The GPE Success Story: The Positive Public Health Impact of the Graduate

Psychology Education Program

Alex Ross, ScD, Health Resources and Services Administration Bruce Rybarczyk, PhD, ABPP, Virginia Commonwealth University Joseph Evans, PhD, University of Nebraska Medical Center Moderator: Karen Studwell, JD, American Psychological Association

Training Health Service Psychologists for Practice in Integrated Care Settings

American Psychological Association

Leadership Conference September 15, 2014

Alexander F. Ross, Sc.D. Senior Behavioral Health Advisor

Division of Nursing and Public Health Bureau of Health Workforce

Health Resources and Services Administration U.S. Department of Health and Human Services

Goal For This Presentation

Highlight the role of training psychologists for practice in the re-designed primary care and broader healthcare system.

Current policy issues involved in integration of behavioral health into the PCMH

Available Workforce • Approximately 11.1 million adults aged 18 or older (4.9 percent of

adults) reported an unmet need for mental health care in 2010, including 5.2 million adults aged 18 or older who reported an unmet need for mental health care and did not receive mental health services.

• Upwards of 11 million of the newly enrolled individuals may have a need for behavioral health services based on the prevalence of behavioral health disorders in the general population.

• According to the Bureau of Labor Statistics, the projected growth in behavioral health employment opportunities nationally between 2010-2020 is: o Psychologists: 22% in job opportunities (+37,000 positions over

2010).

• NHSC - Behavioral health care providers comprise nearly one in three clinicians in the NHSC (2,800/8,900 as of September 2013). 622 of the more than 2,800 behavioral health providers in the Corps are Clinical Psychologists. o More than 1,300 behavioral health providers –

approximately 15 percent of total NHSC field strength of 8,900 clinicians – served at rural sites in the past year.

• Health Centers - Licensed clinical psychologists are key

members of primary care teams in health centers – where the medical home model is taking shape. o There are almost 500 psychologists working in health

centers/over 500,000 patient visits a year.

Supporting the role of psychologists in integrated care

A number of forces are moving the field in the direction of integrated practice:

• The role of interprofessional education in building a more collaborative workforce.

• Primary Care providing more behavioral health Managed Care carve-ins.

• Financing integrated care – Medicare, Medicaid (Health

Homes), CMMI.

How do these forces relate to the future training of psychologists through HRSA-funded programs?

Training Psychologists to Practice on Integrated Teams

HRSA’s Behavioral Health Training and Education Programs

• Graduate Psychology Education Program (GPE) Prepare doctoral psychology students to work in organizations who serve the vulnerable and underserved populations, on integrating behavioral health, primary care, and public health competencies, and on interprofessional practice.

• Mental and Behavioral Health Education and Training Program (MBHET)

Purpose is to increase the number of master level social workers and Ph.D. psychologists who pursue clinical work with high need and high demand populations – namely rural, vulnerable, and/or underserved groups.

Behavioral Health Workforce Education and Training (BHWET) for

Professionals (new) To help fill the gap in available mental health service providers; two new grant programs funded through a joint initiative with SAMSHA and HRSA to train social workers, counselors, psychologists, and other mental health professionals/paraprofessionals.

• Two tracks: 1) didactic focusing on schools/programs and curricula design, 2) experiential focusing on the practice based experience. Recent increase in funding allowed awards to increase from 16 to 40.

• Schools/programs must consult with and utilize the expertise at the pre-degree internship sites in their own curriculum development and instructional design.

• Pre-degree internships must demonstrate how trainees are applying new paradigms and concepts through practice in their internship experiences.

• Hearing from two great examples here today.

Graduate Psychology Education Program

• Special emphasis on serving veterans, military, and their families.

• 24 schools and programs received grant awards in FY 2012 – funded out of the Prevention and Public Health Fund up front for 3 years.

• These grants will train 335 social workers and 98 Ph.D. psychologists over three years.

Mental and Behavioral Health Education and Training Program

In support of the White House’s Now is the Time initiative, aims to expand the mental health and substance abuse workforce targeting children, adolescents, and transitional-age youth at risk for developing or who have developed a recognized behavioral health disorder.

The program has a special emphasis on developing curriculum that address the needs of individuals ages 16 to 25 at high risk for mental illness and include stipends to train more mental health professionals serving young people in our schools and communities.

