the primary care behavioral health model (pcbh) of service delivery: clinical skills, effective...

The Primary Care Behavioral Health Model (PCBH)of Service Delivery: Clinical Skills, Effective

Interventions and Clinical Pathways

Christopher L. Hunter, PhD ABPPSuzanne Bailey, PsyD

Patricia J. Robinson, PhDJeffrey T. Reiter, PhD, ABPP

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

Session # PC3October 16, 2014

Faculty Disclosure

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

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

Learning Objectives:●List the primary content areas for core competency development●Describe 4 evidence-based primary care BH interventions for adults and children.●Discuss at least 1 evidence-based clinical pathway that would work in most health

systems. Practice Tools: 1. Know how to use the 5As paradigm to efficiently & effectively deliver evidence-

based care.2. Will have evidence-based assessment & intervention strategies for effective

adult, child & adolescent primary care behavioral health service delivery.3. Understand what clinical pathway processes they can implement & how to

effectively implement them to improve the population impact of service delivery.

Primary Care Behavioral Health Model

2014 Annual Conference

Core Competencies

Patricia J. Robinson, PhDJeffrey T. Reiter, PhD, ABPP

Behavioral Health ConsultantCore Competency Skills*

I. Clinical Practice Skills II. Practice Management Skills III. Consultation Skills IV. Documentation Skills V. Team Performance Skills VI. Administrative Skills



*Robinson & Reiter, 2014. Behavioral Consultation and Primary Care, 2nd Edition

Behavioral Health Consultant WorkSample Clinic: What To Expect

● Variety of methods for getting pt to the BHC○ Before PCP○ PCP and BHC in room together○ After PCP

● Variety of problems and ages○ Clinical (MH, SA, Beh Med, all ages)○ Case management/Care coordination

● Variety in the goals of visits○ PCP-Prep○ Treatment augmentation○ Medication and treatment planning.



Sample ClinicComplexity and Diversity

● 9:00 PCP wants meds rec○ 52 y/o homeless, ? ADHD vs bipolar

● 9:30 Question re disability expiring○ 64 y/o Russian-speaker, depression

● 10:00 PCP says “I don’t know her problem”○ 62 y/o, psychiatrist d/c’d, on 3 meds from 3 Drs

● 10:30 Open→WH w/ PCP in exam room○ 12 y/o autism, ADHD, recently showing tics, hall’s




● 11:00 N/S→WH in exam room, PCP- prep○ 6 y/o ADHD, insomnia, enuresis

● 11:30 Planned f/u from 1 week earlier○ 20 y/o Spanish-speaker, depressed w/ SI

● 1:00 Team mtg (15-min talk on pain, 5-min on tobacco cessation)● 2:00 Cx→same-day appt for NRT refill




● 2:30 Open→WH for CSA○ 60 y/o severe etoh, chronic arm pain

● 3:00 Planned f/u after 2 weeks○ 47 y/o homeless, MDD w/ psychosis, acute SI due to meds

● 3:30 Planned f/u after 1 month○ 45 y/o homeless, MDD, trying to get disability

● 4:00 Cx→WH for PCP prep on new pt○ 16 y/o expelled from school, needs risk assessmt

● 4:30 Open→Same-day f/u after 4 mos○ 20 y/o seeking disability for PTSD, dep





The 5A’s An Operational Heuristic

Christopher L. Hunter, PhD, ABPP

5A’s-Assess, Advise, Agree, Assist, ArrangeOperational Heuristic

Primary Care Behavioral Health Model *


Diagram adapted from: Glasgow, R. E & Nutting, P. A. (2004). Diabetes. In Handbook of Primary Care Psychology. Ed., Hass, L. J. (pp. 299-311)

ArrangeSpecify plans for

follow-up (visits, phone calls,

mail reminders)

AssistProvide information, teach

skills, problem solve barriers to reach goals

AdviseSpecific, personalized, options for tx, how sx

can be decreased, functioning, quality of life/health improved

AgreeCollaboratively select goals based on patient interest and

motivation to change

AssessRisk Factors, Behaviors, Symptoms,

Attitudes, Preferences

Personal Action Plan 1. List goals in behavioral terms 2. List strategies to change health behaviors 3. Specify follow-up plan 4. Share plan with practice team




The 5A’s format is “strongly” recommended for assessment and intervention across a range

of problems in primary care.

Whitlock, Orleans, Pender & Allen (2002). Evaluating primary care behavioral counseling interventions: An evidence-based approach. American Journal of Preventive Medicine, 22, 267-284.

Goldstein, Whitlock, & DePue (2004). Multiple behavioral risk factor interventions in primary care: Summary of research evidence. American Journal of Preventive Medicine, 27(Suppl 2), 61-79.




