Behavioral Health Skills for Primary

Care Team Members: Increased

capacity to meet the need

Larry Mauksch, M.EdSenior Lecturer, Family Medicine, Univ of WashingtonConsultant

Presentation Objectives

Describe a behavioral health skill model that

transcends primary care team roles

Describe a generic training model for all

team members to learn core behavioral skills

Demonstrate how team members can use

upfront agenda setting to enhance

effectiveness and efficiency

Demonstrate a model for using the EHR to

promote team support of patient goal setting

and action plan creation

Behavioral Health Role(s): Integration Steps

Referral to BH offsiteNo collaboration

BH part of teamDisease mgmt for Complex patients

Supervision of BH

care management

Referral for BH offsiteShared records

Referral to BH onsiteNo collaboration

Referral to BH onsite Shared records

Referral to BH onsite Shared records, shared planning

Team Training and

System Transformation

Mental Disorders in Primary CareJ of Fam Practice 200150(1), 41-47

0% 10% 20% 30% 40% 50% 60%

Prob Alcohol Abuse

Binge Eating Dis

Other Depression

Bulimia

Other Anxiety Disorder

Panic Dis

Major Depression

Any Diagnosis

PHQ-3000 Marillac 500

Primary Care Realities

Primary Care patients average 3-6 problems per visit

Indigent primary care populations have a greater illness burden

50% of adults have two or more chronic illnesses: 80% lack knowledge, confidence and self management skills

• 75% of US health care dollars go to care for chronic illness

Appropriate chronic, preventive and acute care for a panel of 2500 patients estimated to take 24 hours

Teamwork

The solution

Patient Centered Medical Home:Two interdependent components

Rogers, PCMH Movement: Promise and peril for family medicine. JABFP, 2008 21(5)

Infrastructure Care

Info tracking

between HC

settings

E-Planning,

E-Rx

EHR

Open access

Team work

Self

Management

Support

Communication

Larry Mauksch, M.Ed University of Washington Department of Family Medicine

Why Are High Functioning Teams Essential To Primary Care

Too much work for one person

Collaboration produces better

outcomes

Effective teams help sustain healthy

behaviors in their members and in

patients

Less likely that important issues will be missed and more likely that problems

will be solved creatively

Role versus FunctionToward transdisciplinary teamwork

Continuum of Role FunctionMulti-

disciplinary• Clinical

separation• Minimal

sharing of information or responsibility or coordination of care

Interdisciplinary

• Team effort for cooperation, cohesiveness, shared information, responsibility.

• Professional status and protectionism are barriers optimal function

Transdisciplinary

• Complexity of the patient or population informs team membership and process

• “Role release” –overlapping function across disciplinary boundaries, collaborative power sharing.

Behavioral Health Functions• Reflective listening• Explores beliefs• Strengthens coping abilityTherapeut

ic

• Goal setting• Problem solving• Confidence building• Behavior change reinforcement

Self management support

• Diagnosis• Education• Time management• Anxiety reduction

Communication

• Listening• Empathy• Patients feel known• Building trustRelationship

Transdisciplinary Functions and Roles in Primary Care

Role

Function

PCP Nurse Medical Assistant

Pharm Behavioralhealth

Care Management

Relationship 5 5 5 5 5 5

Agenda setting and activation

4 3 5 2 4 4

Self management-simple

4 3 4 3 2 2

Self management-complex

3 4 2 3 4 5

Primary care counseling

3 4 1 2 5 4

Plan confirmation and care integration

3 4 4 3 4 5

Proactive follow-up and stepped care

3 5 4 3 3 4

Intensity: 5 =always; 4= often; 3 = periodic; 2 = support; 1 = reinforce and connectLarry Mauksch, M.Ed UW Family Medicine

Mastering a Skill DomainPractice• Real situations• Learned from

expert:• description• demonstration

Feedback• Specific• Sensitive• Developmentally

appropriate

Reflection• Promotes

analysis• Synthesis• Integration

Common Training Sequence

Presentation Introduction to PCOF

Group rating and discussion of C/B

Videos, or Rating each other

in role plays

Team members follow a patient

across encounters using PCOF for each encounter

Groups meet to share learning

Recurrent observations, team

meetings, and learn new skills

Larry Mauksch, M.Ed University of Washington Department of Family Medicine

Observer Reflections1) What communication and relationship skills did you see demonstrated that you do not use but would like to adopt?

2) What interpersonal skill weaknesses did you see that you recognize in yourself?

3) What are the ways that this team worked well together to maximize quality and patient satisfaction and eliminate unnecessary redundancy or wasted time for the patient?

4) How might this team improve the quality of care for its patients?

