Patricia C. Hasen, CDR, NC, USN Rocio Porras, LT, NC, USN Family Medicine Department Naval Hospital Camp Pendleton Integrating Behavioral Health Care into

Patricia C. Hasen, CDR, NC, USN

Rocio Porras, LT, NC, USN

Family Medicine Department

Naval Hospital Camp Pendleton

Integrating Behavioral Health Care into the

Navy Medical Home Port (Patient Centered Medical Home)

1AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort

Disclosure / Disclaimer

LT Rocio Porras and CDR Patricia Hasen have nothing to disclose.

The views and opinions expressed during this presentation do not necessarily reflect those of Naval Hospital Camp Pendleton,

the Department of the Navy or the Department of Defense.


Objectives

1. Define Behavioral Health and Health.

2. Verbalize the rationale for integrating Behavioral Health (BH) in the Patient Centered Medical Home (PCMH)

3. Discuss how integration of BH is in alignment and consistent with principles of the PCMH, the Quadruple Aim and the MHS.

4. Discuss the benefits of integrating BH in the PCMH.

5. Compare and contrast the three models of BH integration in the PCMH Describe how to build BH in your clinic.

6. Verbalize required elements for successful integration of behavioral health in an outpatient clinic setting.

7. Verbalize principles for leading and managing change


Define Behavioral Healthand Health

BEHAVIORAL HEALTH• “is integral to overall

health as mind and body are inseparable. As a general concept, behavioral health is the reciprocal relationship between human behavior and the well-being of the body, mind, and spirit, whether considered individually or as an integrated whole.” (PC-PCC, 2012)

HEALTH• “Health is a state of

complete physical, mental and social well-being and not merely the absence of disease or infirmity.”(WHO, 1946)


5

‘That depends a good deal on where you want to get to,’ said the Cat.‘I don’t much care where ’ said Alice.‘Then it doesn’t matter which way you go,’ said the Cat.‘ so long as I get somewhere,’ Alice added as an explanation.‘Oh, you’re sure to do that,’ said the Cat, ’if you only walk long enough.’(Carroll, 1865)

“…she was a little startled by seeing the Cheshire Cat sitting on a bough of a tree a few yards off...”‘Would you tell me, please, which way I ought to go from here?’

AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort

Cheshire Cat pictures (screencaps) from Disney's Alice Iin Wonderland. Image Source Page: http://www.alice-in-wonderland.net/pictures/cheshire-cat-pictures.html

Strain of Past Decade of War

6

U.S. Marine Corps photo by Cpl. Reece Lodder. Taken 19 April 2012. http://www.flickr.com/photos/40927340@N03/6963905442/

U.S. Marine Corps photo by Cpl. Alfred V. Lopez. Taken 22 April 2012. http://www.flickr.com/photos/40927340@N03/6963905682/


A Military Readiness Concern

7

U.S. Marine Corps photo by Cpl. Vanessa American Horse. Taken 2 April 2012. http://www.flickr.com/photos/40927340@N03/7044870495/

U.S. Marine Corps photo by Sgt. Mark Fayloga. Taken 19 Feb 2012. http://www.flickr.com/photos/40927340@N03/6776118198/


Whom We Serve

• Beneficiaries by Category

– Active duty: 1.7 million

– Active duty family: 2.4 million

– Retirees: 1 million

– Retiree family: 1.8 million

– Medicare-eligible: 2.1 million

Program Enrollment

• 5.4 million TRICARE Prime o 3.7 mil in direct care system o 1.7 mil in contractor networks

• 2.1 mil TRICARE Standard/Extra

• Others use TRICARE Reserve Select, TRICARE For Life

8

Over 9.6 Million Beneficiaries

Source: TMA, 2011.


