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Session #E1 October 28, 2011 11:15AM. Behavioral Health Lab: Building a Strong Foundation for the Patient-Centered Medical Home. Johanna Klaus, PhD, Director, Behavioral Health Lab Sara Kornfield, PhD, Post-doctoral fellow Erin Ingram, BA, MIRECC Research Coordinator - PowerPoint PPT Presentation
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Behavioral Health Lab: Building a Strong Foundation for the Patient-
Centered Medical HomeJohanna Klaus, PhD, Director, Behavioral Health Lab
Sara Kornfield, PhD, Post-doctoral fellowErin Ingram, BA, MIRECC Research Coordinator
Dave Oslin, MD, MIRECC Director, ACOS MH
Collaborative Family Healthcare Association 13th Annual ConferenceOctober 27-29, 2011 Philadelphia, Pennsylvania U.S.A.
Session #E1October 28, 201111:15AM
Faculty Disclosure
We have not had any relevant financial relationships during the past 12 months.
Need/Practice Gap & Supporting Resources
Primary care mental health (PCMH) integration has blossomed at facilities throughout the VA, and is consistent with the adoption of the Patient Centered Medical Home. However, the implementation of evidence based protocols for the collaborative treatment of depression, anxiety, and alcohol misuse and the consistent use of assessment to evaluate treatment and program effectiveness (i.e. measurement based care) has been slower in adoption.
Systematic use of informatics tools to support evidence-based and measurement-based care can help address this gap.
Objectives• Describe how the Behavioral Health Lab is consistent with the
principles of the Patient-Centered Medical Home including improved access, care coordination, team-based care, and partnering with the patient.
• List the Behavioral Health Lab services and target populations and how the program can be adapted for changing or individual clinic needs.
• Describe the importance of measurement-based care with collaborative care programs for triage, patient education and symptom monitoring, and program quality improvement.
• Identify the use and features of the BHL software system that can assist in implementation of a PCMH approach, including screening of behavioral health problems and ongoing tracking of care.
Expected Outcome
Consider the benefit of a flexible informatics platform to help implement evidence based protocols in primary care to inform both patient treatment outcomes and program effectiveness.
VISN 4 MIRECC6
Patient Centered Medical HomeReplaces episodic care based on illness and patient
complaints with coordinated care and a long term healing relationship
The Primary Care Team • Takes collective responsibility for patient care
• Responsible for providing all the patient’s health care needs
• Arranges for appropriate care with other specialties as needed
Enhanced Access Enhanced communication between
• Patients• Providers• Staff
Continuous Improvement in our work
6
The spectrum of mental health problems
Mild-to-Moderate Severe
Large Numbers“Sub-optimal” functioning
•Depression•Anxiety•Alcohol misuse
Brief InterventionsPrimary Care Providers
Smaller NumbersMajor Impairment•Severe depression, anxiety•Personality disorders•Schizophrenia or
bipolar disorder
Complex interventionsSpecialty Care Providers
VISN 4 MIRECC8
Philadelphia VA Integrated Care program – Behavioral Health Lab
A platform for the delivery of collaborative care in primary care
A public health focus on non-complex patients A partnership with PC A bridge to specialty care Patient centered care – incorporating convenience and
preference A program that stresses self- management and
collaborative decision making Measurement-based care Ever evolving…
VISN 4 MIRECC9
Clinical ProcessPatient Identification
Screening / Clinical Assessment / Casefinding
Initial Assessment
ConsultationOr
Referral Mgt
Treatment Recommendations
Brief Treatment &
Care Management
No treatment &
Refusal of care
Patient Education
and Promote Self-Care
Watchful waiting&
Brief Interventions
Specialty Care Evidence based protocols
Prevention / Health Promotion
BHL software – provides the platform
VISN 4 MIRECC10
Behavioral Health Laboratory: components