Applications are going through the review process and awards will be made shortly.

Behavioral Health Workforce Education and Training for Professionals (new)

• GPE - semi-annual reporting: program characteristics, demographic and program completion data related to student trainees who receive stipends, characteristics of the settings where internships and trainings take place, activities related to curriculum development and enhancement, and characteristics of faculty development programs.

• MBHET – overall number of enrolled students, create more field placement and internship slots for students working with high need and high demand populations, the number of graduates who entered practice in area of high need and low behavioral health resources; place more students in these field placements and internships.

• BHWET - guidance will be provided in the Notice of Award in September.

Measuring the performance of Behavioral Health Interprofessional Training Programs

SAMHSA/HRSA Center for Integrated Health Solutions (CIHS) • Technical Assistance and Training Center on Primary and Behavioral

Health Integration A strong emphasis on building a well trained integrated care workforce www.integration.SAMHSA.gov

• CIHS Framework Tables

Determine where you (as a psychologist) fit with integrated care models http://www.integration.samhsa.gov/integrated-care-models

• Business Models

• The case for integration of behavioral health and guidance on how to evaluate this business case for a primary care provider organization.

http://www.integration.samhsa.gov/resource/the-business-case-for-the-integration-of-behavioral-health-and-primary-care

Partnership to Promote Integration

Core Competencies

1. Interpersonal Communication

2. Collaboration & Teamwork

3. Screening & Assessment

4. Care Planning & Care Coordination

5. Intervention

6. Cultural Competence & Adaptation

7. Systems Oriented Practice

8. Practice-Based Learning & QA

9. Informatics

The Role of Psychologists in Integrated Care and Education/Training

Conclusion HRSA-funded training and education programs – increased investments in training the future psychology workforce to work in integrated care settings and improve care for underserved populations. Themes these programs share in common: • Recruit new students interested in pursuing a clinical concentration with

identified special populations; • Develop and implement interprofessional training; • Add to existing, expand and/or foster the development of new pre-degree

internship slots for PhD/PsyD psychology students or field placements for MSW students;

• Provide stipend support for students for the required field placement or pre-degree internship requirements;

(and)

The role of psychologists as a vital part of the integrated care team is very encouraging.

Contact Information

Julia Sheen-Aaron Branch Chief, Public Health and Behavioral Health

Bureau of Health Workforce Health Resources and Services Administration

Jsheen-aaron@hrsa.gov www.hrsa.gov

The Behavioral Health Training and Education Programs Team

Miryam Gerdine Gloria Ortiz Sylvia Joice Seh Welch

Alexander F. Ross

Senior Behavioral Health Advisor Division of Nursing and Public Health

Bruce Rybarczyk, PhD Professor

Associate Director of Clinical Training

Clinical Psychology Program Virginia Commonwealth University

A Training Program in Primary Care

Psychology: Meeting Future

Workforce Needs & Promoting Mental

Health Access for the Underserved

Primary care medicine is the de facto first line of mental health service in our country.

Jeffrey L. Goodie, Ph.D.

VCU Primary Care Psychology Twofold Mission Mission Part I: to equip future psychologists to meet the

workforce demands of a changing healthcare system --predicated on expansion of PCMH and integrated behavioral services.

Mission Part II: to address unmet mental health and behavioral health needs by providing brief, interdisciplinary-focused services in Richmond safety net primary care clinics.

Barriers to workforce development in PC psychology Training world slow to respond to changes in

health care Absence of faculty with knowledge Absence of sites/partners for training

(reimbursement issues) Clinical Health Psychology training, a natural fit,

has been focused on specialty and inpatient medical services

Paradigm shift Population based care Faster pace (think on feet) Be interruptible & flexible on session length Knowledge of basic disease

management Targeted and brief interventions More psycho-educational; less

psychotherapy No true termination of BHC services

Unique training aspects Variety, complexity, severity Learning to think on your feet and be flexible Inter-professional training, collaboration and

communication Vertical team and co-treatment opportunities:

“watch one, do one, teach one" Real-time same day supervision in place of weekly

hour-long meetings Clinical research opportunities Efficiency of time in clinical hours

