An Integrated Primary Care Behavioral Health Clinic

at a University Health ServiceCheryl A. Flynn, M.D., M.S., M.A.

Kelly S. DeMartini, M.S.Jennifer S. Funderburk, Ph.D.

Cast of Characters

No conflicts of interest to disclose

Objectives

• Define integrated healthcare• Discuss benefits of IBHC in a university health

service• Describe Syracuse University’s pilot IBHC

program• Describe initial results of pilot semester

What is Integrated Behavioral Healthcare?

Health = Integration

Health care = IntegratedFrom: http://cnx.org/content/m13589/latest/

What is Integrated Behavioral Healthcare?

• A cooperative method of caring for patients involving a partnership between primary care providers (PCPs) and behavioral health providers (BHPs) working within primary care.

• “a way to bring the skills and expertise for addressing behavioral health needs to a setting in which the patients who can benefit from those services are already getting care.” (Hunter et al)

Specialty Care vs. Integrated Care

• 50 minute, exploratory appointments

• Course of treatment = 8-10 to… unlimited # sessions

• Delayed access through referral process

• Mental Hlth Provider functions independently from PCP

• High-intensity treatments for low volume of patients

• More gradual improvement

• Brief (15-30 min.), problem- focused appointments

• Course of treatment = 1-4 sessions

• Immediate access through warm hand-offs from PCPs

• Behavorial Hlth Provider collaborates with PCP

• Low-intensity treatments for high volume of patients

• Rapid improvement

Goals of IBHC

• Establishment of a collaborative, multidisciplinary team that focuses on patient’s health

• Encourage all providers to view health from a more multidimensional perspective– Normalizes the need for behavioral health

• Improved outcomes for patients!

Models of IBHC General

characteristics Level of communication Charting

systems Who delivers interventions?

Blount, 1998* BHP member of the PC team

PCP maintains his/her role as the individual in charge of the patient’s care

BHP and PCP develop one treatment plan together

Shared PCP and BHP have joint sessions or meet with patient separately, as needed

Doherty, 1995* BHP member of the PC team

BHP and PCP share decision-making power in patient’s care

BHPs and PCPs meet regularly as a group to discuss team cohesiveness

BHP and PCP develop one treatment plan together

Shared PCP and/or BHP

Dym & Berman, 1986*

No separate BHP, comprehensive family physician trained in biopsychosocial model and family systems theory

N/A N/A Family physician

Stosahl, 1998 BHP as consultant to PCP

The PCP maintains his/her role as the individual in charge of the patient’s care

BHP and PCP talk regularly about patient either in-person, email, or telephone

PCP develops a treatment plan that may integrate BHP recommendations

Shared Depends on type of consultation: PCP only BHP temporarily,

followed by PCP BHP and PCP

providing patient education

Primary Mental Health Care Model

• BHP as member of the primary care team• BHP appts similar to PCP visits

– 15-30min duration– 1-3 visits for given problem– Focused assessment and treatment plan

• BHP’s notes in same medical record• PCP maintains role as provider in charge for pt’s

care; BHP role as consultant

BHP role in 1o care mental hlth model

• BHP modifies involvement depending on need of PCP– Behavioral health consultation– Specialty consultation– Integrated consultation

BHP’s focus as part of 1o care team

1.Targeting the behavioral issues inherent in medical illnesses

2.Addressing the psychological symptoms associated with medical illnesses

3.Increased identification of psychological problems

4.Focusing on non-specific factors related to improved medical outcomes

Why Consider IBHC?

• Additional service/expanded care:– Identify serious mental illness earlier and connect

to specialty services– Identify mild/subclinical disease and treat with

behavioral and medical interventions on-site– Address acute situational distress that does not

require specialty care– Address behaviors (e.g., alcohol misuse, insomnia,

risky sex, smoking) that negatively impact health

Why Consider IBHC?...

• Improves access and increases the number of patients who can receive care (Pomerantz, Corson, & Detzer, 2009)

• Can reduce medical costs, improve patient and provider satisfaction, and enhance clinical outcomes (Blount, 2003)

• Patients receiving IBHC have more anxiety- and depression-free days, and show greater improvement on disability measures at 3 and 6 months (Roy-Byrne Katon, Cowley, & Russo, 2001)

…because it works!

Why Consider IBHC in College Health?