Observation Form Purpose and Training

The value

• Structures vision• Creates and standardizes vocabulary

Primarily for formative assessment and to strengthen the “observer self” (mindfulness)

Online training: http://uwfamilymedicine.org/pcof

PCOF UseBehavior in either of the columns to the right of

thick vertical line is in the competent range

Observers mark accurately and avoid giving the benefit of the doubt

Feedback is best:

When solicited

Specific, rather than

general

Curious, not judgmental

Larry Mauksch, M.Ed University of Washington Department of Family Medicine

PCOF Categories

Assessing patient perspective on health and illness

Gathering information

Maintains efficiency through transparent (out loud ) thinking

Collaborative upfront agenda setting

Maintains relationship throughout the visit

Establishes rapport

Closure and follow up

Co-creating a plan

Informed and shared decisions

Behavior change or action plan development

Sharing information

Physical exam

Electronic medical record use

Relationship Communication and Efficiency:Creating a model from a literature review

Mauksch, Dugdale, Dodson, Epstein 2008, Arch of Intern Med

Ongoing influence

Rapport and Relationship

Mindfulness

Topic Tracking

Empathic response to

cues

Sequential

1. Upfront collaborative

agenda setting

2. Hypothesis testing and

understanding the patient perspective

3. Co-creating

a plan

UW Family Medicine Residency(Mauksch et al

Families Systems, Health, 2001)

Community RCTBrock, Mauksch et al

JGIM, Nov 2011

10 Residents; 7 faculty 162 patients 48 physicians, 1460 patients; two systems

Brief reading, video, written learning confirmation, skill reinforcement

2 hr training w/demo & practice; handout, 2 hrs coaching/wk for 4 weeks, no reinforcement for 6 months

•Higher patient satisfaction

•More MD prioritization

•MDs charted more problems

•More f/u requests

•No difference in visit lengths

•EF MDs showed more upfront elicitations (“something else”*)

•EF patients more likely to say “that’s it” •EF Patients & MDs had fewer “oh by the ways” in phase 3

•Shorter visits 90 seconds (NS)

•No diff in pt / MD satisfaction

Agenda Creation

Avoid premature diving by patient or yourself

When needed interrupt the patient or yourself:

Acknowledge, EmpathizeShare reasoning

If the list is greater than three items, the patient is screen positive for depression or anxiety

Ask, “what is most important”• Listen (feel) for the most important concern

Orient the patient: “I know you are here to talk about ____. Before we get into_____ is there something else important to addresses today? Making a list

will help us make the best use of time”.

Agenda Refinement

First list:

Arthritis

Skin rash

Diabetes

Depression (priority)• “a lot of stress• “Feeling down”

Second list:

Financial problems

Marital problems (priority)

PTSD

Substance Abuse

Grief

Then ask

“What is going on in your life that causes stress and feeling down?”

Upfront Agenda Setting: Impressions

Formulaic, so easier to teach; but may not be sufficient to promote healing or enhance self management

Prompts patients and team members to plan time before using time.

Probably changes time use per problem without lengthening visit

Patients ( in person or online), receptionists and medical assistants can and should contribute to visit planning.

Important in achieving a balance between acute, chronic and preventive care

Larry Mauksch, M.Ed University of Washington Department of Family Medicine

Self Management-Complex(Integration of Goal Setting and Action Plan, Patient Activation and Motivational Models)

ExamplesMultiple

biomedical and mental

illnesses

Conflicting illness beliefs

Distrust in

health care

Financial strain

Low confidence in

self management

Health Behavior Counseling

Education Addressing ambivalence

Problem solving

Building confidence

Relapse prevention

Complexity Care Influences and Collaborators

Minnesota Complexity Assessment Model Peek, Baird, Coleman

Bill Gunn, PhD and colleagues in Concord, NH

UW colleagues work on a Picker Foundation support pilot Study: Kavitha Chunchu, MD., Carol Charles, MSW,

Valerie Ross, MS., Judy Pauwels, MD

Family Care Network in Whatcom County, Wa Berdi Safford, MD, Marcy Hipskind, MD. David Lynch, MD

Collaborative Complexity Care Assessment, Goals and Action Plans

Used by entire team to reinforce and revise action plans

Updated versions in static location, not progress notes

Information flows to and from other sections, e.g AVS

Patient engagement through shared screen interaction

Structure prompts team member skill use (EMR as a training tool)

Front and center form (TAB)

Patient Centered Care Plan or Collaborative Care Plan

“About me” • Patient values, literacy, preferences, support

systems

“My goals” or Action Plan• Helping the patient name health a care goal and

hone it to a practical design

Patient Profile (Complexity Assessment)• Multi-morbidity, trust issues, financial strain, no

change, provider discomfort, etc.

“My progress”• Helping the patient celebrate success and

problem solve challenges

Patient Centered Goal Setting

What can help increase confidence?

Confidence

Barriers

When

How often

Focus the activity

Name an activity

Brainstorm activities

Name the goal

Meet the patient where s/he is and hone

Goal Setting Chart reviewPCCP

51 yrs;60%F

Controls55 yrs; 40% F

Goal documented .96 % .43 %

Ongoing activity .89 .34

Specific activity .78 .41

How often .68 .07

When .68 .07

Barriers .75 .01

Confidence .71 .00

What can help with confidence .53 .00

Continued workGeneralization of learning: How does the relationship between EHR prompting and skill use change over time? What are the training and reinforcement needs?

• In our study 60% of PCCP charts had action plan data in the PCCP section AND in the progress note; 28% of charts had PCCP info only in the PCCP section; 12% only in the progress note

Larger studies need to explore:

• team and patient experience• Use of the PCCP at follow up• time use• Impact on patient behavior and health outcomes• durability• training demands for success