Rationale for Integrating

Population Health•30.5% US adult population meets criteria for one or more mental health problems (estimated for a 1-year period) and only 32% of these receive treatment (Kessler, et. al., 2005).• 12-27% of US pediatric population meet behavioral health problem

criteria (Simonian, 2006; Sakolsky & Birmaher, 2008)• 11-17% of OEF/OIF combat veterans met BH screening criteria

(Hoge, et. al., 2004)• 80% of BH problems in US youths are not identified or treated

(Teen Screen, 2011)• MH problems are 2-3 times more common in patients with chronic

health problems (Katon, 2007; Dowrick, et al., 2005)• Half of all life-time BH disorders start by age 14 (TeenScreen, 2011)



Readiness•52% of all BH treatment occurs in Primary Care (Kessler, et al., 2005) •48% of all psychotropic drug visits occur in PC (Pincus, et al., 1998)•80% with BH disorder visit Primary Care at least once a year (Narrow, et al., 1993)•11-17% of OIF/OEF combat veterans met BH screening criteria; only 38-45% indicated an interest in receiving help; only 23-40% reported received professional help in the past (Hoge, et al., 2004)• 32% (average) of Military Health System beneficiaries report

difficulties accessing BH care (HCSDB, 2008; TMA, 2009)• 64% (average) of MHS beneficiaries report difficulties accessing

urgent BH care (HCSDB, 2008; TMA, 2009)



Per Capita Costs• Mental health conditions 3rd costliest medical condition (AHRQ,

2009)• 33.2% of adults being treated for BH concerns receive minimally

adqequate care (Wang, et al., 2005)• 30-50% of referrals from PC to outpatient BH clinic don’t make 1st

appt (Fisher & Ransom, 1997; Hoge, et al., 2006) • 84% of the time, the 14 most common physical complaints have no

identifiable organic etiology (Kroenke & Mangelsdorf, 1989)• 40% of premature deaths in the US are from behavioral factors

(Kindig & McGinnis, 2007) • Lower costs – medical use decreased 15.7% for those receiving

BH treatment and increased 12.3% for controls who did not receive BH treatment (Chiles, Lambert & Hatch, 1999)


12

Source: MHS 2012 Stakeholder’s Report http://mhs.osd.mil/About_MHS/StakeholdersReport.aspx



Determinants of Health

13

The actual causes of illness and death in the United States oftenrelate to personal behaviors that the health care system fails toaddress. To achieve our transformation from healthcare to health, wewill have to learn better ways to help people adopt a healthierlifestyle. In the near term, we will focus on ways to reduce obesityand reduce tobacco use.


Source: MHS 2012 Stakeholder’s Report http://mhs.osd.mil/About_MHS/StakeholdersReport.aspx


Experience of Care

•Better access to BH services•Stigma-free BH access•Better health outcomes•Improved satisfaction•Ongoing education to Medical Home teams and residents



Current military environment– Stigma– Family Readiness affects Military Readiness– Strain of past decade of war– Lack of BH capacity in MTF for Family members– Lack of community capacity for Family members– Lack of providers who accept TRICARE– Cultural gap between military and civilian providers


Summary of Rationale for Integrating

• BH problems are common• Complex inter-relationship between physical and psycho-social

symptoms• PC is largest platform for health care delivery in the US• PC is the defacto BH treatment platform• BH problems often go unrecognized in PC• When recognized, treatment is often suboptimal• BH problems compromise the quality and outcomes of treatment for

physical health conditions• The leading preventable cause of premature death is behavior• Appropriate BH treatment can alleviate impediments to well-being • BH treatment can assist in building resiliency and maintaining

military readiness


Benefits of Integration

When BH is integrated in the PCMH:•Less stigma - patients prefer to be seen at PCMH rather than specialty clinic•Better coordination - shorter wait times and better communication•Reduce morbidity with early recognition and treatment•Serve all patients - opportunity for prevention •Integration of physical and emotional care•Integrate screening and brief psychosocial update into visit - improved screening, recognition, identification, early intervention, treatment, monitoring •Conduct an assessment alone or collaboratively•Overcome barriers to seeking mental health care•Skills to build resilience, promote healthy lifestyles•Improves Military Readiness


Illustration in PC Morning Clinic

56 yo diabetic with poor control

19 yo smoker for P.E.

