Screening for BH and PH

Conditions

When in Process Flow to Screen &

What Screening Tools to Use?

Screening Tool Checklist

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• Research base demonstrating construct validity

• Free

• Easy to Train Staff on Use

• Sixth Grade Reading Level

• Short and Long Versions

• Face Validity

• Widely Adopted

• Able to be coded into EMR

Screening Tools

Behavioral Health Clinic

• What tools are you currently using for Physical

Health Screening?

• What Physical Health Data do you Collect?

Primary Care Clinic

• What tools are you currently using for Behavioral

Health Screening?

Screening Workflow

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• When, Where, Who?

• Where does the data go?

• How is the data turned into information and

leveraged?

• How are staff trained?

Solutions for Effective

Transportation Supports

Significant Barriers to

Healthcare

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Structural • Availability • Organization •

Transportation • Financial • Insurance coverage •

Reimbursement levels • Public support Personal •

Acceptability • Cultural • Language • Attitudes •

Education/Income

Source: Institute of Medicine. Access to Health Care in America.

National Academies of Science Press, 1993

Burden of Transportation

The poorest fifth of Americans spend 42

percent of their annual household budget on

the purchase, operation, and maintenance

of automobiles, more than twice the national

average.

Source: Surface Transportation Policy Project,

http://www.transact. org/library/factsheets/poverty.asp.

Patient Navigators

• Older Asian and Hispanic youth who do what

they’ve always done for family and friends

• Educated and trained at local community

colleges – 1 year credit bearing certificate

program

• Career ladder - transferable, forward-looking

skills for non-clinical health worker members

of an integrated, culturally-competent,

patient-facing care delivery team (whew)

How we roll • Clinician refers patient for appt./consult

• Software matches patient language/time needs, texts

appropriate patient navigator (PN)

• PN meets patient, accompanies her to referral

service, checks in, interprets/explains, checks out

• App records non-clinical activities.

• After checkout, clinical supervisor reviews before

posting. Instant electronic payment.

Source: Asian Americans for Community Involvement (www.aaci.org)

Transportation Resources

• http://www.apha.org/advocacy/priorities/issues/tr

ansportation

High Performing

Interdisciplinary Teams

“Team” & “Teamwork”

means something different

to everyone…

A Continuum of

Healthcare Teams • Multi-disciplinary Team = hierarchical, each role

separate, some communication, parallel processes.

• Inter-disciplinary Team = interdependent, maintain distinct professional responsibilities & assignments, must make dramatic adjustments in their orientation to co-workers.

• Trans-disciplinary Team = shared decision making, every member can do everyone else's role if needed, one process, much communication.

Source: Cooper et al. (2003). The Interdisciplinary team in the management of chronic condition: Has its time come? RWJF.

The Interdisciplinary Team:

People with distinct disciplinary training

working together for a common purpose,

as they make different, complementary

contributions to patient-focused care.

Leathard , A., ed. (1994). Going Interprofessional: Working Together for Health &

Welfare. Routledge, London.

Adaptive Reserve

• Borrill et al. (2000) found that teams with greater

occupational diversity reported higher overall

effectiveness and the innovations introduced by

these teams were more radical and had

significantly more impact both on the

organization and on patient care.

Borrill & Haynes (2000). Managers' lives. Stressed to kill. Journal of Health

Service.10;110(5691):24-5.

2007 Cochrane Review of

“Shared Care”

“Results from a few of the studies suggested that

shared care may be more effective in certain patient

groups. These include patients with depression and

other serious chronic mental health illness and those

with high levels of morbidity at baseline such as the

elderly and people with moderate to severe

congestive cardiac failure.”

Source: Effectiveness of shared care across the interface between primary and specialty care in chronic

disease management (Review) 13 Copyright © 2007 The Cochrane Collaboration., JohnWiley & Sons, Ltd

Health Outcomes Related to Interdisciplinary

Teams

A study involving >5,000 patients in 13 ICU’s found

significant patient mortality reductions in hospitals

where interdisciplinary teams worked in close

collaboration.

Source: Sommers LS, Marton KI, Barbaccia JC et al. Physician, nurse, and social worker

collaboration in primary care for chronically ill seniors. Arch Intern Med 2000;160:1825–

1833.