A clinical management program focused on:
Identification: screening, pharmacy based, direct to consumer, etc
Seek out patients Assessment and triage to appropriate level of care
Care Management / Brief treatment/ Health Promotion and Prevention
Using Specialty Care and facilitating engagement
Tracking: software program
VISN 4 MIRECC11
Behavioral Health Laboratory: components
A clinical management program focused on:
Identification: screening, pharmacy based, direct to consumer, etc
Assessment and triage to appropriate level of care
Care Management / Brief treatment/ Health Promotion and Prevention
Using Specialty Care and facilitating engagement
Tracking: software program
VISN 4 MIRECC12
Initial Triage
All patients entering the program complete standard initial assessment
Completed via phone or in person (patient preference)
Includes array of behavioral health symptoms and substance use and overall functioning
Helps determine next step in treatment Completion rate of 80% BHL Software output: clinical report, patient
letter
Initial Triage Assessment• Demographics• Current MH care • Financial status• Social support• Blessed Orientation-Memory-Concentration (>55 yrs or head injury)• Mini International Neuropsychiatric Interview (psychosis, mania, GAD, panic)• Depression assessment: PHQ-9• PTSD Checklist (PCL-c)• Anxiety assessment: GAD-7 (optional)• Brief Pain Inventory Interference scale • Current Psychotropic/Pain medications• 5-item Paykel scale for suicidal ideation• Alcohol use (7 day follow-back)• Illicit substance use• Depression history• Work Limitations questionnaire (optional)• SF-12 (optional)
Communicating with PC team
Characteristics of Veterans who completed the BHL pre-assessment
Demographics and Background N = 3348
Age (M, SD) (N=4163) 52.6 (16.1)
Race non-Hispanic White 1617 (49%)
Employed 946 (28%)
Married/PartneredSeparatedDivorced
1462 (44%)298 (9%)
728 (22%)
Finances “Can’t make ends meet” “Just enough to get along”
1016 (31%)1672 (50%)
Served in Iraq/Afghanistan post 9/11 815 (25%)
SF-12 Physical component score Mental component score
41.0 (12.9)38.6 (13.6)
Mental Health and Substance Use Diagnoses N, %
PTSD PCL-c (M, SD); N=2066
1368 (43%)51.8 (17.5)
Major DepressionOther depression PHQ-9 (M, SD)
1422 (43%)433 (13%)12.4 (7.0)
Panic Disorder, current 190 (6%)
Generalized Anxiety Disorder 1206 (38%)
Mania 183 (6%)
Psychosis 91 (3%)
At-risk Alcohol Use/AbuseAlcohol Dependence
467 (15%)
361 (11%)
Used street drugs, ever Marijuana use, past 3 months
1895 (57%)
394 (12%)
Clinically significant MH or SA symptoms 1603 (50%)
VISN 4 MIRECC17
Behavioral Health Laboratory: components
A clinical management program focused on:
Identification: screening, pharmacy based, direct to consumer, etc
Assessment and triage to appropriate level of care
Care Management / Brief treatment/ Health Promotion and Prevention
Using Specialty Care and facilitating engagement
Tracking: software program
VISN 4 MIRECC18
Behavioral Health Lab Interventions
Evidence based (or we are working on it) and stepped care approach
Longitudinal but brief treatments (can be by telephone – patient choice)
Promote patient self-management Collaborate with PCP Pharmacological support Measurement based
VISN 4 MIRECC19
Evidence Base for primary care delivered interventions
Robust Evidence Base Depression Care
management Alcohol Brief
Interventions (alcohol misuse)
Referral management
Growing Evidence Base Alcohol care
management (alcohol dependence)
Watchful waiting Anxiety care
management Pain care management
VISN 4 MIRECC20
Measurement Based: BHL Software
Built in interview for tracking follow-up contacts for care management/brief treatment
6 optional domains:• Depression: PHQ-9• Anxiety: GAD-7• PTSD: PCL-c• Pain: BPI for pain interference• Alcohol: 7-day time line follow-back• Referral Management: to track engagement in
specialty care
VISN 4 MIRECC21
BHL Software support: patient level feedback
Tracking structured assessments:
•Ability to provide feedback to both the provider and the patient •Progress reports generated by BHL software
VISN 4 MIRECC22
BHL Clinician: the Glue
Primary Care Clinician
