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You are NOT fired! Optimizing the PCBH
model for difficult patient encounters
Arissa Walberg, PhD, Behavioral Health Consultant/Faculty, Community Health of Central Washington
Bridget Beachy, PsyD, Director of Behavioral Health, Community Health of Central Washington
Stacy Ogbeide, PsyD, Assistant Professor/Clinical, UT Health Sciences San Antonio
Ragina Lancaster, DO, Faculty Physician, Community Health of Central Washington
Ramin Poursani, MD, Chief of Clinical Operations, UT Health San Antonio
Session # B4
CFHA 20th Annual Conference October 18-20, 2018 Rochester, New York
Faculty Disclosure
The presenters of this session have NOT
had any relevant financial relationships
during the past 12 months.
Conference Resources
Slides and handouts shared in advance by our Conference Presenters are available on the
CFHA website at http://www.cfha.net/?page=Resources_2018
Slides and handouts are also available on the mobile app.
Learning Objectives At the conclusion of this session, the participant will be able to:
1. Explain the negative outcomes of difficult patient
encounters.
2. Identify systemic strategies of the PCBH model for
difficult patient encounters.
3. Employ specific skills for PCP-BHC collaboration
to mitigate negative effects of these encounters.
Learning Assessment
A learning assessment is required for CE
credit.
A question and answer period will be
conducted at the end of this presentation.
A little context…
UT Health Sciences Center, San Antonio
Community Health of Central Washington
Difficult Patient Encounters
15% of Primary Care
Outcomes
Decreased patient and provider satisfaction
Increased burnout
Poorer health
Jackson & Kay, 2013
Hardavella et al. (2017)
• Frequent no-shows or
tardiness
• Medically unexplained,
complex, high-utilization
• Non-Adherence
• Inappropriate behavior
Jackson & Kay (2013)
Strategies
Frequent no-shows/tardy
Strategies
BHC accessibility/flexibility
BHC assesses cause
Case: 36yo, female, SSRI follow-up
15mins late, visit necessary to get refills
Outcome
○ BHC visit: Assessed medication efficacy, side effects
Contextual interview BH intervention for grief
○ PCP visit – 3mins
○ Patient: got refill plus behavioral intervention
Medically unexplained, complex,
high-utilization
Rosa is a 57-year-old woman living in San Antonio with two grown sons. She
retired after 18 years as an instructional aide in the public schools.
Rosa has Type 2 diabetes as well as coronary artery disease. She has
difficulty managing her condition, and as a result she has had both her legs
amputated and also suffers from diabetic gastroparesis, which makes it hard
for her to process food. Her lack of mobility makes it hard for her to access
the nutritious food she needs, which makes it that much more difficult for her
to control her blood sugar.
Camden (a), n.d.
Case example – “Rosa” (Cont’d)
Rosa reports suffering from both depression and anxiety, and her children do not offer much social support. When we met Rosa she did not have a good relationship with a primary care doctor, despite her many health conditions.
Over the past year, Rosa was frequently admitted to the hospital for nausea, vomiting, abdominal pain, diabetes, and depression/anxiety. She’d like to better manage her health, but feels unable to address her own needs in any significant way (ambivalent).
Camden (a), n.d.
Manning &
Gagnon, 2017
Complex patient
definition Patients with complex
care needs, with a combination of multiple chronic conditions, mental health issues, medication-related problems, and social vulnerability.
Martello et al.,
2014
What impacts complexity?
System Barriers
The healthcare system is designed to work for the average
patient, and like many large systems, it struggles to help
the outliers – the small number of patients with complex,
hard-to-manage needs and chronic conditions.
Camden (a), n.d.
What impacts complexity?
95% of variation in chronic disease outcomes is estimated
to be related to patient lifestyle and health behaviors
(Tuerk et al., 2008)
Self-management: to be successful, requires mastery
of transferable skills and strategies for goal-setting,
positive self-reinforcement, self-monitoring, problem-
solving, decision-making, and resource identification.
Also self-efficacy
Don’t forget:“ACES”?