1. Introduction of behavioral health consultation service (1-2 minutes)

2. Identifying/Clarifying consultation problem (10-60 seconds)

3. Conducting functional analysis of the problem (12-15 minutes)

4. Summarizing your understanding of the problem (1-2 minutes)

5. Listing out possible change plan options (selling it) (1-2 minutes)

6. Starting a behavioral change plan (5-10 minutes)

AdviseAgree

AssistArrange

Assess




Assess Phase Introduction● Purpose: the appointment

○ Tell Them Your Profession○ Consultant Role○ Structure of Appointment○ Who will have what access to information gathered



2014 Annual ConferenceAssess PhaseFunctional Assessment ● Referral Question Clarification○ Problem (Duration, Intensity, Frequency)○ What Makes Problem Better or Worse● What is the Functional Impairment○ Work, Performance or Relationships○ Family Relations○ Social Activities○ Recreational Activities○ Exercise




Assess PhaseFunctional Assessment (continued)

● Changes In:○ Sleep○ Energy○ Concentration, Appetite

● Risk Assessment ○ Suicidal Ideation○ Homicidal Ideation○ Thoughts of Death



2014 Annual ConferenceAssess Phase

Functional Assessment (continued)● Caffeine Consumption● TOB Consumption● ETOH Consumption● OTC Medication or Supplements● What does a Typical Work Day Look Like● What does a Typical Week-End Look Like

Patient Ideas on Behavioral Goals● BHC asks patient what one or two things they have control of that if they

changed would improve functioning or decrease symptoms




Assess Phase

Problem Summary (1-2 minutes)

● Clarifies the patient’s presenting problem● Builds empathy




Advise Phase●Give clear, specific & personalized change advice●Changes the pt might make & how those changes might be beneficial




Agree Phase

Collaboratively Select Goals

●Find common ground & define behavior change & goals

●Shared decision making = Greater sense of personal control Choices based on realistic expectations

Change matches patient values




Assist Phase ● Develop and implement a specific tailored action plan

○ Plan should: 1. Help identify, address and overcome barriers 2. Develop self-management skills 3. Develop confidence to successfully change




Arrange Phase●Review goals●Provide additional interventions●Follow-up plan○ Create easy return access○ If pt is to f/u with community provider, bridge the gap...prevents pts

falling through the cracks!



Primary Care Interventions With Adults Suzanne Bailey, PsyD

Primary Care Interventions with Adults

Overview●Essential Components of Interventions

●Intervention Framework

●Population-based Interventions in Primary Care

○ Substance Use

○ Depression



Interventions with Adults:Essential Components

● Brief Encounters

● Emphasis on Self-Management

● Focus on Functional Outcomes

● Flexible Follow-up

● Liaison with Specialty Services



Essential Components: Brief Encounters

● Brief redefined○ 15-30 minute visits○ Limited number of contacts○ Episodes of care within context of longitudinal PC relationship

● Multiple change agents ● Patient is the primary agent of change● Capture teachable moments



Essential Components: Emphasis on Self-Management

● The patient is your guide

● Support with strategies

● Monitor level of engagement and motivation for change

● Provide behavioral rehearsal & resources



Essential Components: Focus on Functional Outcomes

● Target improved functioning

● Symptom reduction is not the only target

● Follow the referral question

● Outcomes are measurable



Essential Components: Flexible Follow-up

● Intervention unified and congruent with overall primary care plan

● Intervention plan is dynamic and evolves based on ongoing assessment of symptoms, functioning, engagement, & motivation

● Flexible scheduling and follow-up strategies

● Conjoint and coordinated appointments



Essential Components: Liaison with Specialty Services

● Primary care is first line

● Triage

● Psychoeducation about treatment options

● Build motivation and engagement

● Facilitate access and coordinate care

● Reabsorption



Interventions with Adults: Framework

● Framework● Define a Target

● Conduct Brief Intervention

● Assess Response to Intervention

● Develop Follow-up Plan

● Coordinate Care



Framework: An Initial BHC Visit

Robinson & Reiter, 2014. Behavioral Consultation and Primary Care: A Guide to Integrating Services. See Chapter 9.



