Raising the Ceiling: A Pilot Curriculum for Interprofessional Training of Care Managers in Behavioral Health Principles and Interventions

• Tziporah Rosenberg, PhD, LMFT, Associate Professor, Psychiatry/Family Medicine• Holly Brown, DNP, RN, PMHNP-BC, Assistant Professor, School of Nursing• George Nasra, MD, MBA, Clinical Professor, Psychiatry, URMC

Session # H3

CFHA 20th Annual ConferenceOctober 18-20, 2018 • Rochester, New York

Faculty Disclosure

The presenters of this session have NOT had any relevant financial relationships during the past 12 months.

Conference ResourcesSlides and handouts shared in advance by our Conference Presenters are available on the CFHA website at http://www.cfha.net/?page=Resources_2018

Slides and handouts are also available on the mobile app.

Learning ObjectivesAt the conclusion of this session, participants will be able to:• Describe key elements in a pilot curriculum designed to enhance the patient

engagement and support skills of a team of primary care embedded complex care managers across the lifespan.

• Identify the impact of behavioral health training on care manager reports of self-efficacy, as well as impact on patient care in practice

• Discuss some of the challenges inherent in stretching nurse and social work care managers' skillset to include more behavioral health content, both at the training and daily practice levels.

ReferencesSubstance Abuse and Mental Health Service Administration-HRSA: Center for Integrated Health Solutions. Retrieved from: https://www.integration.samhsa.gov/integrated-care-models/primary-care-in-behavioral-health

Learning Assessment• A learning assessment is required for CE credit.

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

Acknowledgments and Gratitude• Dr. Daryl Sharp, friend, colleague, and mentor

• The Care Management Team of Accountable Health Partners

• The Board of Directors and Leadership of Accountable Health Partners

SAMHSA: https://www.integration.samhsa.gov/integrated-care-models/primary-care-in-behavioral-health

Co-occurrence between MH and other chronic health conditions

SAMHSA: https://www.integration.samhsa.gov/integrated-care-models/primary-care-in-behavioral-health

SAMHSA: https://www.integration.samhsa.gov/integrated-care-models/primary-care-in-behavioral-health

Enter Accountable Health Partners, a Clinically Integrated Network• A clinically integrated network is defined as a collection of health providers, such as physicians/NPs, hospitals, and post-acute specialists that join together to improve care and reduce costs. • Such networks generally share record systems, track data, and rely on evidence-based guidelines to provide high-quality care across participating providers. • The four components that networks must meet to be considered clinically integrated include: ◦ 1) physician leadership and commitment◦ 2) development and implementation of clinical practice guidelines to improve

performance◦ 3) development of infrastructure and technology◦ 4) financial incentives for achieving goals.

Enter Accountable Health Partners, a Clinically Integrated Network• Over 2,000 community and University of Rochester medical faculty providers located throughout Rochester and the surrounding area

• The region’s leading hospitals: Strong Memorial and GolisanoChildren’s Hospital, Highland Hospital, FF Thompson Hospital, Jones Memorial Hospital, Noyes Memorial Hospital, Arnot Ogden Medical Center, Wyoming County Community Hospital, and St. James Mercy Hospital

• Value based contracts with Excellus/BCBS, MVP, U of R Health Plan, Thompson Health Associate Health Plan, Highland Hospital Health Plan

Within Our Network• Anecdotally, we all know that patients with high degree of medical complexity

often ALSO are at higher risk for psychiatric and behavioral complexities (incl social determinants of health).

• A recent deep dive within our network’s patients revealed that:

• Of the 50 highest cost patient on one of our contracts, 24 had a BH diagnosis (48%). Highest cost= >$100,000/yr

• These patients tended to have diagnoses of cancer, CF, MS, Psoriasis, or had a catastrophic illness or were otherwise medically complex.

• Of note, we have over 300,000 patients under contract.

Image credit: Kuo, D. Z., & Houtrow, A. J. (2016). Recognition and management of medical complexity. Pediatrics, e20163021.

If Only We Could Clone…• Even those of us who are dedicated and awesome can’t keep up with the demand.

• We have more than made a case for integration of BH into primary care, and now the whole universe wants it.

• Workforce limitations and funding and lots of other barriers make it hard to scale up and to have a population level impact as it relates to BH and MH issues in primary care.