Adverse Childhood Experiences Emotional abuse
Physical abuse
Parent substance abuse
Parent incarceration
Sexual abuse
Parent separation or divorce
Mother treated violently
Household mental illness
Physical neglect
Emotional neglect
http://www.cdc.gov/violenceprevention/acestudy/about.html
What can you do to help?
Strategies
Value-Driven
Interventions
Improving the patient’s
engagement in
behaviors or activities
that are consistent with
their identified values
Robinson, Gould, &
Strosahl, 2011
Strategies
Motivational Interviewing
A conversational technique that engages
a patient’s motivation to change based on
his or her own needs and wants rather
than a provider’s goals.
Camden (a), n.d.
Strategies
Trauma-Informed Care
A framework for care that realizes the
prevalence of trauma in a population,
recognizes the presence of trauma
symptoms in an individual, acknowledges
the role that trauma has played in a
patient’s life, and seeks to avoid re-
traumatization.
Camden (a), n.d.
Strategies Accompaniment
The principle that care coordinators
should be active but short-term
participants in health care provider visits
and other interactions, with the goal of
helping develop the patient’s capacity for
self-advocacy and independent navigation
of complex systems.
Camden (a), n.d.
Strategies Harm Reduction
A set of practical strategies and ideas
aimed at reducing negative
consequences of various human
behaviors, legal and illegal, especially
those associated with drug use.
Camden (a), n.d.
Strategies: The Contextual Interview
Love – Work – Play Living situation
Relationship status & sex
Family
Friends
Spiritual life
Work
Income
Fun/hobbies
Health Risk & Behaviors Tobacco
Caffeine
Alcohol
Marijuana
Street drugs
Diet
Exercise
Sleep
Bauman, Beachy, & Ogbeide (2018)
Case
Myra is a 67 y/o female who has morbid obesity, diabetes, chronic pain, chronic open sores, depression and anxiety. She routinely meets w/her PCP in order to get on more medication to treat all these symptoms. It is clear from the PCP’s perspective that if she would start making lifestyle changes and working through her depression and anxiety, that she wouldn’t have to be so reliant on medications. Visit after visit, it is the same story, with worsening outcomes for the patient’s health and a demanding attitude by the patient. The PCP was frustrated, and finally (after several failed attempts previously) gets her to start meeting with the BHC. BHC + PCP visits on the same day for several months and then moved to alternating
months.
Addressed the current and past grief as well as past trauma
Myra’s “hard” exterior and demanding approach, reduced drastically.
The PCP felt supported and understood where the Myra was coming from.
Myra felt her independence was more supported.
“Inappropriate” behaviors
BHC + PCP co-visit If past communication has been difficult (to mediate)
In cases where a contract has been broken (for support, helping to set clear, behavioral expectations, etc.)
BHC acts a “witness” for PCP and/or patient Strength in numbers to decrease aggressive or threatening
behaviors
Help limit “he said – she said”
BHC helps understand the function of a patient’s “inappropriate” - including escalating or threatening behavior Discovering the “motive” or “need” via assessing the context
Case Chad is a 52yo white male who has significant anxiety and irritability that were treated
with Xanax in the distant past. He feels the anxiety is caused by his thyroid medication
and is seeking prescription for Xanax. He is generally distrustful of medical system and
feels he receives poor care. Dr. S has been assigned to maximize continuity. Dr. S does
not feel Chad is an appropriate candidate for Xanax given impulsivity and poor insight.
Chad refuses all other medications. An intermediate benzo was prescribed as a trial. A
few days later, Chad visits the pharmacy to request fill on the medication stating he
never received a prescription and yelling at the pharmacist. Dr. S believes the
prescription was handed to the patient and is concerned about misuse. A refill is
provided but patient refuses to take as it is not Xanax. Comes to next visit with intent of
Firing Dr. S and finding new physician.
