Transcript Integrating Behavioral Health into Primary Care

Integrating Behavioral Health
into Primary Care
Sara Honn Qualls, Ph.D.
University of Colorado Colorado Springs
WHAT’S ALL THE BUZZ IN
INTEGRATED CARE ABOUT?
Older adults…
• Have similar rates of most mental disorders as
other adults (20-25% Dx + 10-15% Sx)
• Seek MH services in MH settings far less
frequently
• Prefer MH services in primary care
• Prefer non-pharmacological interventions
• Have high rates of co-morbidity with other
health conditions that influence MH
Psychological Problems are not well
recognized
 Cognitive and psychological problems
fail to be diagnosed in 66% of primary
care patients*
 Yet psychological problems result in poorer
engagement in health self-care
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Some impressive findings on
depression…
• IMPACT
• PROSPECT
• PRIME-MD
Setting Matters
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Prevalence
Mental Health Salience
Mental Health Provider Role
Assessment Tool Selection
Intervention Approach
Evaluation of Impact
Some local experience in Colorado
Springs…
CU Aging Center
Mental Health and Family Services
• Since 1999, near Senior Center,
in neighborhood
• Operated by UCCS Psychology
department, Clinical
Geropsychology Ph.D. program
• Core Internal Programs
 Psychotherapy
 Neuropsychological Evaluations
 Memory Clinic
 Aging Families and Caregiver
Program
UCCS Integrated Care Partnerships
Partner Agency
Integrated Care Team
Silver Key Senior Services
Home Based Services Team
Peak Vista Community Health
Senior Clinics
FQHC Primary Care with
Integrated Behavioral Health
Program of All-Inclusive Care of
the Elderly (PACE)
Adult Day Health Managed
Primary and Long Term Care
The Resource Exchange
Disabilities Services (Supportive
Living Services, Primary Care)
Palisades at Broadmoor Park –
Senior Housing Campus
Wellness Center Integrated Care
(Primary care, physical wellness,
psychosocial wellness)
Biopsychosocial Frame
• Physiological aging
– systemic changes
– Illnesses
– functional change
• Social contexts
– Aging social stimulus value
– Social structures (or lack of) in later life in particular societies
– Roles and role transitions, social support
• Psychological aging
– Cognitive changes
– Emotional processing changes
– Stress and coping responses
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What do we bring to our partners?
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Screening
Evaluation
Intervention Menu
Consultation with staff
Program design and evaluation
Individual
Assessments
Individual
Intervention
Integrated
Team Care Plan
APA, Blueprint for Change: Integrated Care for an Aging
Population
The WHAT: Assessment and
Evaluation
• In fragmented service systems, each agency has
protocols for assessment of ONE FACET of the Care
Recipient
–Diseases/Medications
–Functioning
–Care Preferences
–Aging and End-of-Live Values
–Resources Needed
Even as professionals we can only learn
about the part of the elephant we can
see…
We might want to know
what the family member
sees on a daily basis, what
has changed recently, and
whether the current care
structure is stable or fragile.
Rule In vs Rule Out
Mr. Howard Thomas is a 72-year-old retired African American veteran living in
the rural Midwest with his wife of 46 years. He had triple by-pass surgery
three months ago and was seeing his primary care provider, a family
physician, for a follow-up visit. He was accompanied by his wife, who shared
concerns that he was spending all of his time alone in the den watching TV.
Mr. Thomas completed a variety of screening measures given on an annual
basis in his primary care clinic. These tools were reviewed by the clinic nurse,
who informed the physician that Mr. Thomas scored in the depressed range
on the PHQ-9. The physician reviewed Mr. Thomas’ health status to assure
that new or unresolved medical and neurological issues were not responsible
for his depressive syndrome. Additional questions about Mr. Thomas’ mood
and activities revealed decreased interest in previously pleasurable activities
such as reading the newspaper and woodworking. With that information, the
physician invited the behavioral health consultant (a psychologist) into the
meeting with the explanation that she was a member of the care team who
specialized in helping patients cope with medical illnesses and other life
stressors. The physician further emphasized his confidence in the consultant’s
ability to help Mr. Thomas address his recent difficulties.
Actions?