Interdisciplinary teamwork correlated to lower

hospital readmission rates the greatest reductions

in readmission rates occurred when physicians,

nurses, and social workers were most satisfied

with their professional relationships on the team.

Source: Knaus WA, Draper EA, Wagner DP et al. An evaluation of outcome from

intensive care in major medical centers. Ann Intern Med 1986;104:410–418.

Health Outcomes Related to Interdisciplinary

Teams

The Team as an Emerging

Standard of Care “The high-performing team is now widely

recognized as an essential tool for constructing a

more patient-centered, coordinated, and effective

health care delivery system.”

Source: Mitchell, P., M. Wynia, R. Golden, B. McNellis, S. Okun, C.E. Webb, V.

Rohrbach, & I. Von Kohorn. (2012). Core principles & values of effective team-

based health care. Discussion Paper, Institute of Medicine, Washington, DC.

www.iom.edu/tbc. P.5.

Five Components of Effective

Interdisciplinary Teams:

1. Defining appropriate team goals.

2. Clear role expectations for team members.

3. A flexible decision-making process.

4. The establishment of open communication

patterns.

5. The ability of the team to “treat” itself.

Source: Leipzig, Hyer et al. (2002). Attitudes Toward Working on Interdisciplinary

Healthcare Teams: A Comparison by Discipline J Am Geriatr Soc 50:1141–1148.

Terms Teams Must be able to

Operationalize Concepts that are

not Yet Well Operationalized

• Team based care

• Care Coordination/Care Navigation

• Patient Centered Care/Medical Home

• Population Health Management

• Treat to Target

• Bundled/Episode of Care

Defining appropriate team

goals

• Develop a team dashboard that includes

measurable, and meaningful/relevant goals.

• The goals must relate to tx plan, staff work plan

& broader organizational goals.

• Tie the goals to a quality improvement/PDSA

process.

• Incorporate discussion of the goals/measures

into every meeting.

Clear role expectations for

team members

• The more complex the task the clearer roles must

be.

• All team members have their own opinions of what

their role is and what their team member’s role is…

• If suspected or seen role ambiguity & conflict should

be discussed right away.

• Routinely, clearly state who “owns” or is

“responsible” for a task to help foster this thinking.

Staff 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 & Quality Improvement

9. Informatics

• A team is a problem-solving, decision-making mechanism. This is not to imply that an entire group must always make all decisions as a group.

• The issue is one of relevance and appropriateness; who has the relevant information and who will have to implement the decision.

A flexible decision-making

process

• Similarly, when a group faces a conflict it can

choose to (a) ignore it, (b) smooth over it, (c)

allow one person to force a decision, (d) create

a compromise, or (e) confront all the realities of

the conflict (facts & feelings) and attempt to

develop an innovative solution.

• The choices individual team members and the

team as a whole make will significantly influence

how the team functions.

A flexible decision-making

process cont.

The establishment of open

communication patterns

• Create avenues for communication (e.g., logs,

regular team meetings, use of common

language, etc.).

• Maintain regular contact with agency leadership.

• Understand how culture & training drives

language and communication styles.

• Maintain regular one-on-one supervision.

What Staff Care About/ Want from a

Leader

Practical Questions • What do you want me to keep doing?

(standardization)

• What do you want me to stop doing? (waste)

• What do you want me to do differently? (CQI)

Personal Questions • Is my job fulfilling my passion/life vision?

• Is my job fulfilling my career goals?

The ability of the team to

“treat” itself

• Include a “Team self-audit” process that is tied to

the team’s dashboard.

• Encourage questioning & the voicing of

alternative views.

• Declare team breakthroughs & team breakdowns

when necessary.

• Encourage necessary acts of leadership.

Team Norms… • Norms take on particular potency because they

influence all of the other areas previously discussed.

• Groups develop norms governing leadership, influence, communication patterns, decision-making, conflict resolution, and the like. Inherently, norms are not good or bad.

• The issue is one of appropriateness — Does

a particular norm help or hinder a group's ability to work?