Define a Target

● Follow PCP referral

● Assess symptoms, functioning, and health behaviors

● Defined target focuses brief interventions



Strategic Reframe

● Distill core elements into a workable problem○ Restate, reflect, refocus

● Be mindful of context, but stay focused on target● Mirror and model the process● Prioritize



Target

Conceptualization

Context

Features of Effective Brief Interventions

● Solution focused● Targets specific behavior

change● Active and empathic

therapeutic style● Support increase in quality

and meaning in life

● Incorporate patient values and beliefs

● Measurable outcomes● Enhance self-efficacy● Patient responsible for change



Effective Brief Interventions

● Relaxation Skills● Cognitive Therapy

Strategies● ACT Strategies● Motivational Interviewing● Mindfulness Strategies● Behavioral Structure and

Hygiene

● Goal Setting● Problem Solving Skills● Behavioral Activation● Stimulus Control● Communication Skills ● Exercise● Solution Focused Strategies



Factors to Consider

● Patient preference● Symptom severity● Readiness to change● Level of engagement● Psychosocial stressors● Co-morbid conditions

● Cultural beliefs● Resources ● Health status● Health beliefs ● Health literacy



Assess Response to Intervention

● Monitor level of motivation and confidence● Monitor symptoms and functioning● Active problem-solving● Discuss obstacles● Review and reinforce progress



Follow-up Plan Options

Close (1-2 weeks)

• Severity & acuity of problem

Intermediate

(1 month)

• Clinical needs of patient

• Overall primary care plan

With PC Visits, PRN, or None

• Level of motivation and engagement




Care Coordination Options

Face-to-Face

• Visit type & timing


Phone

• Severity & acuity of problem


EHR





Application: Population-Based Interventions

● Substance Use

● Depression



Substance Use: Motivational Interviewing



Target: Substance Use

● Enhance motivation to change ● Use values to develop discrepancy● Provide psychoeducation ● Identify strategies to avoid or cope with triggers● Build coping skills● Identify positive social supports and activities● Provide self-help resources (AA/NA)● Collaboratively develop a relapse prevention plan● Coordinate referral to more intensive treatment ● Build motivation for engagement more intensive treatment



Depression:Behavioral Activation



Target: Behavioral Activation

● Increase patient engagement in activities that provide enjoyment and sense of accomplishment

● Behave first, feel later○ “Outside-In”

● Act according to plan or goal, not feeling



Behavioral Activation in Primary Care

● Step 1. Rationale. ○ Explain that when we feel down, we sometimes stop doing many

activities that we used to like to do

● Step 2. Select activities that increase and sense of mastery ○ Ask the patient about activities they used to enjoy and any activities

they already do but would like to do more often ○ Ask if there is something that they need to do they’ve been avoiding

● Step 3. Review, Reinforce, Reset○ In follow up visits, the BHC reviews progress on goals, reinforces

progress, problem-solves barriers to progress, and resets goals as needed.



Primary Care Behavioral Health Model *


Primary Care Interventions With Children and Adolescents

Patricia J. Robinson, PhD

Pediatric PCBH Services: SUPPORT Study

1. Significant increase identification of psychiatric, health-related, or phase of life problems among children

2. Significant increase in pediatrician documentation of behavioral issues addressed

3. Significant increase in appointment show rate among SUPPORT participants compared to non-participants

4. Parent/child satisfaction with SUPPORT services5. Significant increase in child functioning as measured by

Child Behavior ChecklistPediatric Quality of LifeSchool Grades & Attendance



Aims & Objectives

6. Significant decrease in hospitalization/breathing problems among children with asthma/respiratory disorders.

7. Significant decrease in weight & body mass index among obese children.

8. Significant decrease in Hemoglobin A and Fasting Blood Sugar (FBS) among children with diabetes.

9. Significant decrease in office visits and school absence among children with multiple somatic complaints.



Provider Satisfaction

● One month after implementation of SUPPORT, Pediatricians and office staff were very satisfied with the overall clinical skills of the SUPPORT therapist.

● Also, 74.5% strongly agreed that integration of the BH provider enhanced the practice’s efficiency.

RegionSample

Size Mean

Ft. Worth (Cook Children’s) 52 1.48

Dallas (Parkland) 40 1.22

San Antonio 50 1.32

Lubbock 7 1.00

El Paso 34 1.38

Valley 18 1.06

Overall Clinical Skills Mean Satisfaction by Region

Mean Range: 1 (very satisfied) to 5 (very dissatisfied)



Clinical Improvements for Multiple Problems

Children 18 months to 5 yearsSignificantly fewer problems on the

Child Behavior Checklist at 3-month F-U



Children 6 – 18 years Significantly fewer problems on the

Child Behavior Checklist at 3-month follow-up



Clinical Improvements for Multiple Problems

Components of an Initial BHC Visit

Robinson & Reiter, 2014. Behavioral Consultation and Primary Care: A Guide to Integrating Services. See Chapter 9.



·

Interview & Intervention Skills

Life Context Questions for Children and Teens (see pdf)

Functional Analysis Questions (see pdf)



● Values Clarification

● Values Connection

● Approach (not avoidance)

● Perspective taking (observer stance)

● Supports on-going planning

● Involves SMART goals

● Encourages PCMH team support of committed health promoting actions over time

A Great Intervention for Adolescents & AdultsBulls Eye Plan: Prevention & Intervention

See Robinson, Gould, & Strosahl, 2010. Real Behavior Change in Primary Care: Improving Outcomes and Increasing Satisfaction



Your Clinic

Your Phone Number

Love Work PlayPlan: _____________________________________________________________________________________________________________________________________________________________

RX Pad for PCBH Team: Preventive and On-Going Management of Chronic Pain



FACT Worksheet

● Overview of worksheet● Role Play set up● During role play, use Worksheet as if you were the BHC● After role play, work with partner: Conceptualize

powerful interventionsIs patient clear about values? connected to values?Engaged in life? Accepting of challenges? Able to defuse? Can shift from participant to observer perspective?