How to be effective Be accessible Be a generalist Be a teacher: help PCPs build skills,

knowledge Be in the chaos Be a team player

Mission Part 1 Outcomes • Since 2008, over 55 students from all class levels of the VCU Clinical and Counseling

Psychology PhD programs have participated; > 20 fully or partially funded. • ~75% of students who have advanced to internship selected a site where they continue

primary care training. • 6 students have advanced to post-doctoral fellowships that include primary care and 4

licensed graduates since the program inception are now in primary care staff positions • 7 licensed clinical faculty members or affiliate faculty members have received funding to

provide training and on-site supervision. • Since 2010, 10 tri-annual team-based learning workshops to foster interdisciplinary

collaboration with >90 trainees per session from psychology, medicine, and pharmacy.

Table 2: Psychology Trainee Satisfaction Ratings Mean answers for N= 30 graduate student trainees (January, 2013) (0 = Strongly Disagree, 1 = Moderately Disagree, 2 = Neutral, 3 = Moderately Agree, 4 = Strongly Agree) MEAN Score "My training experience in Primary Care Psychology..." 3.6 1. Substantially enhanced my interdisciplinary communication skills. 3.2 2. Led me to view primary care as a top choice for a career path if a job opportunity was available. 3.6 3. Led/will lead me to look for an internship that includes a similar rotation. 3.5 4. Greatly enhanced my confidence in working with challenging situations. 3.5 5. Provided excellent training in administering brief interventions. 3.9 6. Enhanced my belief that integrating psychologists into primary care will be important for reducing health care costs.

Anonymous Internal Medicine Resident Survey (N=34)

Strongly Disagree

Somewhat Disagree

Somewhat Agree

Strongly Agree

EFFECTIVENESS

Having psychology clinicians present has enhanced the care received by patients at Primary Care.

3% (1) 0% (0) 23% (8) 74% (25)

TRAINING EXPERIENCE

The presence of psychology clinicians has significantly enhanced the training at the Primary Care residency program.

3% (1) 6% (2) 60% (20) 30% (10)

CAREER PLANNING IMPACT

I am more likely to continue working in underserved care if I can work with a program similar to the Primary Care Psychology Program.

19% (6) 13% (4) 50% (16) 18% (6)

EFFICIENCY

I am able to see a greater proportion of my patients within the 20 minute appointment times as a result of the Primary Care Psychology Program.

23% (7) 32% (10) 39% (13) 7% (2)

Mission Part 2 Outcomes Since 2008, provided over 8,000 sessions of free care to

underserved patients.

Most patients have significant difficulty accessing mental health services and many have never seen a mental health clinician.

Services provided at 4 different urban clinics in Richmond: adult

and pediatric primary care at the VCU Medical Center, the Daily Planet Clinic for the Homelessness, and the Fan Free Clinic.

Dissemination: 4 publications, 3 master’s theses, and 3 dissertations addressing the efficacy of integrated primary care.

Services We Provide Mental Health

Depression Anxiety Panic Disorder Somatization Adjustment Suicide Risk

Assessment Brief Cognitive

Evaluations

Behavioral Health Motivational

interviewing Pain management Behavioral Treatment

of Insomnia Smoking Cessation Medication

adherence Diabetes

management Diet/Weight loss Coping with chronic

disease

Interventions are brief, problem-focused, and generally based on cognitive-behavioral principles

Does not feel like getting out of bed most days.

Underserved = Complex, Multi-layered

SRRS-R

Sadock, E., Auerbach, S.M., Rybarczyk, B. Aggarwal, A., & Lanoye, A. (in press). The Relationship of life stressors, mood disorder and health care utilization among primary care patients referred for integrated behavioral health services. Journal of Nervous and Mental Disorders.

Snapshot of Data from Recent Studies by Students

10

11

12

13

14

15

16

17

referral day last session 6-12 months f/u

PHQ-9 Scores over time

MCV N= 147 subset (n=48) Hays Clinic Control (N = 139)

9

10

11

12

13

14

15

Referral Day Last Session 6-8 month F/U

GAD 7 scores over time

MCV N = 147 subsample (N = 48) Hays Control (N = 139)

The Impact of a Primary Care Psychology Training Program on Medical Utilization

in a Community Sample Autumn Lanoye ● Thesis Defense ● July 25, 2014

Results: ER Use Not Followed by Inpatient

*

***

† p < .10 * p < .05

** p < .01 *** p < .001

ns

Integrated Behavioral Health in Pediatric Primary

Care

Joseph H. Evans, PhD Professor

Munroe-Meyer Institute University of Nebraska Medical

Center

UNMC Munroe-Meyer Institute

Addressing Pediatric Behavior Issues • Parents most often bring their children with

behavior problems to primary care physicians first (Wildman, Stancin, Golden, & Yerkey, 2007).