Team Value Systems… • Wilmot (1995) reported that nurses valued

individualism, caring, autonomy, holism & patient

well-being, while social workers internalized

collectivity, liberty, equality & justice.

• Family practice and internal medicine medical

students and residents were found to be least

inclined to interdisciplinary practice while social

workers were most inclined. Source: Wilmot (1995). Professional values & inter-professional dialogue. Journal of Inter-professional

Care. 9(3):257–266

Take Care of Your Team… • “Transformation occurs, not at a steady & predictable

pace, but in fits & starts. After the strenuous task of

implementing a particular PCMH component, the

practice had to simultaneously manage the ripple

effects, maintain the change, & prepare for the next…”

• “…the work is daunting, exhausting & occurring in

practices that already felt as if they were running as

fast as they could. This type of transformative change,

if done too fast, can damage practices and often result

in staff burnout, turnover, & financial distress.”

Source: Nutting et al. (2010) Effect of Facilitation on Practice Outcomes in the

National Demonstration Project Model of the Patient-Centered Medical Home Annals

of Fam. Med., VOL. 8 (1). 533-544.

Team Care • Recognize teams are dynamic, emotion laden, and

need constant attention and reassurance.

• Hardwire rewards into the work flows.

• Be careful to hire team members not positions.

• Get in the habit of monitoring and responding to changes in morale/trust.

Team Tools/Scales

• ATHCT Scale: Attitudes Toward Health Care Teams

Scale

• Team Skills Scale (TSS): a self-assessment instrument

• Inter-professional Collaboration Scale (IPC): Team

function from individual team members’ perspective

specifically, effectiveness of communication,

accommodation and appearance of isolation

• Primary Health Care Team Effectiveness Survey

• Scale for Leadership Assessment & Team

Evaluation (SLATE),

Other Sources • Bosch M, Faber MJ, Cruijsberg J, et al. Effectiveness of Patient Care Teams and the Role of Clinical

Expertise and Coordination: A Literature Review. Med Care Res Rev. 2009. 66:5S-34S.

• Mitchell, P., M. Wynia, R. Golden, B. McNellis, S. Okun, C.E. Webb, V. Rohrbach, & I. Von Kohorn.

(2012). Core principles & values of effective team-based health care. Discussion Paper, Institute of

Medicine, Washington, DC. www.iom.edu/tbc. P.7.

• O’Leary KJ, Wayne DB, Haviley C, Slade ME, Lee J, Williams MV. Improving Teamwork: Impact of

Structured Interdisciplinary Rounds on a Medical Teaching Unit. J Gen Intern Med. 2010;25(8):826–32.

• Mudge A, Laracy S, Richter K, Denaro C. Controlled Trial of Multidisciplinary Care Teams for Acutely Ill

Medical Inpatients: Enhanced Multidisciplinary Care. Intern Med J. 2006. 36:558–63.

• Smith ST, Enderby S, Bessler RA. Teamwork in Leadership and Practice-Based Management. In:

McKean SC, Ross JJ, Dressler DD, Brotman DJ, Ginsberg JS, eds. Principles and Practice of Hospital

Medicine. 1st ed. New York, NY: McGraw-Hill; 2012:860-65.

• Internet Citation: Essentials Instructional Module: TeamSTEPPS® Long-Term Care Version. July 2012.

Agency for Healthcare Research and Quality, Rockville, MD.

http://www.ahrq.gov/professionals/education/curriculum-

tools/teamstepps/longtermcare/essentials/index.html

Primary Care Behavioral Health Ohio Integrated Health Learning Community Suzanne Daub, LCSW

May 15, 2014

What is Behavioral Health Integration?

The Primary Care Behavioral Health

(PCBH) Model

At the simplest level, integrated behavioral and physical

health care occurs when behavioral and primary care

providers work together to address the physical and

behavioral health needs of their patients.

A Standard Framework For

Describing Integrated Health

Services

Integrating Behavioral Health and

Primary Care: Behavioral Health

Consultation

PCBH and Role of Primary Care

Provider

Serves as team leader

Screens for depression, anxiety and trauma

Refers a broad range of patients to behavioral health

Uses behavioral health consistently at certain types of visits (chronic pain, initial dx of diabetes, well child visits, etc.)