Because Cloning Ain’t Easy• Whether they want to or not, whether they are experienced or not, and whether they have the skills/time/interest, they ARE encountering and managing behavioral health issues

• Many of our small community practices do not have embedded, nor access to, behavioral health or substance use services◦ Rural vs urban, small communities, stigma, unspeakable needs

• Consider our biggest workforce resource: nurse and social work care managers who all have at least some exposure to mental health intervention and skills in their professional/clinical training

Role of Care Management in the Network• Care managers through AHP have three main foci in their work (in partnership

with primary care practices):

• Complex care management

• Transitions (adult and pediatric)

• Population health

• Hands on, one to one, practice-wide, catch-all, jacks- and janes of all trades

• Often RN or SW professional backgrounds

Role of Care Management in the Network• Pediatric team consists of embedded RN and SW care managers

• Pediatric populations and practices have greater/different behavioral health needs

• The model for care management referral, function, and integration therefore needs to be more focal around BH needs as compared with the adult, chronically ill population

• No centralized care manager resources as yet

• Adult, family medicine and centralized care managers

Care Managers as PC AND BH Extenders?• The function of care management is predicated upon them being extenders and

proactive activators of “traditional” healthcare (biomedical AND psychosocial).

• Expertise in connecting, coordinating, educating, enhancing self management, triaging, and monitoring on a population-health level

• Some fundamental education and clinical experience in mental health.

• Care managers may be uniquely positioned to recognize, screen for, intervene around behavioral mediators of physical health issues and mental health symptoms in both adult and pediatric primary care practices

Integrating Behavioral Health- The Next Level• In 2016, with the champion support of Dr. Daryl Sharp, AHP made the decision to

pilot the advent of a team of Behavioral Health clinicians and educators in order to move the needle on addressing unmet BH needs across a large network of practices, patients and families spanning urban, rural, and disenfranchised populations.

“I had a lot of experience with treating tobacco dependence through the integration of clinical practice guidelines with motivation science… my [clinical] experience underscored the importance of integrating behavioral health with lifestyle interventions targeting [chronic health conditions]. I had also been providing clinical supervision for care managers embedded in primary care practices and knew that the care managers needed support in building behavioral health assessment and intervention skills in order to more effectively care for their patients and help them meet their health goals. Given that experience, and the fairly easy financial case for addressing behavioral health to improve outcomes and bend the cost curve (from the literature), I made the argument for the BHI team in our CM strategic plan (which the AHP Board approved unanimously).”

Daryl Sharp, PhD, RN, FAANSenior Director of Care Management

Integrating Behavioral Health- The Next Level

• 1 MD, 3 Doctorally-prepared APRNs and 1 PhD MFT

• Our own training and expertise

• Flexibility, spirit of pilot programs, and skills in program evaluation

Introductions- Meet our Team

Integrating Behavioral Health through Care Management• Once monthly small group consultation with care managers

• Weekly consultation with pediatric care management team

• Consultation on integration of new skills (ie stuck points, “how do I…?”)

• Consultation to primary care clinicians and care managers on all things BH

• Technical assistance with implementation (patient care, team dynamics, systems issues)

• Ready access to the team

Behavioral Health Consultations• Ready access for in-time behavioral health consultation around complex

diagnostics, psychopharmacologic management

• Guidelines for bridging systems of care

• Technical assistance for complex medication management, triage, and referral

• Practice-based and team-based dynamics

• Feedback and closing the loop

Weekly Pediatric Team Meetings• Participants: Care Managers, Psych NP, Administrative Consultant

• Purpose: Debrief of complex patient situations, system issues, navigating service systems, reinforcing skills training, identify places to close system gaps, share resources

• Celebrate: Each and every win

Small Group Consultation • Role and scope of care management

• Problem-solving behavioral health facets of complex patients

• Debriefing and building skills around challenging dynamics with others in the team

• Tending to the person of the care manager

Focus on Skill Development• Twice monthly large group training in behavioral health, mental health, and patient

engagement skills

• Emphasis on combination of didactics, skills demonstration, rehearsal, real-life examples and problem-solving stuck points

• Between session reminders and resources

• “Booster shots”

• Learning with us, learning from each other

Focus on Skill Development• Curriculum focuses on bite-sized trainings on evidence-based, brief behavioral

health interventions usable in the primary care setting

• Brief didactic lesson including rationale, concise review of the literature, target population, and intended goals of intervention

• Demonstration of the skill through modeling

• Practice of the skill through dyadic or small group rehearsal

• Closing the loop with teachback, as well as reflections on how they may use the skill, what they observed, what barriers they anticipate, commitment to practice

Focus on Skill Development• Motivational interviewing/enhancement

• Problem solving treatment

• Behavioral activation

• Suicide risk assessment, means restriction, safety planning

• Cognitive behavioral therapy basics

• Dialectical behavioral therapy- emotional regulation, distress tolerance

Focus on Skill Development• Mindfulness

• Agenda setting

• Values clarification and values-directed behavior

• Depression screening and response

• Boundary setting (related to personality disorders)