• Up to 25% of all Pediatric visits are for specific behavioral health concerns (Lavigne, Gibbons, Arend, et al, 1999; Williams, Klinepeter, Palmes et al, 2004, Cooper, et al, 2006).

• During 50% to 80% of child health care visits,

parents or physicians raise concerns of behavioral or psychosocial issues (Sharp, Pantell, Murphy, & Lewis, 1992).

What Parents/Docs Expect!!!!

What Parents/Docs Sometimes Get!!!

Behavioral Problems Presenting in Pediatric Primary Care • Non-compliance • Excessive Tantrums • Elimination Disorders

– Enuresis – Encopresis

• ADHD – Inattentive – Hyperactive/Impulsive – Combined

• Sleep Disorders • Learning Disabilities • School Behavior

Problems & Refusal • Developmental Delays • Depression • Anxiety • Relationship Problems

LB 556 Screenings (11-2013 through 5-2014)

Addressing Pediatric Behavior Issues Problem: Shortage of Trained Peds BH Specialists - Significant MH professions shortages exist in 2/3

of U.S., particularly in rural areas (HRSA, 2009) - Appointments for Child Psychiatry or Psychology

or LMHP can take weeks or even months - Patient follow-through with BH referrals = 46%

for children and 25% for adults (Briggs-Gowan, 2000; Strosahl, 2006)

- Physicians not well-trained nor comfortable with Behavioral Health problems

One Solution: Integrated

Behavioral Health in Primary Care

• Defined as – Provision of BH care within a primary health

care setting – Integration of behavioral and physical health

care services – Preventive and first line interventions for

common behavioral/mental health problems presenting in primary care practices

MMI Pediatric Psychology Integrated BH Internship Data • Last 11 Years (2004 to 2016) - Funding

from HRSA BHPr: Graduate Psychology Education (GPE) grants

• Last 3 Years (2012 to 2015) – HRSA Mental & Behavioral Health Education and Training (MBHET) grant

• Other Funding: LEND and Americorps • NICPP – MMI Interns = 113 • 50%+ enter Primary Care

Why Pediatric Integrated Care? Primary Care Pediatricians are “de facto”

first line mental health providers!!! – 60% of all care mental health visits occur in Primary

Care settings (Magill & Garrett, 1988)

– 25% pediatric PC visits include behavioral health concerns (Cooper, Valleley, Polaha, Begeny, Evans, 2006)

– Pediatricians ranked behavior as most common problem (over otitis) (Arndorfer, Allen, & Aljazireh, 1999)

– Pediatricians receive one month of Developmental and Behavioral Peds formal training during their residencies!!!

BH Treatment in Pediatric Primary Care

80-85% BH Tx in PC

10-15% Referral & Community Tx 5% Specialty Care

UNMC Training in Integrated Behavioral Health in Primary Care-

1997-2014 Mission

• Attract, Recruit, Train, Place and Retain Behavioral Health Providers in Primary Care Practices (Pediatric and Family Medicine)

• Provide “Learning Through Service” & Modeling Opportunities - Provision of Behavioral Health in underserved areas

• Training for Physicians in Community Settings • Research and Program Evaluation • DISSEMINATION and Replication

MMI Integrated Pediatric Behavioral Health Training Program

Medical psychology training focuses on “Bodily Systems” and Diseases:

– Cardiology – Pulmonology – Endocrinology – Oncology – Gastroenterology – Orthopedics, etc – Psychiatry (OCD,

Dementia, Schizophrenia Depression, etc)

Primary Care psychology training focuses on Prevention & Wellness: In Pediatrics, • Scheduled check-ups • Anticipatory guidance • Screening • Acute Care protocols • Management of Common