Components of A Follow-Up BHC Visit2014 Annual Conference


*


Clinical Pathways

Christopher L. Hunter, PhD ABPPPatricia J. Robinson, PhD

Jeffrey T. Reiter, PhD, ABPP




Clinical Pathways: The Military Health System

Christopher L. Hunter, PhD ABPP

Military Health System



What Is A Clinical Pathway?

● Method of pt screening/assessment/intervention for a well-defined group of people

● States the goals and key elements of care ● Based on Evidence Based Medicine guidelines, best practice and

patient expectations by facilitating the communication, coordinating roles and sequences of multidisciplinary care team activities.

● Goal is to improve quality of care, reduce risks, increase pt satisfaction and increase the efficiency in the use of resources



● Developed by behavioral health and physician PCMH leads● Designed to increase use of BHCs as part of standard care● Designed to improve pt outcome & pt & PCP satisfaction with care● 9 Pathways developed

○Alcohol Misuse

○Anxiety

○Depression

○Diabetes

○Obesity

○Chronic Pain

○PTSD

○Sleep Problems

○Tobacco Use

Military Health System



Clinical Pathways: Neurodevelopmental Screening

Patricia J. Robinson, PhD

Neurodevelopmental Screening Pathway

● Target: Children 18-24 months● Methods: Exam Room Poster, Well-Child Visits● Objectives:

○ Increase early screening○ Increase child and family access to BHC services○ Address behavioral concerns at primary care level as possible○ Improve relationships with community partners○ Provide earlier referrals to community resources○ Improve parent satisfaction See PDFs:

M-CHAT EXAM ROOM POSTERN-D Dev Pathway StatementTemplate for charting ASQ





Clinical Pathways: Chronic Pain

Jeffrey T. Reiter, PhD, ABPP

Overview: Chronic Pain and Opioids

●Participants: Patients considered for long-term opioid treatment

●Goals:○improve functioning○decrease opioid abuse

●Core Pathway Components:○Initial risk assessment stratifies care protocol○Process for regular CSA, planned UDS○Group/class substitutes for PCP visit



Assessing Risk of Medication Abuse

● Commonly used paper-and-pencil screens○ SOAPP, ORT○ Aberrant behavior checklist

● Urine drug screen (UDS) at 1st visit—matches hx?● Substance use hx● Review old records

○ Problems w/ past Drs? Inconsistent history?



Controlled Substance Agreements (CSA)

● Purposes of a CSA○ Decrease: abuse/diversion, self-dosing, urgent pt calls, conflicts

w/ staff, early RF○ Increase: discussion about meds issues, PCP satisfaction

● Components of a helpful agreement○ Education, conditions for RF, functional goals

● Important to use routinely (not after a problem is suspected)



Group Workflow

● Weekly class, different time each week● PCPs notified in advance of patients attending● Check-in begins 30 mins prior to group● Lab tech obtains UDS● BHC conducts group for 45 mins● Pts return to lobby● BHC checks UDS results, confers with PCP as needed● Pts retrieved for brief PCP visit for refill only

Primary Care Behavioral Health


QUESTIONS?



Bibliography / Reference

1. Hunter, C. l., Goodie, J. l., Oordt, M. S. & Dobmeyer, A. C. (2009). Behavioral Health in primary care: A practitioners handbook. Washington, DC: American Psychological Association

1. Nash, J. M., Khatri, P., Cubic, B. A., Baird, & Macaran, A. (2013). Essential competencies for psychologists in patient centered medical homes. Professional Psychology: Research and Practice, Vol 44(5), 331-342.

1. Robinson, P. J., & Reiter, J. D. (2014). Behavioral Consultation in Primary Care: A Guide to Integrating Services. NY: Springer.

1. Robinson, P. J., Gould, D. A., & Strosahl, K. (2011). Real Behavior Change in Primary Care: Improving Outcomes and Increasing Job Satisfaction. Oakland: New Harbinger.

1. Strosahl, K. D., Robinson, P. J., & Gustavsson, T. (2012). Brief Interventions for Radical Change. Oakland: New Harbinger.


Learning Assessment

• A learning assessment is required for CE credit.

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

Session Evaluation

Please complete and return theevaluation form to the classroom

monitor before leaving this session.

Thank you!


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