• Increasing rates of mental health conditions in college population– Also increasing complexity of MH problems

• More students typically use health services than specialty mental health services on campus– Medical setting as treatment site for MH issues– Greater pot’l for screening and prevention

• Barriers to seeking specialty mental health

Integrated Primary Care Behavioral Health Clinic at Syracuse University

• Collaboration among:– Health Services– Doctoral Clinical Psychology Program– Psychological Services Center– Counseling Center

SU’s Student Health Center• Population:

– ~20,000 undergrad and grad students• Patient visits

– 150-200/day; 15-30 min appt– Urgent care > primary care model; no formal

assigned PCP– EMR begun 1 year prior

• Providers:– NPs>>MDs, – limited background in mental health issues

History of mental health services at SUHS

• No mental health care (eval or tx)– Referral to CC &/or off-campus

• 2004, new director, began medical MH care– Lots of ADHD, increasing amt depression, anxiety– Recruited staff internist & NP to prescribe onsite

• 2008—new provider at SUHS: family med/family therapy– Primary care mental health– Another FNP also expanded medical role

Evolution to IBHC at SU

• Proposal of IBHC onsite in SUHS– New Health Psychology course director

experienced in this area, began 2008– SUHS as placement site, limited structure 08-09– Spring ‘09 began developing pilot IBHC

• Engaged CC and PSC & psychology dept in planning– CC as main MH resource for students– PSC as ongoing therapy resource, grad student therapists– Psychology dept for interns, specialty assessment &

intervention tools• Decision to incorporate screening into formal activity

RoadblocksResource issues• No funding• Limited timeStructural changes• 1 yr into EMR• Loss of Director of SUHSCultural issues• Relative silos• Medical team w/o

orientation to MH care

$

Half Full…

• Course director passionate about IBHC

• Open-minded Assoc Medical Director

• Willingness of psychology grad students for new/expanded experience

• Change as an opportunity

Sales pitch: win-win all around• Students

– Gain expanded services, easier access to care• SUHS

– Additional providers, possibility to screen, training and support for BH/MH care

• Psychology Dept/PSC– Clinical site for grad students, valuable training– Pre-screening ADHD referrals

• CC– Pot’l to off-load wait list/decr “unnecessary” referrals,

expanded MH services, linkage w/ PSC

SUHS Pilot Program IBHC

Description of the Pilot Program

WHO?• Integrated BHPs were 3 advanced clinical

psychology doctoral students– 1 had IBHC experience; 2 did not– Offered workshop prior to fall semester: IBHC 101– Ongoing supervision by course director/licensed

psychologist trained in IBHC

Pilot Program

WHEN?• Provided service ~20 hours a week

WHERE?• BHP office in medical clinic at SUHS• BHP notes entered in EMR

– Written feedback in addition to verbal communication, warm hand-offs

Pilot Program: What?Brief assessments &

interventions• Mental health sx

– Anxiety>>depression– Unclear diagnosis

• Behavioral concerns– Substance use– Medication &/or

treatment compliance• ADHD “pre-screen”

Behavioral Hlth Screening• No prior screening• Areas chosen:

– Tobacco use– ETOH use– Depression, suicide– Sleep concerns

• Positive screens prompted referral to BHP

BHP services compliment other mental health services on campus

Why Screen These Areas?• Prevalence

– Suicide #3 cause of death among 15-24y.o.– Rates of depression >10% on NCHA data

• Early intervention has benefit– Brief alcohol interventions efficacious in reducing alcohol

use with college students– Addressing sleep problems improves functioning

• Recommended/evidence-based– USPSTF supports screening for ETOH misuse and

depression in young adults

Pilot Program: How?

• All BHP appts as referrals from PCP – “warm hand-offs” from PCP appt– Schedule if BHP not available– BHP schedule own f/u

• Further explanation of assessment tools, interventions and screening tools

IBHC at SUHSResults of Pilot Semester

Fall 2009

Steps in a BHP Visit

• Review Screening Results• Conduct Assessment• Begin Intervention

Part 1: Screening

Step 1: Administer and Review Screening Results

Behavioral Health Screening

• Only screened students with a provider visit– Approx. 10 FTE providers (2 MDs, 8 NPs)– Average PCP visits/day = ~116– Total of 704 screens collected on 42 days

• Fall ‘09 - Screened only when BHP in clinic– Inconsistent collection

What Screening Tools?• Depressed Mood/Suicidal Ideation

– Personal Health Questionnaire (PHQ9)– Positive: Moderate symptoms (≥ 10) or any

thoughts of death/self-harm

• Alcohol misuse– Alcohol Use Disorders Identification Test-

Consumption (AUDIT-C)– Positive: Hazardous drinking level (scoring ≥ 8)

• Sleep problems – Insomnia Severity Index (ISI)– Positive: Anyone who said they were interested in

discussing sleep problems

• Smoking– Positive: Anyone who said they were interested in

discussing smoking

What Screening Tools?