• Fundamentals of psychopharm prescribing and decision to use medication

1. Problem Solving Treatment2. Behavioral Activation3. Suicide Risk Assessment4. Safety Planning for Suicide5. Distress Tolerance6. Emotional Regulation7. Mindfulness8. Agenda Setting9. Boundary Setting (personality)10. Values Clarification11. Triple E Interruption12. Assessing for Depression13. Assessing Readiness for Change14. Motivational Enhancement

Once Once Once Never Monthly Weekly Daily N/A4 4 13 12 04 12 10 7 04 19 8 1 18 16 7 1 14 8 12 9 02 5 14 9 34 1 10 18 04 6 9 14 02 9 13 9 06 7 13 6 111 5 2 0 150 3 14 16 00 3 10 20 04 4 12 14 0

Care Manager Reports on Utility

1. I feel confident in my ability to respond to patients with emotional and behavioral needs.2. I am able to help patients make progress with problem solving around their health issues (including emotional health).3. I feel capable of addressing my patients' emotional and behavioral needs. 4. I am able to achieve my goal of effectively engaging patients around behavioral aspects of their healthcare.5. I can demonstrate empathy toward a patient without feeiing like I'm losing myself.6. I have the support I need from my practice(s) to implement strategies to improve behavioral health in my patients.7. I feel confident in my ability to assess patient readiness to make a change in their behaviors.8. I am able to help patients enact change when they are ready to do so.9. I routinely incorporate patient culture/race/ethnicity into considering which strategies may work best for them.10. I am able to set limits in my conversations with patients while also maintaining rapport.11. I routinely set agendas in my patient encounters.12. I routinely use teachback in my patient encounters.13. I have confidence around assessing patient risk for suicidal behavior.14. I know how to mobilize supports and resources for patients who are experiencing suicidal thinking.15. I am able to effectively coach patients around increasing pleasurable activities in their lives as an important factor intheir overall health.16. I see the value in learning strategies to address my patients' behavioral health needs.

Care Manager Self-Assessment

Care Manager Self-Assessment

1 4.82 4.573 4.734 3.95 5.636 3.677 4.688 4.879 4.8310 5.0711 4.112 4.8713 4.7314 5.0715 4.8316 6.67

5.515.095.435.066.125.245.265.505.865.214.985.455.405.765.626.79

Average per Item

T1 (N= 15) T2 (N=44)

• Difference between time points 1 and 2 is one year

• Some additions in personnel/ respondents

“I am a CM in a family practice and have reached out to Holly for help and direction with supporting adolescent patients in my practice that have had inpatient or ED visits for depression and anxiety. She has been supportive to me with my questions and has guided me on ways that I can assist these young individuals and family during difficult times. The clinical support that the Behavioral Health team offers to care managers is simply wonderful and an asset to my role in the practice.”

Susan Kinney, BSN, RNNurse Care Manager

Naples Valley Family Practice

“While no specific case comes to mind, I do feel strongly that behavioral health support has been a main factor in my success with patients. I utilize elements of the Motivational interviewing, the decisional balance worksheet and DBT while working with patients in my office. The insight into Borderline personality disorders has been of exponential value – without this perspective it would be almost impossible to have a sympathetic understanding of behaviors that were in the past baffling and frustrating. Behavioral health support in the medical arena is crucial to treating the whole person.”

Judy Meyers, BSN, RNNurse Care Manager

Tri-County Family Medicine

“As an AHP Care Manager embedded into a rural family practice, the BH team has been an extremely valuable resource for me and my practice. There are not enough behavioral health resources in rural settings to meet the needs of the population. The BH team has provided regular education about mental health conditions, resources and various tools helpful in working with our patients.”

Kathleen Hoven, BSN, RNNurse Care Manager

Valley View Family Practice

“Kate has come to do a site visit, to better understand the unique challenges one of the communities I work with, faces. She also regularly checks in with me to ensure that I feel supported and prepared in this position…Holly has provided us with information about pediatrics which has been fantastic as this is an extremely limited resource in my area. She has also assisted me in learning about the resources available to me…Tziporah has met with me on more than one occasion for the purpose of helping me improve my comprehension, provide tools to better serve patients, and has given me books to read to better assist my patients as well. She has donated her time to do this, and also regularly asks how the program of collaborative care has been going in my facilities. [They] ask for our feedback on interventions that have been taught to us to assist with trouble shooting. This allows us to grow and learn as we fold these interventions into our daily practice.”

Erica Boccia, BSN, RNBehavioral Health Care Manager

Valley View Family Practice

Next Steps- Looking Ahead

•Time constraints for busy nurse and social work care managers◦ Pediatric vs. Adult differences

•Quadruple Aim and ROI•More robust program evaluation

•Competing demands and priorities

•Penetration of BHI education and skills•Scale and scope

Questions? You’ve Got ‘Em, We’ll Take ‘Em!

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