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Pathways in Primary Care
Victoria Egizio, PhDProgram DirectorPrimary Care Behavioral HealthUnityPoint Health-Meriter
Learning Objectives
• Be able to explain the rationale for integrating behavioral health services in primary care
• Be able to describe different models of integration
• Be able to identify options that may work at your organization
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Agenda• What Does the Research Tell Us?
• Models of Integrating Behavioral Health Services in Primary Care
• Steps You Can Take Back to Your Organization
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What Does the Research Tell Us?
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What Does the Research Tell Us?Disorder/Risk Factor Patients with at least 1
psychiatric diagnosisPatients with no psychiatric history
Hypertension 21.9% 18.8%Smoking 36% 21%Heart Disease 5.9% 4.2%Diabetes 7.9% 6.6%Obesity 42% 35%Asthma 15.7% 10.6%
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Data excerpted from www.samhsa.gov
What Does the Research Tell Us?
• 70% of all health care visits are generated by psychosocial factors, if not by frank psychiatric symptoms (Fries et al., 1993)
• Per a national survey-32% of undiagnosed, asymptomatic adults would likely turn to their primary care physician to help with mental health issues while only 4% would see a mental health provider (National Mental Health Association, 2000)
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What Does the Research Tell Us?
• A study of patients treated at 56 integrated care clinics showed greater improvement in hemoglobin A1c, cholesterol levels, and hypertension compared to patients treated at control clinics (Scharf et al., 2014)
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What Does the Research Tell Us?• The addition of psychological interventions
for Kaiser Permanente patients with serious medical conditions resulted in: – 77.9% reduction in their average length of
hospitalization – 66.7% reduction in hospitalization frequency – 48.6% decrease in number of prescriptions
written– 48.6% decrease in office visits– 45.3% decrease in emergency room visits– 31.2% decrease in telephone contacts
9Data excerpted from www.samhsa.gov
Models of Integrating Behavioral Health Services in Primary Care
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Excerpted from:Heath B, Wise Romero P, and Reynolds K. A Review and Proposed Standard Framework for Levels of Integrated Healthcare. Washington, D.C.SAMHSA-HRSA Center for Integrated Health Solutions. March 2013
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Models of Integration
• What does it look like clinically?– Team consultation and collaboration– Timely access to services– Generalist approach– Brief, empirically-based interventions
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Models of Integration• Collaborative Care
– Patients screened for depression in primary care (usually using PHQ-9)
– Patients with positive screenings (usually PHQ-9 scores of 10+) are assigned a care manager
– Care managers can be• Bachelor’s level providers • Psychiatric RNs• Master’s prepared therapists• Psychologists
• Further reading: UW AIMS (Advancing Integrated MH Solutions) Center at www.aims.uw.edu
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Models of Integration
• Care managers– Manage about 90-120 patients– Offer additional behavioral health screenings– Provide solution-focused interventions:
motivational interviewing, problem-solving, goal-setting, behavioral activation
– Offer triage to specialty behavioral health services
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Models of Integration
• Care managers support medication management– Have close communication with PCP and
Psychiatric Consultant• Enforce psychotropic medication compliance,
monitor for side effects, re-administer screening tools to assess symptom progression, etc.
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Models of Integration
• Behavioral Health Consultant– Embedded behavioral health providers in primary
care– See patients same-day and for scheduled
appointments– Visits are brief and solution-focused– Consultation resource
• Further Reading: Robinson, P. J., & Reiter, J. T. (2007). Behavioral Consultation and Primary Care. New York, NY: Springer.
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Models of Integration• Behavioral health consultant can be
– Psychologist – Master’s prepared therapist
• Behavioral health consultant workflow– Patient seen by PCP for psychiatric symptoms– “Warm handoff” to onsite behavioral health
consultant on same day as PCP visit• About 15-30 min encounters
• Initial interview• Solution-focused, evidence-based treatment
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Models of Integration
• Behavioral health consultants offer– 3-6 follow-ups (often linked to PCP visits)―Focal coping skills training aimed at referral
question NOT comprehensive psychotherapy―Bridge connection to specialty behavioral
health
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Steps You Can Take Back to Your Organization• Screen primary care patients for
behavioral health symptoms– PHQ-9, GAD-7 demonstration
• Administer PHQ-9 and GAD-7 at med checks to measure treatment response
• Discuss results with the patient to refine treatment plan
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Steps You Can Take Back to Your Organization• Assessing lethality risk
– In response to elevated scores on PHQ-9 item 9, administer C-SSRS
• C-SSRS demonstration– Helps determine thoughts vs plans vs intent– Use as treatment planning tool– Use to determine need for calling 911
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Steps You Can Take Back to Your Organization• Collaborative Safety Planning• https://suicideprevention-icrc-
s.org/sites/default/files/sites/default/files/events/17_7_26_icrc-sslides.pdf
• https://www.mirecc.va.gov/VISN16/docs/Safety_Planning_for_Older_Adults_Manual.pdf
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Steps You Can Take Back to Your Organization• Counseling on Access to Lethal Means
(CALM) – Online Training• http://training.sprc.org/• http://training.sprc.org/enrol/index.php?id=
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