Behavioral Medicine: The Future of Behavioral Health Integration

Sheila North, LMFT, Executive Director

Chris Farentinos, MD, MPH, CADC II,

Chief Operating Officer

Behavioral Medicine• Behavioral Medicine (BM) is an

interdisciplinary field of medicine concerned with the development and integration of behavioral and biomedical science knowledge and technics relevant to health and illness, and the application of this knowledge and technics to prevention, diagnosis, treatment and rehabilitation. (Yale Conference on Behavioral Medicine Schwartz and Weiss, 1978)

Behavioral Medicine

• BM has expanded its area of practice to interventions with providers of medical services

• Provider behavior influences patient outcomes

• Quality of relationship and communication between clinician and patient

• Other areas: Clinicians attitudes; bias toward illness as opposed to wellness

Society of Behavioral Medicine (SBM)

• “Better health through behavioral change”

• 34th annual meeting in San Francisco in March 2013

Society of Behavioral Medicine 2013

• Adherence – theoretical and practical methods for adherence

• Behavioral treatments for chronic diseases – improved self-efficacy and self-regulatory skills

• Bio-behavioral mechanisms (psychoneuroimmunology, psychophysiology such as cardiovascular reactivity)

• Health communication

Jon Kabat-Zinn

• Professor of Medicine and Director of the Stress Reduction Clinic and the Center for Mindfulness in Medicine, Health Care, and Society at the University of Massachusetts Medical School

• Kabat-Zinn is student of Zen Buddhism.• He integrates Buddhist teachings Western

science. • A mindfulness based stress reduction program

created by Kabat-Zinn is offered at medical centers, hospitals, and HMOs.

Health Literacy Conference (Legacy) March 2013, Portland

OR• Health care reform and health

literacy• Health disparities• “Plain language”• “Teach back”: two-way

communication• Community health workers and

health literacy• Health communication in cultural

competence

Balancing Budget

• Cut people from care• Cut provider rates• Cut services

• “We either improve or we cut” (Don Berwick, former Director for CMMI)

Triple Aim(Quadruple Aim)

Better HealthBetter Care - Improve Patient Experience Reduce CostsEquity

11

Inverting the Cost Pyramid

Acute

CareSpecialty Care

Prevention and Primary Care

Acute Care

Specialty CarePrevention and Primar

y Care

Current Configuration Desired Configuration

Focus

Medical Care 10%

Lifestyle & Behavior 40%

Social Determinants

15%

Environmental

5%

Human Biology 30%

Cost of Behavioral Health

25% of CareOregon’s patients account for 83% of CareOregon’s adult medical costs. This group’s most common health problems (CareOregon data, 2011):

1) 35% Asthma2) 30% Drug and Alcohol Problems3) 24% Diabetes4) 17% Complex Mental Illness5) 14% Chronic lung disease and

Congestive Heart Failure

Cost of Substance Use Disorders

Individuals with SUD incur between two (Parthasrathy et al., 2001) and three (McAdam-Marx et al., 2010; Thomas et al., 2005) times the total medical expenses of people who do not have SUD.

Payment Reform•Fee for service•Pay per volume

•Pay for value•Pay for performance

(OHA) Oregon Metrics and Scoring Committee – CCO Performance

Michael Bailit October 10, 2012

1. CAHPs Composite (7Qs)2. Rate of PCPCH enrollment3. ED Utilization (HEDIS)4. Initiation and Engagement of AOD5. Follow-up after hospitalization for mental

illness6. Composite measure: mental health and

physical health/assessment for children in DHS custody

7. Screening for clinical8. Depression and follow-up plan

(OHA) Oregon Metrics and Scoring Committee – CCO Performance

Michael Bailit October 10, 2012 (Continued)

9. Prenatal care10. Developmental screening by 36 months (hybrid)11. Colorectal Cancer12. Screening (hybrid)13. Alcohol and Drug misuse, screening, brief

intervention and referral for treatment (SBIRT)14. Optimal Diabetes Care (D3)15. Controlling Hypertension16. Adolescent Well-Care Visit17. EHR Composite measure

Behavioral Medicine: Rediscovering the Neck

PatientsTargeted Behavior Change

Skilled CommunicationRelationshipPatient Satisfaction

PractitionersEBP Guidelines

What is Treat to Target?• The concept gained traction in

diabetes and rheumatology care, but it is now achieving wider applications in all health care

• Treating to achieve a measurable and agreeable target (practitioner and patient), and changing the care plan when the interventions are not achieving the target

• Common sense (but common sense is not that common)

Treat to Target

• Some examples: Hemoglobin A1C in Diabetes Disease activity markers in

Rheumatology Days of use in Substance Use Disorders Symptom Reduction in Mental Health :

ACORN

Motivational Interviewing and Patient Centered Care

• Big demand on training new and current medical and BH practitioners workforce in Motivational Interviewing skills

• Addresses Motivation and Behavioral Change

• Hand and glove with Treat to Target• Hand and glove with patient

activation, patient self-regulation and self-efficacy enhancement

• Hand and glove with patient satisfaction

MI efficacy on treatment adherence

• In a majority of controlled studies (12 of 21) MI was found to produce significant adherence effects (Miller and Rollnick, Motivational Interviewing, second edition page 306, 2002)

• Nicotine cessation: MI has shown to impact outcomes of nicotine cessation efforts when coupled with NRT

• Example of adherence studies: MI and effectiveness in facilitating transition of

clients from one level of care to the another (Swanson, Pantalon and Cohen 1999)

Six studies found effects on measures of attendance, treatment commitment, readiness for change, and task completion, and medication compliance

What are the active ingredients?

