-show rates in PC compared to specialty mental health

Development and Infrastructure

• Previous Primary Care and Behavioral Health Practice Structure– Historically a collocated model of care with behavioral health

services on site (on the same floor as the medical clinic)3, 4. – Behavioral health team: 5 case managers (4 full, 1 half), 2 half-time

master’s level mental health providers, and 1 half-time psychiatrist.• There are also 6 community health workers

Development and Infrastructure

• Program Development– Initial leadership support– Continuous education of medical, mental health, case

management, and administrative staff.– Outside PCBH consultant (Dr. Reiter) role – Weekly meeting took place with part of leadership team (e.g.,

medical director, PCBH consultant) to discuss implementation progress and well as barriers to implementation.

– The medical director and BHC provided onsite clinical oversight and management of the BHC service.

Development and Infrastructure

June July August0

150

300

450

600538

612

455

128 119 100

PCP VisitsBHC Consults

Development and Infrastructure

Top 5 Reasons for Consultation - June 2014

Depression

Anxiety

Psychosis

Relapse Prevention

Other

Development and Infrastructure

Top 5 Reasons for Consultation - July 2014

DepressionAnxietyRelapse PreventionWellness InterventionOther

Development and Infrastructure

Top 5 Reasons for Consultation - August 2014

DepressionAnxietyRelapse PreventionStressOther

Development and Infrastructure

• Example interventions:– Sx/mood management

• Patient Education• Building Awareness/Options for bx change (L.E.A.P.)• Problem Solving• Goal Setting

– Behavioral Activation– Relapse Prevention Skills– Behavioral Medicine (e.g., self-mgmt for diabetes, sleep

hygiene)

Development and Infrastructure

• System Integration and Operation Issues– Clinical service delivery altered(e.g., cold consult, joint consult,

warm-hand off). – EHR already in place - allowed for BHC to create a same-day

encounter with a patient as well as create a note that can be viewed by the entire treatment team, as well as a note that can have additional signers (e.g., PCC and BHC, BHC and case manager).

– Medical assistants: continued role as ancillary staff to the PCCs, but also provided additional assistance for the BHC such

– BHC access to schedule

Development and Infrastructure

• Financial Sustainability– Sustainability: BHC’s ability to increase clinical revenue through

Medicaid and Medicare over time • Difficult to sustain

– Grant funding: Medicaid 1115 Waiver: Texas Healthcare Transformation and Quality Improvement Program

– Increase # of PCP patients– Work in progress…

Level of PCBH Integration

• Level 4 collaborative care model1: • Close collaboration in a partly integrated system. • BHC is embedded in the medical clinic. • PCC and BHC share the same scheduling system and EHR, thus

allowing all providers real-time access to each other’s appointments, notes, and labs/tests.

• BHC participates in medical staff, behavioral health, and case manager meetings.

• The interdisciplinary team manages patients’ primary medical and behavioral health problems in a comprehensive, integrated fashion.

• BHC is changing the culture of the medical clinic by educating staff and patients about behavioral health consultation services.

Implementation Challenges

• 4 months thus far!• An ongoing challenge: addressing operational

differences between behavioral health consultation vs. traditional mental health services.

Implementation Challenges: The Implementation Dip

Michael Fullan, The Six Secrets of Change

Implementation Challenges

• Clinic space and patient flow:– The Search Clinic

• 4 exam rooms

– Cathedral Clinic• 3 exam rooms

– Small or no nurses station: • BHC is working out of an exam room (rather than being housed at the nurses

station).

– Patient flow: • Because there are only 1-2 medical providers at a clinic at any given time, each

provider typically works out of one exam room (compared to 2-3 rooms at a time).

Implementation Challenges

• Clinic space and patient flow:– The current volume does not allow for a high amount of BHC contacts at

this time.– At the end of 2015, new building with 10 exam rooms– The new space may allow for an improved patient flow and an increase in

the amount of patient contacts per day.

Future Directions• Overall, the medical clinic has been receptive to an integrated PCBH

practice model. • Long term and ongoing goals include:

• measuring patient function (at least once per year)• continuing with PCBH program outcome measurement (e.g.,

patient/provider satisfaction, fidelity to PCBH model)• develop the business case for sustainability.

• Create a system in which patients recognize they have a “health team” that cares for behavioral medical care needs.

Questions? Comments? Feedback?

Session Evaluation

Please complete and return theevaluation form to the classroom monitor

before leaving this session.

Thank you!