Results – Screening Demographics

Results – Screening Demographics

Screening Results - Smoking

• 16% (N = 115) smoke at least some days

• Of those who smoke…– 96.5% smoke 1-9 cigarettes per day– Only 7% (N = 8) of participants who smoke were

interested in talking to someone about quitting

Screening Results – Sleep

• 45% (N = 314) reported being dissatisfied with their sleep to some extent

• 60% (N = 420) reported that their sleep problems interested with their functioning at least somewhat

• 9% (N = 61) were interested in talking to someone about their sleep

Screening Results - Depression

• 11% (N = 78) were positive on the PHQ9• Of those who were positive…

– 74.4% moderate sxs (scores 10-14)– 15.4% moderate-severe sxs (scores 15-19)– 10% severe sxs (scores 20-27)

• 3% (N = 18) endorsed suicidal ideation

Screening Results – Alcohol Use• 592 (84%) drink alcohol

– 11% (N = 77) scored positive (> 8)

• Of those who drank…– Frequency of Use

• 43% drank 2-3x/week• 6% drank 4 or more times per week

– Amount• 40% consumed 3-4 drinks on days they consumed alcohol• 28% drank at least 5-6 drinks• 2% drank 10 or more drinks

Screening Results – Alcohol Use: Binges

• Of those who reported any drinking:– 31% (N = 186) reported 0 binge episodes– 35% (N = 205) reported < monthly binge episodes– 18% (N = 109) reported 1x/month binges– 15% (N = 86) reported weekly binges– 1% (N = 6) reported almost daily or daily binge

episodes

Part 2: BHP Visits

Behavioral Health Provider Visits

• Screening resulted in a total of 110 BHP visits for 83 students

• Patient visit frequency– 61 had single visits– 17 had two visits– 5 had 3 visits

Results – Visit Demographics

Results – Visit Demographics

Results – Visit Demographics

Results – Visit Reason

Part 2: BHP Visits

Step 2 – BHP Conducts Assessment

BHP Assessment Tools

• Clinical interview (approx 5-10 min)• Additional symptom inventories or

psychological questionnaires – Beck Anxiety Inventory (BAI) ® (Beck, 1993)– Insomnia Severity Index (ISI) (Bastien et al., 2001)– Daily Drinking Questionnaire (DDQ)

BHP Assessment Goals

• Diagnosis– Determine whether patient meets criteria for a

mental health diagnosis• If yes, determine severity

• Determine patient’s priorities for tx• Generate preliminary treatment plan based

on dx results

Part 2: BHP Visits

Step 2 – BHP Intervention

General BHP Interventions

• Motivational Enhancement Interventions– Motivation for entering treatment– Motivation to initiate behavior change

• Relaxation Techniques– Incorporated into treatment of depression,

anxiety, chronic pain, IBS

• Stress-Management

Diagnosis Specific BHP Interventions

• Sleep Hygiene/Stimulus Control Interventions for Sleep Problems

• Feedback- and Norms-based Harm Reduction Intervention for Alcohol

• Brief CBT for Anxiety and Depression

Qualitative Feedback on IBHP

• Providers have heightened awareness of behavioral health issues– Rely on BHPs as team members to collaboratively

and efficiently care for students

• Allows for greater access to mental health services

• BHPs gaining training experience• Improved collaborative efforts to care for

students

Case Example

Medical Provider Viewpoint

Case Example

Behavioral Health Provider Viewpoint

Conclusions

• Subjective Strengths of the Program– Implementation of Screening helps to identify

students in need of services---early intervention– Gives students immediate access to mental health

services– Provides complementary service to on-campus

specialty services– Gives PCPs someone to rely on for additional help

with behavioral health concerns

Conclusions

• Obstacles or Areas of Improvement– Implementing screening is difficult due to time

pressures, lack of familiarity– Takes time to develop skills of PCPs to discuss

these issues– Funding a more permanent service– Coordinating services among on-campus specialty

clinics to maximize experience for the student

Contact Information

• Cheryl Flynn– caflynn@syr.edu

• Kelly DeMartini– klsmit03@syr.edu OR kdemartini05@gmail.com

• Jennifer Funderburk– Jennifer.Funderburk@va.gov