Health issues • Wellness Activities • Knowing When & to Whom to

Refer

UNMC/MMI Integrated BH Faculty, Interns, & Post-Docs-2014

Scottsbluff

Pawnee Richardson

Saline

Nebraska Cities Served by Munroe-Meyer Pediatric Behavioral Health

Banner

cc

Dakota

Clay Fillmore

Gage

Sioux Dawes Sheridan Cherry

Kimball

Box Butte

Morrill

Cheyenne

Garden

Deuel

Grant Hooker

Arthur

Keith

Perkins

Chase

Dundy Hitchcock

Hayes

Red Willow

Frontier Gosper

Furnas

Thomas Blaine Loup

McPherson Logan

Lincoln

Custer

Dawson Buffalo

Phelps

Harlan Franklin Webster

Kearney

Sherman

Valley Greeley

Howard

Wheeler Garfield

Keyapaha Boyd

Brown Rock

Holt Knox

Antelope

Boone

Cedar

Dixon

Pierce

Adams

Nuckolls Thayer Jefferson

Wayne Thurston

Nance

Stanton Cuming Burt

Platte Colfax Dodge

Madison

Washington

Polk Butler Saunders

Douglas

Johnson Nemaha

Merrick

Hamilton York Seward Lancaster

Sarpy

Cass

Otoe Counties Served by Pediatric Behavioral Health

Hall

Clinics Serving Pediatric Behavioral Health

129 69

137

6

133

15

148

119

40

43

68

12

7 45

36 33

237 198

159

269 99

64

301

156

233

202 142

153 21

272

151

280

79

117

131

60

101

98 112

256

168

263

41

95

35

197

279

226 47

171

201

243

3 262

113

54

259

305

190

164 85

70

147 160

146

249 14

81 252

143

254

267

82

120

4 138

26

274 84 275

19

167

293

281

28

158

221

49

232 161

16

34 106

234 285 31 89 210

29

213

270

76

207

240

38

3

52

155

189

236

294

223

195

228

1. Abie (Butler) 2. Ainsworth (Brown) 3. Albion (Boone) 4. Alda (Hall) 5. Allen (Dixon) 6. Alliance (Box Butte) 7. Alma (Harlan) 8. Amelia (Holt) 9. Amherst (Buffalo) 10. Anselmo (Custer) 11. Ansley (Custer) 12. Arapahoe (Furnas) 13. Arcadia (Valley) 14. Arlington (Washington) 15. Ashby (Grant) 16. Ashland (Saunders) 17. Auburn (Nemaha) 18. Aurora (Hamilton) 19. Avoca (Cass) 20. Axtell (Kearney) 21. Ayr (Adams) 22. Bassett (Rock) 23. Battle Creek (Madison) 24. Beatrice (Gage) 25. Beaver City (Furnas) 26. Beaver Crossing (Seward) 27. Belgrade (Nance) 28. Bellevue (Sarpy) 29. Bellwod (Butler) 30. Bennet (Lancaster) 31. Bennington (Douglas) 32. Bertrand (Phelps) 33. Bladen (Webster) 34. Blair (Washington)

35. Bloomfield (Knox) 36. Blue Hill (Webster) 37. Boelus (Howard) 38. Brainard (Butler) 39. Bridgeport (Morrill) 40. Broken Bow (Custer) 41. Burwell (Garfield) 42. Cairo (Hall) 43. Callaway (Custer) 44. Cambridge (Furnas) 45. Campbell (Franklin) 46. Carleton (Thayer) 47. Carroll (Wayne) 48. Cedar Bluffs (Saunders) 49. Cedar Creek (Cass) 50. Central City (Merrick) 51. Ceresco (Saunders) 52. Chadron (Dawes) 53. Chambers (Holt) 54. Chapman (Merrick) 55. Chappell (Deuel) 56. Chester (Thayer) 57. Clarks (Merrick) 58. Clarkson (Colfax) 59. Clatonia (Gage) 60. Clay Center (Clay) 61. Clearwater (Antelope) 62. Coleridge (Cedar) 63. Columbus (Platte) 64. Cook (Johnson) 65. Cordova (Seward) 66. Cortland (Gage) 67. Cotesfield (Howard) 68. Cozad (Dawson)

