Improving Behavioral Health Access for At-Risk Patients in an

Integrative Healthcare Site

Cassidy Freitas, M.A.Zephon Lister, Ph.D.William Sieber, Ph.D.

Collaborative Family Healthcare Association 15th Annual ConferenceOctober 10-12, 2013 Broomfield, Colorado U.S.A.

Session # D1bFriday, October 11, 2013

Faculty Disclosure

We have not had any relevant financial relationships during the past 12 months.

Objectives

1) Describe rates of depression screening by social demographics2) Describe the rates in which at-risk patients (lower SES, geriatric, minority group patients) are being identified as depressed, receiving behavioral health referrals, and following-through on behavioral health referrals3) Describe a multi-level integrative healthcare model that may bridge the disparity gap for these at-risk populations4) Discuss the experience of physicians who are practicing under the multi-level integrative care model that is suggested

Learning Assessment

Who are we?

Who are you?

What were your hopes in attending this presentation?

C.J. Peek’s Lexicon:Parameters of Integration

UCSD Department of Family and Preventive Medicine

1. Range of care team function and expertise that can be mobilized to address needs of particular patients and target populations

Foundational plus others for population•Triage/identification with registry and tracking/coordination functions•Complex or specialized mental health therapies•Complex or more specialized pharmacologic intervention

2. Type of spatial arrangement employed Co-located space•BH and PC clinicians in different parts of the same buildingFully shared space•BH and PC clinicians share the same provider rooms, spending all or most of their time seeing patients in that shared space•Typically, the clinicians see the patient in the same exam room

3. Type of collaboration employed Full collaboration/integration•Fully shared treatment plans and documentation, regular communication facilitated and/or clinical workflows that ensure effective communication and coordination

4. Method for identifying individuals Universal screening or identification process•All or most patients or members of clinic panel are screened or otherwise identified for being part of a target population

Health disparities can be defined as the unequal spread of disease across differentgroups, psychiatric disorders included.

Why the Focus on Depression?Depression is commonly found at the center of many medical illnesses

At-Risk Populations, Primary Care, and Depression

• Major Depressive Disorder affects approximately 15 million American adults a year1, and remains a costly and significant public health concern2.

• The United States Preventive Services Task Force suggests that depression screening should occur within primary care when support is in place to assure accurate diagnosis, treatment, and follow-through3.

1. Kessler et al., 2005; SAMHSA, 2007; U.S. Census Bureau, 20042. World Health Organization, 20043. US Preventive Services Task Force, 2002

At-Risk Populations, Depression, and Primary Care

• At-risk populations (such as the elderly, minority groups and low income) are at higher risk for depression and are likely to present within primary care1.

• These populations are also less likely to follow-through on behavioral health referrals and recommendations due to stigma and challenges in accessing care2.

1. Kessler et al., 20052. Kessler et al., 2001

The Elderly, Depression, and Primary Care

• In the month prior to their suicide, a majority of elderly patients had visited their primary care physician1.

• One study found that 20% of older adults who committed suicide saw a primary care provider on the same day2.

1. Luber et al., 20012. Luoma, Martin, & Pearson, 20023. Conwell, Duberstein, & Caine , 2002

• Depressed elderly primary care patients have increased

• Frequency of appointments (on average 2 more appointments a year)

• Number of lab tests, x-rays and scans• Nonspecific medical complaints1

Minorities, Depression, and Primary Care

• PC providers recommend depression treatments for Latino and African-American patients as frequently as they do for white patients, however…– Latino and African-American

patients are less likely to take anti-depressant medications

– Latinos are less likely to obtain specialty mental health care

– Both groups are more likely to present themselves within primary care rather than a specialty mental health clinic.1

• Ethnic minority patients have less collaborative relationships with their white providers than do white patients.5

• African Americans, Asian Americans, and Latinos had differing beliefs regarding the causes of mental illness when compared with whites.6

• Race/ethnicity associated with– Who makes healthcare decisions– Treatment preferences.6

1. Miranda & Cooper, 20042. Lee, Lei, & Sue, 20013. Duldulao, Takeuchi, & Hong, 20094. Cooper-Patrick et al., 19995. Jimenez et al., 2012

• While sometimes considered the ‘model minority,’ Asian Americans are also at risk for depression and suicidal ideations, particularly when they are U.S. born.3,4

Low Income, Depression, and Primary Care

• Expected challenges for low-income patients– Less resources– Poor access to care– Poor health behaviors

• 29% of Low income (<24k a year) Americans report they have been diagnosed with Depression, with an 18.7% gap difference between Low and High income (>90k a year) Americans.1

– Depression being one of the largest health disparity gaps experienced by Low Income Americans

1. Gallup-Healthways Well-Being Index, 2010

• An IPC model can create more – efficient coordination of services– can allow for scheduling of

several services in one appointment

– thus reducing the cost and ensuring greater follow-through for at-risk groups such as low-income minorities*1

* This is important since ethnic minority groups are more likely to delay treatment and receive less follow-up appointments.2, 3

• Simply having co-located mental health and primary care is not always the answer.

– One clinic serving predominately MediCaid patients found that co-located mental health care and primary care was providing only minimally adequate care for depressive patients, and that minority patients were less likely to receive any care.4

– Yet, there is a demand for specialty mental health services within primary care for those patients whose needs go beyond the several brief visits and interventions they would receive within other IPC models.

1. Peterson, 20112. Edelman, Gao, & Mosca, 20083. Mosca et al., 20104. Uebelacker et al., 2009

.