• Brief (20-30 min) assessment
– Mental status – IN TACT
– Depression - YES
– Cognitive functioning – NO PROBLEMS
– Suicidal thought, plan, intent – NO INTENT OR
PLAN
Action?
• Share findings (include wife)
– Assessment results
– Education about depression and cardiac illness
– Offer Tx options
• Wife: hesitant about medications
• Patient: open to medication but prefers not
– Schedule 3 behavioral intervention sessions
• Adjustment to chronic disease
• Behavioral activation
Action?
• Confer w PCP on assessment findings and Tx
plan
• Chart plan
• Include in chart results of ongoing
assessments
Strategy #1:
Screen Elders for MH
• Bypass the need for
–Professionals to notice underlying problems
–Elders to have insight and courage to self-identify
• Screens must cover common areas of mental health
problems in older adults, AND fit work flow of
primary care
–Cognitive problems
–Depression and Anxiety
–Sleep Disorders, Substance Abuse, Pain
Screen
• Case finding
• Brief
Diagnostics
• Depth of psych info
• Contextual info
• Multidisciplinary info
Intervention
design
• Heavy on context info
Outcome
assessments
• User-friendly
• Outcome focused
• Brief
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Cognitive Impairment:
Hidden Epidemic?
• 6.5 million have Alzheimer’s Disease with or
without another form of dementia
Plassman et al (2007)
• CI is a leading cause of functional decline in
older adults
• Costs?
– 4.9 million unpaid caregivers
– $183 billion/year societal cost in US
How does it look in your office?
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Frustration and anger
Vague responding and excuses for errors
Slow responses
Personality changes
Memory
Difficulty with complex tasks
Inappropriate responding
Reduced rate of behavior (lack of initiation)
Benign agreement but no follow-through
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Risks to Quality of Care
– Poor historian – long term or recent
– Medication mismanagement
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Medications not taken at all
Medications taken on alternate time schedule
Multiple medication administrations
Arbitrary dosages
– Appointment follow-up
• Appointments not made, or forgotten
• Person arrives at appointment without instructions as to why they are
there
– Activity, diet, therapy instructions
– Inability to read instructions
– Inability to report symptoms
Disconnect …..
Health
System
•“Families can’t be included
because of HIPAA”
•“If the family was just taking
better care, she wouldn’t be so
depressed.”
•“Why won’t the family let us do
our job?”
Family
Challenges
•“Why won’t they talk to
me…I’m the one who has to
take care of her??”
•“Why didn’t they tell me that
____ was an option?”
•“I just thought it was normal
aging.”
Screening
• Concept – starting age 50… personal baseline
• Controversial so no standards set yet
• Medicare’s new Annual Prevention Visit
– Requires cognitive screening
– Requires depression screening
• Challenges
– High sensitivity/specificity measures take 20-30 minutes which
is not feasible in primary care
– Computerized tools reduce labor but
• typically do not provide information on multiple domains of cognition
or alternative causes
• Require some familiarity with computers, vision, English language
When suspicious of CI
• Mental status exam
• Collateral report on daily functioning
– Basic Activities of Daily Living: bathing, dressing,
etc
– Instrumental Activities of Daily Living:
appointments, financial management,
transportation, cooking
• Medical rule-out
Sx are Evident
• Neuropsychological Evaluation -> cognition
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Attention
Executive Function
Memory
Language
Problem-Solving/Reasoning
Psychological/Psychiatric conditions
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Depression
Anxiety
Substance Abuse
Pain or Sleep disruption or pain
• Medical Rule-out of delirium causes
Dx is known
• Re-assess regularly
• Engage family
– Learn about the life context in order to make
judgments about safety – driving, finances, housing
– Inquire about surrogate decision-makers
– Respect the critical role of family in the unfolding of
this disease – caregiver self-care
• Ensure that the elder with dementia has
emotional support
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Example: Cognitive Impairment
Screen
Profile for
General Planning
• MoCA
• SLUMS
• Dementia Rating Scale
• CogniStat
Diagnostic
Decisions
• Neuropsychological Evaluation
Legal Capacity
• Neuropsychological Evaluation
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Mr. Johns
Today Mr. Johns clearly did not recall what you discussed
just a week ago, even after you prompted him. His labs
suggest he may not be responding well to his medication
regimen. Although he does not recall your instructions
from last week, he was delighted to see you, and seemed
earnestly interested in implementing the advice you gave
today.