171. Madison (Madison) 172. Marquette (Hamilton) 173. Marsland (Dawes) 174. Martell (Lancaster) 175. Martin (Hall) 176. Mason City (Custer) 177. Max (Dundy) 178. Maxwell (Lincoln) 179. Maywood (Frontier) 180. McCool Junction (York) 181. McCook (Red Willow) 182. Mead (Saunders) 183. Meadow Grove (Madison) 184. Memphis (Saunders) 185. Merna (Custer) 186. Milford (Seward) 187. Miller (Buffalo) 188. Minatare (Scottsbluff) 189. Minden (Kearney) 190. Monroe (Platte) 191. Mullen (Hooker) 192. Murdock (Cass) 193. Murray (Cass) 194. Naponee (Franklin) 195. Nebraska City (Otoe) 196. Nehawka (Cass) 197. Neligh (Antelope) 198. Nelson (Nuckolls) 199. Nenzel (Cherry) 200. Newman Grove (Madison) 201. Norfolk (Madison) 202. Norman (Kearney) 203. North Bend (Dodge) 204. North Platte (Lincoln)

273. Swanton (Saline) 274. Syracuse (Otoe) 275. Talmage (Otoe) 276. Taylor (Loup) 277. Tecumseh (Johnson) 278. Tekamah (Burt) 279. Tilden (Antelope) 280. Trumball (Clay) 281. Union (Cass) 282. Upland (Franklin) 283. Utica (Seward) 284. Valentine (Cherry) 285. Valley (Douglas) 286. Venango (Perkins) 287. Wahoo (Saunders) 288. Wallace (Lincoln) 289. Walthill (Thurston) 290. Walton (Lancaster) 291. Waverly (Lancaster) 292. Wayne (Wayne) 293. Weeping Water (Cass) 294. West Point (Cuming) 295. Western (Saline) 296. Weston (Saline) 297. White Clay (Sheridan) 298. Whitman (Grant) 299. Whitney (Dawes) 300. Wilber (Saline) 301. Wilcox (Kearney) 302. Winside (Wayne) 303. Wisner (Cuming) 304. Wood River (Hall) 305. York (York) 306. Yutan (Saunders)

Cities Outside of Nebraska Served by MMI

Pediatric Behavioral Health

IOWA 1. Ankeny 2. Atlantic 3. Carson

4

8

4

KANSAS 1. Almena

SOUTH DAKOTA 1. Batesland 2. Martin 3. Pine Ridge 4. Porcupine

1

258 204

24

58

115

125

175

103. Farnam (Dawson) 104. Filley (Gage) 105. Firth (Lancaster) 106. Fort Calhoun (Washington) 107. Franklin (Franklin) 108. Fremont (Dodge) 109. Friend (Saline) 110. Fullerton (Nance) 111. Furwell (Howard) 112. Geneva (Fillmore) 113. Genoa (Nance) 114. Gering (Scottsbluff) 115. Gibbon (Buffalo) 116. Giltner (Hamilton) 117. Glenvil (Clay) 118. Gordon (Sheridan) 119. Gothenburg (Dawson) 120. Grand Island (Hall) 121. Grant (Perkins) 122. Greeley (Greeley) 123. Greenwood (Cass) 124. Gresham (York) 125. Gretna (Sarpy) 126. Guide Rock (Webster) 127. Hallam (Lancaster) 128. Hampton (Hamilton) 129. Harrison (Sioux) 130. Hartington (Cedar) 131. Harvard (Clay) 132. Hastings (Adams) 133. Hay Springs (Sheridan) 134. Hazard (Sherman) 135. Heartwell (Kearney) 136. Hebron (Thayer)