Methods

• Our data set• Sample• The variables that were used and how they

were defined

UCSD Stepped-Care Model

Physician Interviews

• Sample– 6 Physicians, 2 from each clinic– 2 Males, 4 Females– DO’s, MD’s– 4 Caucasian, 2 Asian American– All Physicians were either chosen to participate in T-CARE’s pilot year

or were identified as high T-CARE utilizers

• Physicians were interviewed who had been utilizing our complete stepped-care behavioral health model

• Our aim was program quality improvement, but we also uncovered that PC providers believed our new behavioral health structure was bridging gaps for our at-risk populations

Physician Interviews

– How do the doctors see the availability of BHC’s during patient visits in addition to having co-located traditional behavioral health options benefiting their at-risk patients?

– Themes:• Warm hand-off• Reducing stigma• Easier access• Resources

Physician Interviews

– “They [Depressed Geriatrics] are so hard to get into therapy, but there’s so much need. Their health is poor, their friends are dying so their social circle is getting smaller, their sphere of the world is getting smaller as they no longer feel safe driving on the freeway, their health is poor. I have one guy that I see every 2 weeks, I think just because he is lonely…having T-CARE put a face to this ‘voodoo thing called Therapy’ and when he got to see [BHC] we were then finally able to get him connected to one-on-one therapy.”

Physician Interviews

• “It [the stepped-care model] has been really useful for the patients who, if they don’t have a face that they’ve connected to in the office, would probably never follow-up.”

• “A specific example would be when I had a patient [Medi-Cal Latina Patient] whose daughter had recently committed suicide. She needed to talk to someone right then and there, and she was able to. I think she was comforted in knowing that somebody cares, somebody’s going to help me, and I don’t feel so desperate because I know help is coming. I think she was comforted in knowing that she had a follow-up appointment [with BHC] and a face to connect with to that appointment.”

Physician Interviews

• Other patient-types that PC Provider’s identified as finding our structure useful in behavioral health follow-through– Young families that are just overwhelmed and

have busy schedules– Depressed males– Military spouses and families– Postpartum mothers and fathers

Clinical Implications

• How is it impacting us programatically• Broader implications- how our findings might

be important to others who are working in similar environments or working with similar populations

Conclusions

• What can we say about our findings, what can’t we say

• Lessons learned• Future studies/directions

References• Conwell, Y., Duberstein, P. R., & Caine E. D. (2002). Risk factors for suicide in later life. Biological Psychiatry, 52(3), 193-204.• Cooper-Patrick, L., Gallo, J.J., Conzales, J. J., et al. Race, gender and partnership in the patient-physician relationship, JAMA, 1999, 282-583.• Duldalao, A. A., Takeuchi, D. T., & Hong, S. (2009). Correlates of suicidal behaviors among asian americans. Archives of Suicide Research, 13(3),

277-290.• Jimenez, D. E., Bartels, S. J., Cardenas, V., Dhaliwal, S. S., & Alegría, M. (2012). Cultural beliefs and mental health treatment preferences of

ethnically diverse older adult consumers in primary care. The American Journal Of Geriatric Psychiatry, 20(6), 533-542.• Kessler, R. C., Berglund, P. A., Bruce, M. I., Koch, J. R., Laska, E. M., Leaf, P. J., Manderscheid, R. W., Rosenheck, R. A., Walters, E. E., & Wang P. S.

(2001). The prevalence and correlates of untreated serious mental illness. Health Services Research Journal, 36, 987-1007.• Kessler, R. C., Chiu, W. T., Demler, O., Walters, E. E. (2005). Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the

National Comorbidity Survey Replication (NCS-R). Archies of General Psychiatry, 62(6), 617-627.• Lee, J., Lei, A., & Sue, S. (2001). The current state of mental health research on asian americans. Journal of Human Behavior in the Social

Encironment, 3, 159-178.• Luoma, J. B., Martin, C. E., & Pearson J. L. (2002). Contact with mental health and primary care providers before suicide: A review of the evidence.

American Journal of Psychiatry, 159(6), 909-916.• Luber, M., Meyers, B. S., Williams-Russo, P. G., Hollenberg, J. P., DiDomenico, T. N., Charlson, M. E., & Alexopoulos, G. S. (2001). Depression and

service utilization in elderly primary care patients. The American Journal Of Geriatric Psychiatry, 9(2), 169-176.• Miranda, J., & Cooper, L. A. (2004). Disparities in Care for Depression Among Primary Care Patients. Journal Of General Internal Medicine, 19(2),

120-126.• Petersen, S., Hutchings, P., Shrader, G., & Brake, K. (2011). Integrating health care: The clear advantage for underserved diverse populations.

Psychological Services, 8, 69-81.• Substance Abuse and Mental Health Services Administration (SAMHSA). (2007). Results from the 2006 National Survey on Drug Use and Health:

National Findings (Office of Applied Studies, NSDUH Series H-32, DHHS Publication No. SMA 07-4293). Rockville, MD.• Uebelacker, L., Smith, M., Lewis, A., Sasaki, R., Miller, I. (2009). Treatment of depression in a low-income primary care setting with colocated

mental health care. Families, Systems & Health, 27(2), 161-171.• US Preventive Services Task Force. (2002). Screening for depression: recommendations and rationale. Annals of Internal Medicine, 136, 760-764.• World Health Organization. (2008). The global burden of disease: 2004 update. Geneva, Switzerland: WHO Press.

Session Evaluation

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