Mental status exam showed him oriented x3, recalling 2
of 3 objects, and able to create a clock although he
couldn’t recall the exact time you asked him to draw.
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Example: Depression
Screen
• WHO-5
• PRIME-MD
Diagnostics
• SCID – research level
• Clinical INterview
Intervention
Design
• Pleasant Events Scale
• Suicidal Beliefs
Outcome
Assessments
• GDS-15 item
• Staff observer scale for dementia
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Strategy #2
Gather information from collateral
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Concerns
Observed behavior changes
Daily functioning
Health beliefs
Care burden
Behavior Problem Checklist
In what areas do you find your family member having difficulty?
Please rate the degree of problems your family member is experiencing by circling the appropriate
number in each of the following areas on a scale from 1(no problem) to 7 (frequent problem or intense
problem). Place a check beside the areas of functioning that have changed with in the past four to
six months.
1
Memory
1 2
3 4
5 6
7
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Aggressive Behavior
1 2
3 4
5 6
7
2
Concentration
1 2
3 4
5 6
7
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Suspiciousness
1 2
3 4
5 6
7
3
Planning
1 2
3 4
5 6
7
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Personality Changes
1 2
3 4
5 6
7
4
Decision-making
1 2
3 4
5 6
7
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Finances
1 2
3 4
5 6
7
5
Follow through on plans
1 2
3 4
5 6
7
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Medical Care
1 2
3 4
5 6
7
6
Mood
1 2
3 4
5 6
7
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Safety Issues
1 2
3 4
5 6
7
7
Anxiety/Worry
1 2
3 4
5 6
7
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Household Tasks
1 2
3 4
5 6
7
8
Irritability
1 2
3 4
5 6
7
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Self-care/Hygiene
1 2
3 4
5 6
7
9
Sadness
1 2
3 4
5 6
7
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Appointments
1 2
3 4
5 6
7
10
Depression
1 2
3 4
5 6
7
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Driving
1 2
3 4
5 6
7
11
Apathy
1 2
3 4
5 6
7
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Medical Problems
1 2
3 4
5 6
7
12
Suicidal Thoughts
1 2
3 4
5 6
7
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Falls/Balance
1 2
3 4
5 6
7
13
Homicidal Thoughts
1 2 3 4 5 6 7
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Nutrition
1 2
3 4
5 6
7
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Social Relations
1 2
3 4
5 6
7
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Appetite
1 2
3 4
5 6
7
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Isolation
1 2
3 4
5 6
7
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Incontinence
1 2
3 4
5 6
7
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Withdrawal
1 2
3 4
5 6
7
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Sleep
1 2
3 4
5 6
7
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Inappropriate behavior
1 2
3 4
5 6
7
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Energy Level
1 2
3 4
5 6
7
Other:
1 2
3 4
5 6
7
Other:
1 2
3 4
5 6
7
Instrumental/ Activities of Daily Living Assessment Form
Please rate the degree of problems your family member is experiencing by circling the appropriate
number in each of the following areas on a scale from 1(no assistance) to 7 (full assistance). Place a
check beside the areas of functioning that have changed with in the past four to six months.
1
Ambulation
1 2
3 4
5 6
7
10
Laundry
1 2
3 4
5 6
7
2
Bathing
1 2
3 4
5 6
7
11
Medication Administration
1 2
3 4
5 6
7
3
Dressing
1 2
3 4
5 6
7
12
Food Preparation
1 2
3 4
5 6
7
4
Transfers
1 2
3 4
5 6
7
13
Heavy Chores
1 2
3 4
5 6
7
5
Toileting
1 2
3 4
5 6
7
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Telephone
1 2
3 4
5 6
7
6
Eating
1 2
3 4
5 6
7
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Financial Management
1 2
3 4
5 6
7
7
Grooming
1 2
3 4
5 6
7
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Household Tasks
1 2
3 4
5 6
7
8
Transportation
1
2 3
4 5
6 7
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Appointment Management
1 2
3 4
5 6
7
9
Shopping
1
2 3
4 5
6 7
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Access Resources
1 2
3 4
5 6
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Patricia travels to Florida for a week each quarter to help her
parents who live in a condo there. In the past 6 months,
however, her mother has been hospitalized 4 times for
uncontrollable heart irregularities. Pat’s father is well meaning
but rarely communicates accurate or complete information to Pat
about medical treatment or decisions. She realizes he is
beginning “to slip a little”. Her mother is sharp when she is not
heavily medicated, but this series of illnesses have made her
thinking a bit fuzzier than normal. Pat has caught a couple of
times when her mother’s report from the doctor was inaccurate.