33 yo with multiple somatic complaints

7 yo for earache

67 yo w/insomnia

70 yo w/sinusitis

52 yo hypertensive patient for f/u

45 yo w/tinnitus

38 yo w/acute asthma

29 yo w/chest pain & SOB


Source: Blount, http://www.massleague.org/Calendar/LeagueEvents/BehavioralHealthConference/Blount-IntegratedPrimaryCareStories.pdf

Example with Highlighted Mental Health Needs

• 56 yo diabetic with poor control• 19 yo smoker for P.E.• 33 yo w/ multiple somatic complaints• 7 yo for earache• 67 yo w/insomnia• 70 yo w/sinusitis• 52 yo hypertensive patient for f/u• 45 yo w/tinnitus• 38 yo w/acute asthma• 29 yo w/chest pain & SOB

• Old Dx BPD

• Depression

• Alcohol abuse

• Panic disorder



Example with Highlighted Psychosocial Distress

• 56 yo diabetic with poor control• 19 yo smoker for P.E.• 33 yo with multiple somatic

complaints• 7 yo for earache• 67 yo w/insomnia• 70 yo w/sinusitis• 52 yo hypertensive patient for f/u• 45 yo w/tinnitus• 38 yo w/acute asthma• 29 yo w/chest pain & SOB

• Anxious (Old Dx BPD )

• (Depression)

• Bedwetting • (Alcohol abuse)• Family violence

• Hypochondriasis

• (Panic disorder)



Example with Highlighted Behavioral Health Needs

• 56 yo diabetic with poor control

• 19 yo smoker for P.E.• 33 yo with multiple somatic

complaints• 7 yo for earache• 67 yo w/insomnia• 70 yo w/sinusitis• 52 yo hypertensive patient for f/u• 45 yo w/tinnitus• 38 yo w/acute asthma• 29 yo w/chest pain & SOB

• Smoking/weight loss (Anxious; Old Dx BPD )

• Smoking cessation • (Depression)

• (Bedwetting )• (Alcohol abuse)• (Family violence )• Cardiac risk factors• (Hypochondriasis)• Medication compliance• (Panic disorder)



Integration is Consistent with Joint Principles of the PCMH

– Personal Physician

– Physician-directed Medical Practice

– Whole Person Orientation

– Care is Coordinated and/or Integrated

– Quality and Safety

– Enhanced Access

– Payment Reform


Integration is Consistent with the Quadruple Aim

• Readiness – Pre- and Post-deployment – Family Health – Behavioral Health – Professional Competency/Currency – Delivering the Right Care at the Right Time

• Population Health – Healthy service members, families, and retirees – Quality health care outcomes – Prevalence of BH conditions in PC

• A Positive Patient & Staff Experience – Patient and Family centered Care, Access, Satisfaction

• Cost– Responsibly Managed – Focused on value – Cost of unmet needs; decreased costs when address BH

needs


Integration is Consistent with the MHS Mission

• Provide optimal health services in support of our nation’s military mission—anytime, anywhere.

• DoD Mission To provide the military forces needed to deter war and to protect the security of our country.


Source: MHS. http://www.health.mil/About_MHS/Organizations/MHS_Offices_and_Programs/OfficeOfStrategyManagement.aspx

3 Models of Integration

1. Care Management Model

2. Primary Care Behavioral Health Model

3. Blended Model


Care Management Model

• Population-based model of care typically focused on a discrete clinical problem (e.g., depression).

• It incorporates specific pathways to systematically address how BH problems are managed in PC.

• PC providers & care managers share information via direct communication, shared medical record, treatment plan, and standard of care.

• Typically, there is some form of systematic interface with the outpatient mental health


Primary Care Behavioral Health Model

• Population-based model of focused on all enrolled patients (e.g., depression, anxiety, substance use, stress, obesity, diabetes, insomnia, chronic pain)

• BHC is embedded with PC team serving as a team member in the assessment, intervention & health care of the patient

• BHCs & PCMs share patient information, medical record & coordinate health care plans

• Brings a team-based management approach to care• BHC helps PC team improve BH assessment & intervention• BHC sees patients in 15-30 minute appointments in PC clinic• Same day as well as scheduled appointment availability• BHC focuses on full range of BH & health behavior change


Blended Model

• Focused on all enrolled patients• Care Manager and Embedded BHP

oContinuity of CareoStepped CareoAccess to all enrollees to BHC in the PCMH oClinical Feasibility and EfficiencyoImplements DoD/VA guidelines


Re-Engineering Healthcare Integration Programs (REHIP)

29

From: REHIP https://www.pdhealth.mil/education/2011_Presentations/AFPCH%2011%20Re-Engineering%20Healthcare.pdf


Blended Model

30

From: REHIP https://www.pdhealth.mil/education/2011_Presentations/AFPCH%2011%20Re-Engineering%20Healthcare.pdf