209

282

248 211

264

193

1

118

63

132

108

163

I drive/Psych/Evans/Cities BHC located in 2006.ppt

299

114 276

112

183

9

20

56

261

273

222

105

1

69. Crawford (Dawes) 70. Creston (Platte) 71. Crete (Saline) 72. Crookston (Cherry) 73. Curtis (Frontier) 74. Dannebrog (Howard) 75. Davenport (Thayer) 76. David City (Butler) 77. Denton (Lancaster) 78. Deshler (Thayer) 79. Deweese (Clay) 80. Dewitt (Saline) 81. Dodge (Dodge) 82. Doniphan (Hall) 83. Dorchester (Saline) 84. Dunbar (Otoe) 85. Duncan (Platte) 86. Eagle (Cass) 87. Edgar (Clay) 88. Elgin (Antelope) 89. Elkhorn (Douglas) 90. Ellsworth (Sheridan) 91. Elm Creek (Buffalo) 92. Elmwood (Cass) 93. Elwood (Gosper) 94. Emerson (Dakota) 95. Emmet (Holt) 96. Ericson (Wheeler) 97. Eustis (Frontier) 98. Exeter (Fillmore) 99. Fairbury (Jefferson) 100. Fairfield (Clay) 101. Fairmont (Fillmore) 102. Falls City (Richardson)

137. Hemingford (Box Butte) 138. Henderson (York) 139. Hershey (Lincoln) 140. Hildreth (Franklin) 141. Holdrege (Phelps) 142. Holstein (Adams) 143. Hooper (Dodge) 144. Hordville (Hamilton) 145. Hoskins (Wayne) 146. Howells (Colfax) 147. Humphrey (Platte) 148. Hyannis (Grant) 149. Imperial (Chase) 150. Indianola (Red Willow) 151. Inland (Clay) 152. Johnson Lake (Gosper) 153. Juanita (Adams) 154. Julian (Nemaha) 155. Kearney (Buffalo) 156. Kenesaw (Adams) 157. Kilgore (Cherry) 158. LaVista (Sarpy) 159. Lawrence (Nuckolls) 160. Leigh (Colfax) 161. Leshara (Saunders) 162. Lexington (Dawson) 163. Lincoln (Lancaster) 164. Lindsay (Platte) 165. Litchfield (Sherman) 166. Loomis (Phelps) 167. Louisville (Cass) 168. Loup City (Sherman) 169. Lyons (Burt) 170. Macy (Thurston)

205. Oakdale (Antelope) 206. Oakland (Burt) 207. Octavia (Butler) 208. Odell (Gage) 209. Ogallala (Keith) 210. Omaha (Douglas) 211. Ord (Valley) 212. Orleans (Harlan) 213. Osceola (Polk) 214. Osmond (Pierce) 215. Overton (Dawson) 216. Oxford (Furnas) 217. Page (Holt) 218. Palisade (Hitchcock) 219. Palmyra (Otoe) 220. Panama (Lancaster) 221. Papillion (Sarpy) 222. Peru (Nemaha) 223. Petersburg (Boone) 224. Phillips (Hamilton) 225. Pickrell (Gage) 226. Pierce (Pierce) 227. Platte Center (Platte) 228. Plattsmouth (Cass) 229. Pleasanton (Buffalo) 230. Plymouth (Jefferson) 231. Polk (Polk) 232. Prague (Saunders) 233. Prosser (Adams) 234. Ralston (Douglas) 235. Randolph (Cedar) 236. Ravenna (Buffalo) 237. Red Cloud (Webster) 238. Richfield (Sarpy)

239. Richland (Platte) 240. Rising City (Butler) 241. Riverdale (Buffalo) 242. Riverton (Franklin) 243. Rosalie (Thurston) 244. Roscoe (Keith) 245. Roseland (Adams) 246. Rushville (Sheridan) 247. Saint Libory (Howard) 248. Sargent (Custer) 249. Schuyler (Colfax) 250. Scotia (Greeley) 251. Scottsbluff (Scottsbluff) 252. Scribner (Dodge) 253. Seward (Seward) 254. Shelby (Polk) 255. Shelton (Buffalo) 256. Shickley (Fillmore) 257. Shubert (Richardson) 258. Sidney (Cheyenne) 259. Silver Creek (Merrick) 260. Smithfield (Gosper) 261. Springfield (Sarpy) 262. St. Edward (Boone) 263. St. Paul (Howard) 264. Stanton (Stanton) 265. Stapleton (Logan) 266. Sterling (Johnson) 267. Stromsburg (Polk) 268. Sumner (Dawson) 269. Superior (Nuckolls) 270. Surprise (Butler) 271. Sutherland (Lincoln) 272. Sutton (Clay)