She can’t travel any more often and keep her job, but also can no
longer rely on her parents’ reports of what is happening in the
hospital or at home.
Strategy #3
Assessment feedback
• Describe findings
• Educate about disorders
• Link information about MH and Physical
health
• Explore health beliefs
• Explain Tx options (Pharm/Non-Pharm)
• Offer Tx source options (primary or MH)
Cognitive Impairments Impact …
• Executive Function –
time, sequencing,
impulse control
• Problem-solving
• Memory
• Language –
expressive/receptive/pro
cessing
• Attention
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WHO is relevant?
Medical Model
WHO is relevant?
Individualistic
Model
WHO is relevant?
Familistic
Model
Selling Family Involvement to Patient
• “Your family needs to know more about your health
before there is a crisis and you can’t tell them”
[Information only model]
• “You deserve to have some help with the detail work
of managing your all of these medical details, while
you direct the overall picture”
[staff person model]
• Now is a great time to figure out how you want your
family to work as your “team”
[restructuring
model]
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Selling Increased Involvement to Family
• Your ____________ is concerned that no one
knows the details of his/her health and thinks
it is time to share information with you
• Your ____________ is finding it more and
more challenging to handle the details of dayto-day management of medications, nutrition,
and other aspects of health
• Your ____________ would like to invite you to
become more involved in managing his/her
health
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Strategy #4
Apply findings to Daily Life Context
Key Q: How do findings inform daily life?
• Apply to engagement in health and life
• Determine role of patient vs others in
implementing recommendations
• Establish benchmarks/milestones
• Anticipate next transitions
• Use community resources
Interventions
Criteria:
- Evidence-based
- Brief; focus in quickly on problem
Specific options:
- Problem-Solving Therapy
- Brief Problem-Focused Solution
- Motivational Interviewing
H & B Codes
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Address non-psychological disorders only
Behavioral medicine
Health behaviors
APA tutorial @ http://www.practicecentral.org
Chronic disease management= IS a
behavior issue
• Engagement in choice to change
– Information feedback
– Education
– Risk assessment and pro/con review
– Motivational interviewing
– Problem-focused, solution-focused interventions
Integration of Behavior Change into
Treatment Planning
• Who can best deliver information and
education?
• What data can be shared, in what format, at
what pace?
• Coordinating the team
• Tracking outcomes
Practice Pragmatics
Where is the integration?
› Team membership and roles
› Challenges
› Hierarchical structures
› Overlapping roles
› Virtual teams with unknown membership
› HIPAA concerns about sharing information
› Consent form within unit
› Specific consent for particular agency partners
› Define scope of disclosure to family members carefully
Individual
Assessments
Individual
Intervention
Integrated
Team Care Plan
APA, Blueprint for Change: Integrated Care for an Aging
Population
Communication
 Facility paper charts
› Find out who reads what sections
› Find out who doesn’t read any section
› Consider carefully who needs to know what
 EHRs
› Is there a comprehensive care plan?
› Read carefully
› Consider carefully who needs to know what
 Your records
› Medicare rules rule
› Medical necessity, time of service, plan
 Keeping family in the loop, with what?
Watch out for special cases…
 Capacity evaluations
› Only billable to Medicare IF meet medical necessity
› Private payment is common (attorneys)
 Family meetings
› Medicare only reimburses if relates to care for elder who
is patient of yours
› Carriers vary, but usually, patient must be present
 Staff interactions typically are not billable
Local resources
• Disease organizations
Alzheimer’s Association, stroke association, etc.
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Health provider groups
Area Agency on Aging
Hospitals and FQHC
Public health department