Transcript Title of Presentation - Collaborative Family Healthcare Association

Session #_H2b__
Friday, October 11, 2013
Symptom Presentation and Intervention Delivery by
Veterans Administration (VA) and US Air Force (USAF)
Behavioral Health Providers in a Primary Care
Behavioral Health Model of Service Delivery
Jennifer S. Funderburk, Ph.D., Clinical Research Psychologist
Robyn L. Fielder, Ph.D., Postdoctoral Fellow
Christopher Hunter, Ph.D.,
Anne Dobmeyer, Ph.D.
Stephen A. Maisto, Ph.D., Professor and Director of the
VA Center for Integrated Healthcare
Collaborative Family Healthcare Association 15th Annual Conference
October 10-12, 2013
Broomfield, Colorado U.S.A.
Faculty Disclosure
We have not had any relevant financial relationships
during the past 12 months.
Objectives
• Discuss the most prevalent presenting symptom
combinations reported by BHPs in VA and USAF primary
care clinics
• Describe the types of clinical interventions employed by
BHPs to target these symptom combinations
• Examine the use of empirically-based interventions within
this dataset
• Discuss the implications of these results on the clinical
practice of BHPs within integrated primary care settings as
well as potential avenues for future clinical intervention
research
Background
• VA and USAF have adopted co-located, collaborative
care (CCC) within primary care
• Based on Primary Care Behavioral
Health or Behavioral Health
Consultant model (Strosahl, 1998;
Robinson & Reiter, 2007)
• Integrated behavioral health
providers (BHPs) see patients on a short-term basis
Background
• Many BHPs use elements of empirically-supported,
CBT-based interventions (Bryan, Morrow, & Appolonio, 2009; Corso et al.,
2012; Funderburk et al., 2011)
• Interventions usually developed
to target a single disorder (Strosahl,
1998; Robinson & Reiter, 2007)
• Yet many patients have multiple
presenting symptoms (Funderburk,
Dobmeyer, Hunter, Walsh, & Maisto, in press)
Goals of the Study
• Assess the prevalence of comorbid symptom
presentations among patients seen by VA &
USAF integrated BHPs
• Describe the types of interventions used by
BHPs for common symptom presentations
• Examine the extent to which BHPs use
empirically-support interventions
Method
• National study of VA & USAF BHPs
• Prospective data collection using web-based survey
• Descriptive data from 1 day of clinical practice
• N = 75 VA BHPs, response rate 35%
• N = 23 USAF BHPs, response rate 43%
• Research staff oriented interested BHPs via phone
• Measures: Background on BHP, Appointment
Appointment Questionnaire
• Presenting Symptoms at Visit
• Depression, Anxiety, Mania,
Psychosis, Suicidal Ideation,
Behavior change (e.g., alcohol,
weight, exercise, smoking,
medication compliance),
adjustment to a life change,
coping with a medical
condition, bereavement, pain,
sleep problems
Appointment
Questionnaire
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Education about Medicine either Taking or Prescribed
Psycho-education about a diagnosis
Education about the relationship between thghts/feelings/beh
Discuss what the patient is already doing that provides relief of
symptoms
Discuss communication style within a certain relationship (i.e.,
assertiveness skills)
Discuss the importance of interpersonal relationships (i.e.,
increase social support)
Discuss increases in the patient’s pleasurable activities
Discuss behavior change
Discuss relaxation training
Education about pain
Appointment
Questionnaire
• Problem solving skills training (i.e., education about relationship
between symptoms and problems, discuss problems and potential
resolutions)
• Cognitive reframing (i.e., discussing thghts, change distortions)
• Discuss cognitive distortions (i.e., all or none thinking, etc.)
• Discuss relapse prevention
• Discuss referral to specialized care
• Develop a pain management plan
• Discuss sleep restriction (i.e., only being in bed for the typical
number of hours the patient reports sleeping)
• Education about healthy sleep habits (i.e., sleep hygiene: go to bed
when sleepy, get out of bed if not asleep in 15 minutes)
• Provide education about hazardous/high risk drinking
Results
• 98 BHPs
– Working in PC for 4 years on average
– Orientation most commonly cognitive-behavioral or
behavioral
• 403 patients/visits
–
–
–
–
74% male
Mean age = 49 (SD = 16, median = 51, range: 2-90)
42% initial sessions, 58% follow-up sessions
Mean session length = 38 minutes (SD = 16, median = 30,
range: 2-120)
Results: Symptoms
Results
• 57% (n = 222) of patients reported multiple
symptoms at their visit
– 78% male
– Mean age = 50 (SD = 15, median = 53, range: 19-84)
• Visits
– 44% initial visits, 56% follow-up visits
– Mean length = 40 minutes (SD = 17, median = 33,
range: 3-120)
Results
• Among the 222 patients reporting >1 symptom
• Mean = 3.5 symptoms (SD = 1.5, median = 3,
range: 2-11)
Results
Results
Most common interventions used for depression/anxiety
*
*
*
Results
Less common interventions for depression & anxiety
*
*
*
Most Common Clusters of
Interventions
18%
Psychoeducation on diagnosis
Psychoeducation on medications
11% Psychoeducation on CBT concepts
7% Medication adherence
Review what already provides relief
Increase social support
Psychoeducation on diagnosis
Psychoeducation on medications
Psychoeducation on CBT concepts
Medication adherence
Review what already provides relief
Assertiveness skills
9%
11%
Psychoeducation on diagnosis
Psychoeducation on CBT concepts
Review what already provides relief
Assertiveness skills
Increase social support
Increase pleasurable activities
Results
• Common combinations of interventions within clusters
– Psychoeducation about diagnosis & CBT concepts, review
what already provides relief (52% I, 58% F)
– Psychoeducation about diagnosis & medications
(47% I, 44% F)
– Psychoeducation about CBT concepts, review what already
provides relief, increase social support (42% I, 42% F)
– Psychoeducation about diagnosis & medications, medication
adherence (40% I, 35% F)
– Psychoeducation about diagnosis, CBT concepts, &
medications (37% I, 37% F)
I = initial visit, F = follow-up visit
Limitations
• Limited to those BHPs and Patient experiences
within VA and DoD
• Based on BHP Report
– Mean # of interventions: 9.1 +/- 3.7
– Median: 9
Discussion
• The majority of patients reported multiple symptoms
– Depression and anxiety were most common with
depression/behavioral change; anxiety/behavioral change
coming in 2nd
– Evidence base for brief interventions that can be used to
target these symptoms is limited at best
• BHPs report using a variety of interventions
– Many with empirical support for depression and anxiety,
but many without specific support
– BHPs are using numerous intervention approaches within
brief sessions
Learning Assessment
Does the symptom clusters that came out
match with your experience as a clinician
or as an administrator overseeing an
integrated practice?
What things do you think might affect the
types of patients a BHP might see?
What types of interventions do you gravitate
towards in clinical practice? Why?
How do you incorporate evidence into your
daily practice?
Session Evaluation
Please complete and return the
evaluation form to the classroom monitor
before leaving this session.
Thank you!