Building BH into Your Clinic

• Educate yourself – read your instructions, support documents• Educate your staff• Staffing ratios• Facilities – patients seen in the exam room; common check-in

areas; BH providers imbedded into the PCMH; can share office spaces with other providers

• Administrative support– Templates, business operations, position descriptions, 4th level

MEPRS, coding, POM, documentation– Ancillary support staff support– Handling referrals– Referrals to MH


Building BH into Your Clinic

• Training primary care providers and staff in prevention, recognition, management, and referral of adult and pediatric patients with social and emotional concerns is essential to fully integrating Behavioral Health into Primary Care

• Required skills of the Behavioral Health providers• Training program

– Phased training program through BUMED by qualified trainers– Didactic and practicum– Phase I – self guided, didactic– Phase II – Didactic, In Vivo, Feedback (San Antonio, July 2012)– Phase III – (6 mo following Phase II), Sustainment training, site

visits• Monthly teleconferences with other BH personnel


Principles for Leading & Managing Change

• Leading and managing change– Involve the stakeholders – that is the entire staff – in who, what,

where, when of integration, accessing BH, utilizing BH– Communicate, communicate, communicate – early and often– Delineate roles– Set up business plan – templates, coding, referral management,

appointing, develop patient registry– Care Coordination– Celebrate victories

• Lessons learned • Outcomes/Metrics/Dissemination


8-Step Process forLeading Change

1. Create urgency

2. Form a powerful coalition

3. Create a vision for change

4. Communicate the vision

5. Remove obstacles

6. Create short-term wins

7. Build on the change

8. Anchor the changes in corporate culture


Source: Kotter, J. (1996). Leading Change. Boston: Harvard Business School Press.

References

AHRQ. (2009). Heart Conditions, Cancer, Trauma-related Disorders, Mental disorders, and Asthma Were the Five Most Costly Conditions in 1996 and 2006. AHRQ News and Numbers, August 5, 2009.

Blount, A. (unk). What Does a Behavioral Health Clinician Add in a Primary Care Practice?: A Set of Stories. Available at http://www.massleague.org/Calendar/LeagueEvents/BehavioralHealthConference/Blount-IntegratedPrimaryCareStories.pdf

Carroll, L. (1865) Alice’s Adventures in Wonderland. London: Macmillan and Company. Available at http://www.readcentral.com/chapters/Lewis-Carroll/Alices-Adventures-in-Wonderland/003

Chiles, J., Lambert, M., & Hatch, A. (1999). The impact of psychological interventions on medical cost offset: A meta-analytic review. Clinical Psychology: Science and Practice, Vol., 6, pp. 204-220.

Croghan, T. W. and Brown, J. D. (2010) Integrating Mental Health Treatment Into the Patient Centered Medical Home. (Prepared by Mathematica Policy Research under Contract No. HHSA290200900019I TO2.) AHRQ Publication No. 10-0084-EF. Rockville, MD: Agency for Healthcare Research and Quality. Available at http://pcmh.ahrq.gov/portal/server.pt/gateway/PTARGS_0_12547_955657_0_0_18/Integrating%20Mental%20Health%20and%20Substance%20Use%20Treatment%20in%20the%20PCMH.pdf

Dowrick, C., Katona, C., Peveler, R., and Lloyed, H. (2005) Somatic Symptoms and Depression: Diagnostic Confusion and Clinical Neglect. British Journal of General Practice, pp. 829-830. Available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1570790/pdf/bjpg55-829.pdf

Fisher, L., & Ransom, D. (1997). Developing a strategy for managing behavioral health care within the context of primary care. Archives of Family Medicine, Vol. 6, Issue 4, pp. 324-333.


References

HCSDB. (2008). MHS Beneficiaries’ Access to Behavioral Health Care Issue Brief, Health Care Survey of DoD Beneficiaries (HCSDB), July 2008. Available at http://www.tricare.mil/survey/hcsurvey/issue-briefs/issuebriefQ4FY08.pdf

Hoge, C., Auchterlonie, J., and Miliken, C. (2006). Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. Journal of American Medical Association, Vol. 295, Issue 9, pp. 1023-1032. Available at http://jama.ama-assn.org/content/295/9/1023.full.pdf+html

Hoge, C., Castro, C., Messer, S., McGurk, D., Cotting, D. and Koffman, R. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine, Vol. 351, pp. 13-22. Available at http://www.nejm.org/doi/full/10.1056/NEJMoa040603

Katon, W., Lin, E., and Kroenke, K. (2007) The Association of Depression and Anxiety with Medical Symptom Burden in Patients with Chronic Medical Illness. General Hospital Psychiatry Vol 29, Issue 2, pp. 147-155.