Mental Health Supervisor
BHL clinician Patient
VISN 4 MIRECC23
Behavioral Health Laboratory: components
A clinical management program focused on:
Identification: screening, pharmacy based, direct to consumer, etc
Assessment and triage to appropriate level of care
Care Management / Brief treatment/ Health Promotion and Prevention
Using Specialty Care and facilitating engagement
Tracking: software program
VISN 4 MIRECC24
Referral Management
Problem: low attendance rates for MH/SA treatment (30-40%)
Goal: increase referral adherence in symptomatic patients with complex behavioral health care needs
Possible psychosisDrug addictionManiaSevere/complicated depression or anxiety
Uses a motivational interviewing style to provide clinical support and promote problem-solving skills
VISN 4 MIRECC25
Appropriate Use of Specialty Care:Referral Management Module
Attended 1st
Appointment
Motivational Session 70%
Control Group 32%
Zanjani et al, 2008
p < .001
VISN 4 MIRECC26
Behavioral Health Laboratory: components
A clinical management program focused on:
Identification: screening, pharmacy based, direct to consumer, etc
Assessment and triage to appropriate level of care
Care Management / Brief treatment/ Health Promotion and Prevention
Using Specialty Care and facilitating engagement
Tracking: software program
VISN 4 MIRECC27
BHL Software Platform• Provides structured assessments across providers
and settings• Programmable decision logic that is exportable across
sites and testable• Allows capacity to define and follow a cohort of
subjects with prompts for additional clinical actions (panel management for follow ups)
• Allows integration across mental health conditions (not just one disorder)
• Creates patient material, including treatment progress• Provides program level outcome data• Allows rapid research engagement
VISN 4 MIRECC28
Patient Tracking: Panel Management
VISN 4 MIRECC29
Patient Tracking: Patient History Page
VISN 4 MIRECC30
Patient Tracking– Measurement based care
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Patient Level Reports Progress Note Creation for all interviews:
• Treatment plan• Results of all assessments
Patient letters and Progress reports• Patient education • Visual for treatment
progress
VISN 4 MIRECC32
Program Level Outcome Data
OUTCOME DATA: Available at the program, clinic, Primary Care Provider and staff level
VISN 4 MIRECC33
BHL as a platform: ex. Developing a Treatment for PTSD
• Of >17,000 BHL assessments 5,651 (33.2%) positive for PTSD; PCL-c mean = 49.8 (18.2)
• PTSD positive veterans: more symptomatic– 66% with depression vs 29% of PTSD negative
– More likely to have psychosis, mania, illicit drug use, problem drinking, other anxiety disorders
But 17% of Veterans at Philadelphia referred to specialty care because they endorsed symptoms consistent with PTSD had PCL scores < 60.
VISN 4 MIRECC34
PTSD Brief Treatment
For lower level PTSD symptoms 6-8 sessions of about 30 minutes 1-4 sessions focus on psychoeducation,
behavioral activation, and mindfulness Extra sessions for anger management, sleep,
alcohol misuse as needed Current pilot; outcomes soon
• Effective treatment? • Secondary triage?• Warm-up for evidence based treatment?
VISN 4 MIRECC35
Increase identification of patients needing behavioral health services (Oslin et al, 2006)
Increase engagement in specialty care (Zanjani et al, 2008)
Improve outcomes for depression and alcohol misuse (Oslin et al, 2003)
Platform for new treatments and research Allows for efficient staffing and collaboration with PC
The triage and tracking mechanisms allow for seamless referral and the ability to reduce waiting times, prioritize care, and provide administrative support for monitoring.
Behavioral Health Lab: In Summary
VISN 4 MIRECC36
Patient-Centered Medical Home and the Behavioral Health Lab
Key Principles Behavioral Health Lab
Patient-driven
Team-based
Efficient
Comprehensive
Continuous
Communication
Coordinated
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VISN 4 MIRECC37
More information?
Session Evaluation
Please complete and return theevaluation form to the classroom monitor
before leaving this session.
Thank you!