173

297

298

149

271 139

73

181 150

22

202

103

268

215

32

166 141

8

217

96

134

67

74

111

37

255

91

245

304

42

61

27 110

102

266

169

206

227

104

66 59

109

83 300

80 295

253

306

127

220

174 30

291

290 123

86 92 196

219

STATEWIDE IMPACT

225

2

135

50

296

218

90

93

97

65

159

144

187

212

192

235

72

2

3

71

162

246

4

188

251

39

205

88

229

241

278

62

130

235

199 284 157

87 100

303

10

11

176

185

94

55

203

177 107

140

194 242

179

216 44

128

208

152

260

250

128 18

116

224

172

53

191

247

230

277

244

77

178

288

265

23

200

57

154

17

286

121

214

239

231

257

238

287

51

184

182

48

283

186

165

136 78

46 75

289 170

13

292

302 145

126

124

180

South Dakota

Kansas

2

1

7

6

5

9

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31

32

33

34

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37

39

40

41

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44

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46

47

48

Iowa

38

4. Carter Lake 5. Clarinda 6. Clarksville 7. Cornelia 8. Council Bluffs 9. Crescent 10. Defiance 11. Emerson 12. Griswold 13 H b

14. Harlan 15. Honey Creek 16. Logan 17. Macedonia 18. Magnolia 19. Malvern 20. McClelland 21. Merrill 22. Minden 23 Mi l

24. Missouri Valley

25. Moorhead 26. Neola 27. New Market 28. Oakland 29. Pacific

Junction 30. Persia 31 R d l h

32. Red Oak 33. Shelby 34. Shenandoah 35. Sidney 36. Sioux City 37. Soldier 38. Spaulding 39. Tennant 40. Treynor 41 U d d

42. Vail 43. Walnut 44. Waterloo 45. Whiting 46. Whitten 47. Wiota 48. Woodbine

The Integrated Behavioral Health Model Components:

– Location, Location, Location: In the primary care practice

– Frequent contacts re: referrals with physicians and nurses

– Relationships with community schools, courts, agencies, other providers

– Provision of dx assessment info and clinical data for physicians (e.g., ADHD diagnostic protocols)

– Training in the “Business” of BH and primary care

Behavioral Health Clinics in Underserved Areas

Kearney (27,000) Physicians Clinic

Columbus (20,000)Pediatrics

Crawford (900) Medical Clinic

The MMI Integrated Behavioral Health Training Program

• Dissemination Locations: Current:

– Danville, Pennsylvania (Geisinger Health Systems – see APA Monitor)

– Tampa, FL (University of South Florida Peds) – Ann Arbor, Michigan (Univ of Michigan Peds) Planned: – Johnson City, Tennessee (ETSU) – Greenville, NC (Eastern Carolina University)

MMI Successes in Integrated Care RURAL Nebraska Clinics - 19 Integrated Sites with MMI Trained BH staff:

– 8 Owned – 4 Contracted – 7 Collaborating private practices URBAN Clinics (Omaha and Lincoln): – 19 of 24 Pediatric Practices in Omaha are integrated (13 with MMI trained Psychologists) – 4 of 7 Peds practices are integrated in Lincoln DISSEMINATION at 3 additional University/Community training sites in Florida, Pennsylvania and Michigan

BH Referral Follow Through:Traditional Referral vs Integrated BH Resources

0%10%

20%30%40%

50%60%70%

80%90%

BH Appointment FollowThrough

Strosahl AdultsBriggs-Gowan-kids0Overall IBH Clinics

Medication Cost Off-Set: Geisinger Clinics Pilot Project

Clinician Time Usage: University of Michigan Integrated BH Project

% Visit Type

Reimbursement Rate when NO

Behavioral Concern Raised

M (SD)

Reimbursement Rate when Behavioral

Concern Raised M (SD)

Average Difference in Reimbursements

per Minute

Acute 35% $16.68 (21.35) $5.89 (2.53) $10.79

Well-Child 28% $20.17(15.42) $9.34 (4.36) $10.83

Chronic 1% $7.37 (4.55) ‡ NA

Psych Consult

36% ‡ $5.02 (6.01) NA

Average $18.12 (18.56) $5.53 (15.57) $12.59 ‡Not included due to no occurrences

Reimbursements per Minute for Pediatric Primary Care Visits: MMI Integrated BH

Clinics