• Practitioner empathy – MI teaches active listening and empathic responses

• MI trained practitioners do less of non empathic interactions such as directing the conversation, not listening, not collaborating, and confronting

• Practitioners who are better in MI have patients who respond with more “change talk” and change talk predicts behavioral change

Patient Centered Care Clip 5 min

• http://www.youtube.com/watch?v=dm-rJJPCuTE

Challenges and Opportunities

• Find a partner in the audience.• Take a few minutes to jot down what

do you think the transformation towards behavioral medicine will look like?

• What are the challenges?• What are the opportunities?

Models for Integration

What is “Primary Care Integration”?

• Collaboration between SUD and MH service providers and primary care providers (e.g., FQHC’s, CHC’s)

• Collaboration can take many forms along a continuum*

*Source: Collins C, Hewson D, Munger R, Wade T. Evolving Models of Behavioral Health Integration in Primary Care. New York: Millbank Memorial Fund; 2010.

MINIMAL BASICAt a Distance

BASICOn-Site

CLOSEPartly Integrated

CLOSEFully Integrated

Coordinated Co-located Integrated

The Primary Care System

SUD Care Syste

m

Minimal Coordination

• BH and PC providers – work in separate facilities, – have separate systems, and – communicate sporadically.

MH Care Syste

m

The Primary Care System

• BH And PC providers Engage in regular

collaboration and communication about shared patients leading to improved coordination

Basic AT A DISTANCE

SUD Care Syste

m

MH Care Syste

m

Two-way communication

Two way communication

Two-way communication

At a Distance Example• De Paul Treatment Centers counselor

attends interdisciplinary team meetings at Legacy Pain Management Center (pharmacist, physicians, nurse, social worker).

• Patients with chronic pain and SUD are referred to De Paul’s chronic pain tx. program (DBT and CBT).

• Information exchanged bi-directionally throughout treatment.

• De Paul expert provided patient centered care training for practitioners at Legacy

The Primary Care System

• BH and PC providers Still have separate systems, or

share some systems (EMR access, scheduling)

Allows for face to face between providers

Basic On Site (co-location of services)

Referral

MH Care Syste

m

Referral

SBI

Counseling

SUD Care Syste

m

MH Services

Counseling

Co-location Example• Legacy Good Sam clinic care team: Outreach

caseworker from CareOregon, social worker, nurse case manager, pharmacist, SUD counselor from De Paul.

• Behavioral health clinicians are co-located at the primary care clinic. Behavioral health and primary care providers share patients and coordinate care.

• Specialty mental health or SUD referrals happen but most BH treatment happen in primary care.

• The patients experience MH and SUD counseling as part of PC

• BH and PC providers share the same facility, patient experiences BH tx as

part of PC have systems in common (e.g., financing, EMR,

management) regular face-to-face communication, treatment plan

and treat to target plans are shared and coordinated

Integrated

The Primary Care SystemSUD Care Syste

m

MH Care Syste

m

CCO’s Leadership and Management New Core Competencies

CCO’s need leaders and managers who are skilled in:• Leadership• Innovation and change management,• How health care and behavioral health operates,• How to incorporate evidence based prevention and innovation to reduce preventable disease (obesity, tobacco, eating, exercise, depression, risky drinking and drug use)•And can embrace payment reform.

Several New Team MembersCare Manager/ BH Consultant• Behavioral activation• Health literacy• Health education• Case management• Coaching• Follow up

Consulting MH Expert• Caseload consultation for PCP and CM• Diagnostic consultation in difficult cases• EB guidelines for referrals to specialty

SUD counselor• Recovery management• EB guidelines for

referrals to specialty• Case management• Health literacy

Community Health Worker• Promote health • Trusted community

members• Address social

determinants• Remove barriers to

health• Advocacy and

education• Health literacy

Peer mentor • Recover

y• Wellnes

s

What about the Physicians???

Physicians• Have big demands on their time• Vary on “health care transformation

readiness”• Are glad to have a BH experts on care team

to do a warm hand off• Seldom have expertise or skills to deal with

MH and SUD• Depend to a large extent on their

communication skills to be successful• Training on “Patient Centered Care”

What about the BH providers?

BH Providers• Have big demands on their time• Vary on “health care transformation

readiness”• Would be glad to collaborate with doctors

on patient care but feel unskilled in the medical field

• Training on basic concepts of chronic disease management (such as diabetes, hypertension, asthma etc.)

• Are skilled on improving client self-efficacy and self regulatory skills using Motivational Interviewing and Brief Therapy

Behavioral Health Field Transformation

• Less long-term – “fern and lamp” – 50 min session therapies

• Shorter inpatient and outpatient lengths of stay

• More short term, brief intervention, Treat to Target treatment – increase on the “back door”

• More treatment at non-traditional settings; e.g., primary care, mobile van, housing site, community based, school and home

• More access to primary care at BH facilities

Medicine will look more like BH and BH will look more like

medicine = Behavioral Medicine

Contacts

• sheilan@depaultreatmentcenters.org

• chrisf@depaultreatmentcenters.org

De Paul Treatment Centers

503-535-1151 (Downtown- Adult)503-535-1181 (NE- Youth)

503-693-3104 (Hillsboro- Outpatient)

www.depaultreatmentcenters.org