Kessler, R., Demler, O., Frank, R., Olfson, M., Pincus, H., Walter, E., Wang, P., Wells, K., Zaslavsky, A. (2005) Prevalence and Treatment of Mental Disorders, 1990 to 2003. New England Journal of Medicine. Vol 352, No 24, pp. 2515-23. Available at http://www.nejm.org/doi/pdf/10.1056/NEJMsa043266

Kotter, J. (1996). Leading Change. Boston: Harvard Business School Press.

Kroenke, K. & Mangelsdorff, D. (1989). Common symptoms in ambulatory care: Incidence, evaluation, therapy and outcome. American Journal of Medicine. Vol. 86, pp 262–266.


References

Kindig, D. & McGinnis, J. (2007). Determinants of U.S. population health: Translating research into future policies. Altarum Policy Roundtable Report. 28 Nov 2007; Washington, D.C. Available at http://www.altarum.org/files/pub_resources/07_28Nov_Roundtable_Determinants_of_Health-RTR.pdf

Narrow, W. E., Regier, D. A., Rae, D. S., Manderscheid, R. W., Locke, B. Z. (1993) Use of Services by Persons with Mental and Addictive Disorders: Findings from the National Institutes of Mental Health Epidemiologic Catchment Area Program. Archives of General Psychiatry, Vol 50, pp. 5-107.

PC-PCC. (2012) Behavioral Health Defined. Available at http://www.pcpcc.net/behavioral-health.

Pincus, H. A., Tanielian, M. A., Marcus, S. C., Olfson, M., Zarin, D. A., Thompson, J., & Zito, J. M. (1998) Prescribing Trends in Psychotropic Medications: Primary Care, Psychiatry, and Other Medical Specialties. The Journal of the American Medical Association, Vol 279, Issue 7, pp. 526-531. Available at http://jama.ama-assn.org/content/279/7/526.full.pdf+html

TMA. (2009). Health Care Survey of DoD Beneficiaries 2009 Annual Report. Sept 2009.Available at http://www.tricare.mil/survey/hcsurvey/downloads/hcsdb-2009-20090910.pdf

TMA. (2011) The Evaluation of the TRICARE Program: Fiscal Year 2011 Report to Congress. Available at http://www.tricare.mil/tma/StudiesEval.aspx

Sarkolsky, D., & Birmaher, B. (2008) Pediatric Anxiety Disorders: Management in Primary Care. Current Opinion In Pediatrics, Vol 20, pp. 538-543.


References

Simonian, S. J. (2006). Screening and Identification in Pediatric Primary Care. Behavior Modification. Vol 30, pp. 114-131.

TeenScreen . (2011) TeenScreen Primary Care Fact Sheet: Research Supporting the Integration of Mental Health Checkups Into Adolescent Health Care. National Center for Mental Health Checkups at Columbia University. Available at http://www.teenscreen.org/images/stories/PDF/TS_PC_FactSheet_1.18.11.pdf

Wang , P., Berglund, P., Olfson , M., Pincus, H., Wells, K. and Kessler, R. (2005). Failure and Delay in Initial Treatment Contact after First Onset of Mental Disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, Vol 62, pp. 603-13. Available at http://archpsyc.ama-assn.org/cgi/reprint/62/6/603

Wang, P., Lane, M., Olfson, M., Pincus, H., Wells, K. and Kessler, R. ( 2005) Twelve-Month Use of Mental Health Services in the United States: Results from the National Comorbidity Survey Replication. Archives of General Psychiatry, Vol 62, pp. 629-640. Available at http://archpsyc.ama-assn.org/cgi/reprint/62/6/629.pdf

WHO. (1946) Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19-22 June, 1946.


Questions & Comments

39

CDR Patricia C. Hasen, NC, [email protected]@hotmail.com

760-908-9568

LT Rocio Porras, NC, [email protected]

760-725-0952


Documents

Patricia C. Hasen, CDR, NC, USN Rocio Porras, LT, NC, USN Family Medicine Department Naval Hospital Camp Pendleton Integrating Behavioral Health Care into