Conducts medication evaluation, prescribing, and monitoring

PCBH and Role of Behavioral Health

Work alongside primary care providers as Behavioral Health Consultants (BHCs)

Immediately accessible for both curbside and in-exam room consults, same-day visits (15 – 30 minute consults between 7 – 10/day)

Shared records: chart in the medical record using a Subjective, Objective, Assessment, and Plan (SOAP) note format

Reimbursement by encounter – not by time

No office, No caseload, No “no shows”

Robinson, P.J. and Reiter, J.T. (2007). Behavioral Consultation and Primary Care (pp 1-16). N.Y.: Springer Science + Business Media.

Clinical Approach of Behavioral

Health Consultant

Problem-focused and functional-contextual approach to

assessment and treatment of behavioral health

disorders

Use evidence-based instruments to develop treatment

plans, monitor patient progress, and flexibly provide

care to meet patient’s changing needs:

1. Motivational Interviewing

2. Behavioral Activation

3. Acceptance and Commitment Therapy

4. Screening, Brief Intervention, and Referral to

Treatment (SBIRT)

Robinson, P.J. and Reiter, J.T. (2007). Behavioral Consultation and Primary Care (pp 1-16). N.Y.: Springer Science + Business Media.

Role of the Behavioral Health Consultant

Address a variety of issues common to

primary care:

Affective concerns: depression;

anxiety

Response to physical illness; pain;

substance use and abuse

Health behavior change: obesity,

smoking, sleep, medication

adherence, self management of

chronic conditions

Engage in prevention activities

Hunter, C.L., Goodie, J.L., Oordt, M.S., & Dobmeyer A.C., (2009), Integrated behavioral health in primary care: Step-by-step guidance for assessment and intervention. Washington, DC: American Psychological Association

PCBH − Collaborative Approach

PCPs systematically screen and do “warm hand-offs” according to patient needs

PCPs and BHCs regularly review each other’s notes in the Electronic Medical Record

Regularly consult about patient care and change or adjust treatments if patients do not meet treatment targets

Co-monitor treatment response at each contact with valid outcome measures

Patients who are not improving are identified and targeted for move to a higher level of care

Case Example

Ms. T is a 73 year old African American woman. She is a retired teacher with chronic back pain, hypertension, and a history of multiple hospitalizations for coronary artery disease. She is depressed, has stopped going to church, misses her PCP appointments, and takes her HBP medications “on her own terms.”

To work in integrated care settings…

Basic understanding of primary care medical conditions

Screening, rapid assessment and brief intervention

Motivational interviewing, behavioral activation, self

management

Systems oriented practice including care planning

and care coordination

Primary care communication skills and

interdisciplinary care

Working knowledge of psychopharmacology

Substance use/addiction treatment

(Source: /Forthcoming/ Annapolis Coalition on Behavioral Health Workforce White Paper, “Core Competencies for Integrated Behavioral Health and Primary Care“)

Questions

Resources

SAMHSA/HRSA Center for Integrated Health Solutions (CIHS)

Field-based & Research-based Materials

Council on Social Work Education (CSWE)

Free Integrated Health Social Work Curriculums

Integrated Care Resource Center (ICRC)

Medicaid State Level Tech. Asst. for Integrated Health

AHRQ Academy for Integrating Behavioral Health & Primary Care

Great Research-based Resources

Dear State Medicaid Letters/Centers for Medicaid & Medicare

Services (CMS)

Variety of IH Directives including: Health Home Core Quality

Measures

Resources

Clinical Social Work & Behavioral Medicine Certificate Program

http://www.bu.edu/academics/ssw/programs/clinical-social-work-and-behavioral-medicine-certificate-program/

University of Michigan

Certificate in Integrated Health

http://ssw.umich.edu/offices/continuing-education/certificate-courses/integrated-behavioral-health-and-primary-care

University of Massachusetts

Two Certificate Programs in Integrated Health

http://www.umassmed.edu/cipc/

Fairleigh Dickinson University

Certificate in Integrated Primary Care

http://integratedcare.fdu.edu/

Arizona State University Doctor of Behavioral Health

http://asuonline.asu.edu/dbh