BHC + PCP co-visit
○ Established plan ahead of time, talked through main points
○ Explained purpose of co-visit to Chad: BHC as mediator and witness
○ Chad did not fire Dr. S, did not receive Xanax, has resumed medical care w/Dr. S
Role-Play John is frustrated he’s been called for an opioid pill count at the request of his
PCP. He tells the nurse how upset he is that Dr. Smith “doesn’t trust him,” nor
does he feel like “she ever listens” to him. He begrudgingly agrees to the pill
count, which shows he’s off by a handful of pills. At the next visit, Dr. Smith asks
him about the situation. He gets louder than usual stating how he is tired of
being treated like “an addict.” John explains that he had to take his wife to the
hospital several hours away, which caused him to be traveling for longer than
expected, so he took a few extra pills. Dr. Smith had also tapered down these
medications when he started care with her due him being over the recommended
limit of MEUs. John feels targeted. Dr. Smith feels disrespected. Dr. Smith cites
how she’s given him several chances to be in compliance with the pain contract.
She’s fed up and John is requesting another PCP or he threatens to leave the
clinic. John shows up for his appointment w/Dr. Smith and Dr. Smith pages BHC.
Groups of 3: 1) Patient; 2) PCP; 3) BHC
References Bauman, D., Beachy, B. & Ogbeide, S. A. (2018). Stepped care and behavioral approaches for
diabetes management in integrated primary care. In W. O’Donahue & A. Maragakis (Eds), Principle-based stepped care and brief psychotherapy for integrated care settings. New York, NY: Springer Science, Business Media, LLC.
Bridges, A. J., Gregus, S. J., Rodriguez, J. H., Andrews, A. I., Villalobos, B. T., Pastrana, F. A., & Cavell, T. A. (2015). Diagnoses, intervention strategies, and rates of functional improvement in integrated behavioral health care patients. Journal Of Consulting And Clinical Psychology, 83(3), 590-601.
Camden Coalition of Healthcare Providers(a) (n.d.) Healthcare hotspotting. Retrieved from https://hotspotting.camdenhealth.org/
Camden Coalition of Healthcare Providers(b) (n.d.) Introduction: What is hotspotting? Retrieved from http://healthcarehotspotting.com/wp/introduction/
Center for Integrated Health Solutions Trauma Informed Care (CIHS TIC; 2013). It’s just good medicine: Trauma-informed primary care. SAMHSA/HRSA Webinar. Retrieved from www.Integration.samhsa.gov
Dahlgren, G., & Whitehead, M. (1991). Policies and strategies to promote social equity in health. Stockholm: Institute for Futures Studies.
Hardavella, G., Aamli-Gaagnat, A., Frille, A., Saad, N., Niculescu, A., & Powell, P. (2017). Top tips to deal with challenging situations: doctor–patient interactions. Breathe, 13(2), 129–135.
Jackson, J. L., & Kay, C. (2013). Heartsink Hotel, or “Oh No, Look Who’s on My Schedule this Afternoon!” Journal of General Internal Medicine, 28(11), 1385–1386.
References Martello, C., Bessière, G., Bigras, M., et al. (2014). What Do We Mean When We Say "This
Patient is Complex"? . NAPCRG Annual Conference (North American Primary Care Research 22 Group). New York.
Miller, W. & Rollnick, S. (2012) Motivational interviewing (3rd ed.). New York: Guilford.
O’Donohue, W.T., Byrd, M.R., Henderson, D. A., & Cummings, N. A., (Eds.). (2005). Behavioral integrative care: Treatments that work in the primary care setting. New York: Routledge.
Reiter, J., Dobmeyer, A., & Hunter, C. (2018). The Primary Care Behavioral Health (PCBH) Model: An Overview and Operational Definition. Journal of Clinical Psychology in Medical Settings. Published online: 26 February 2018. https://doi.org/10.1007/s10880-017-9531-x
Robinson, P., Gould, D., & Strosahl, K. (2011). Real behavior change in primary care: Improving patient outcomes and increasing job satisfaction. Oakland, CA: New Harbinger Publications
Robinson, P., & Reiter, J. (2016). Behavioral consultation and primary care: A guide to integrating services (2nd Ed.). New York: Springer.
Tuerk, P. W., Mueller, M., & Egede, L. E. (2008). Estimating physician effects on glycemic control in the treatment of diabetes: Methods, effects sizes, and implications for treatment policy. Diabetes Care, 31, 869-873.
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