+ Behavioral Health Screening Tools Joane Baumer, MD Chair, Department of Family Medicine JPS Health Network Residencies In absentia Mary R. Talen, Ph.D. Director Primary Care Behavioral Health Northwestern Family Medicine 1

2

+ Overview and Agenda Rationale and Evidence for BH Screening Tools in PCMH Behavioral Health Screening Tools Pediatric Adult Seniors Team-Based Care: Roles and Responsibilities Quality Improvement Opportunities Discussion Challenges Strategies 3

+ Objectives 1. Understand the purpose and evidence for behavioral health screening. 2. Describe reliable behavioral health screening tools from pediatric to senior patients. 3. Delineate team roles and responsibilities in behavioral health screening 4. Describe quality improvement opportunities using screening tools. 4

+ INTRODUCTION - Why Assess Behavioral Health in Primary Care? Paradigm Shift: Biopsychosocial Model is central to Integrated Healthcare in emerging care delivery models and is supported by: Research: Significant correlations between physiological and psychological functioning that inform: Payment: Population Management requires screening to meet the Employers’ and CMS triple aim Clinically Efficacious Patient Valued Cost Effective 5

Medical & Pharmacy Costs $3,376 PEPY 25% 75% Personal Health Costs Medical Care Pharmacy Productivity Costs Presenteeism Overtime Turnover Temporary Staffing Administrative Costs Replacement Training Off-Site Travel for Care Customer Dissatisfaction Variable Product Quality Total Costs = $13,504 PEPY Absenteeism Health-Related Productivity Costs $10,128 PEPY Short-term Disability Long-term Disability Sources: Edington DW, Burton WN. Health and Productivity. In McCunney RJ, Editor. A Practical Approach to Occupational and Environmental Medicine. 3rd edition. Philadelphia, PA. Lippincott, Williams and Wilkens; 2003: and Loeppke, R., et al. Health and Productivity as a Business Strategy. Journal of Occupational and Environmental Medicine. Vol 49, No. 7, July, Pages and the 2006 Mercer Employer Annual Survey; The Real Problem: The Full Cost of Poor Employee Health

+ BUT…… Screening requires that the care team can follow-up on positive screens Efficiently Effectively Timely Can you screen a specific population systematically? So… if you do not have the follow-up resources and treatment tools in place – Should you screen? 7

+ Definitions and Distinctions: Life-style behaviors Diet choices Exercise Routines Self-management, self-efficacy Quality of Life Social Support Family Dynamics and Health Emotional Regulation Cognitive Functioning Behavioral Symptoms Cluster of Signs and Symptoms DSM criteria 8 Behavioral Health Mental Health

+ Clinical Context for Behavioral Health Screening 9 Health Promotion Support effective functioning, coping Self-efficacy, self-management Primary Prevention Screen for Adolescent Risk Factors Augment Protective Factors: Resiliency Monitor maladaptive coping with chronic disorders Secondary Prevention Substance and Tobacco Abuse Mental Health diagnosis PTSD Depression/Anxiety

+ Why Assess Behavioral Health in Primary Care Populations? 66-75% patients do NOT have mental disorders, but fall on a continuum… Psychologically healthy At-risk for psychological distress Psychologically distressed (subclinical) Simple interventions can prevent progression to full-blown disorders. 10

+ Why Assess Mental Health and Behavioral Health? 25-33% of patients in primary care have a behavioral health disorder. Behavioral Health Disorders and Serious Mental Illness are underdetected SMI - Major Depressive Disorder – Midlife Males Post-Partum Depression Bipolar Disease – confused with drug effects 11

+ AND, Detection Makes a Difference Silent heart attack syndromes which are confused with anxiety or GI disorders can be treated. Failure to screen may result in high morbidity – Most suicide patients have seen a physician within 90 days Early intervention predicts better prognosis from both a clinical and a behavior change perspective 12

13

USPSTF FOR two 1. Screening all adults for obesity. Clinicians should offer or refer patients with a body mass index (BMI) of 30kg/m2 or higher to intensive, multicomponent behavioral interventions Grade B 2. Because evidence that the health benefit of initiating behavioral counseling in the primary care setting to promote a healthful diet is small, clinicians may choose to selectively counsel patients rather than incorporate counseling into the care of all adults in the general population Grade C uspreventiveservicestaskforce.org/tools

USPSTF Important Draft Screen women of childbearing age for intimate partner violence (IPV) and provide or refer women who screen positive to intervention services. Grade B Elderly screening is currently not recommended due to insufficient evidence

+ USPSTF GUIDELINES (uspreventiveservicetaskforce.org) A Recommendation Statement An Article on the Specific Guideline and Research on the guideline and tools An Evidence Synthesis A Clinical Summary 16

+ Parameters of Behavioral Health Screening Identified Population Non Targeted vs. Targeted Clinical Protocol EB Screening Tools Team Based Care Roles and Communication Office Management and Billing Practice-based Quality Improvement 17

+ Patient Populations and Screening Children Developmental Screen Adolescents Depression Adults Substance Abuse Depression Patient Engagement Quality of Life Children Developmental Risks Developmental Delays ADHD Women and Pregnancy Depression Violence Substance Abuse Seniors Cognitive Functioning 18 Non-Targeted Targeted

+ Clinical Protocols: Screening Tools Have been utilized in large clinical populations Have been studied in the populations that are appropriate for the screening Have demonstrated high sensitivity and specificity Have been validated 19

+ Clinical Protocols: Tool Characteristics: Requires minimal training Can be utilized by multiple members of the care team Can be incorporated into the regular workflow Can be easily incorporated into EMR Add Value - Billable Educational level at 5 th grade literacy One page or 10 questions or less Can be completed easily by Parent Patient Teacher/Caregiver 20 PCMH Factors User-Friendly

+ Clinical Methods: Validated Behavioral Health Screening Tools Pediatric Pre-school School-age Adolescents Adult men and Women Pregnant Women Senior Patients 21 Children/Adolescents Adults/Seniors

Pre-School Pediatric Screening Tools Pediatric Evaluation PEDS Ages and Stages Questionaire (ASQ) BINS: Bayley Neurodevelopmental Infant Screen - Premature infant development Tool Autism Screening Tool - (M- CHAT) – Used at 18 month well child check 22

School Age Screening Tools Pediatric Symptom Checklist: (PSC17)( entalhealth/pdf) entalhealth/pdf Vanderbilt ADHD Assessment forms (www. nichq.org/toolkits) Parent Teacher Conners ADHD Assessment (requires clinician purchase) has short version – one page Parent/Home Teacher Adolescent 23

Adolescent Screening Tools Depression: PHQ-A Rapid Adolescent Assessment Preventive Screen (RAAPS) Guidelines for Adolescent Preventive Services assn.org/ama/pub/category /1980.html Middle-Older Teen Parent Form 24

Adult Mental Health Screening Tools Depression Patient Health Questionnaire (PHQ): PHQ items if + then PHQ-9 – 9 items Generalized Anxiety Disorder GAD -7 Bi-Polar Mood Disorder Questionnaire: MDQ Substance Abuse CAGE/AUDIT/SBIRT 25

+ Patient Health Questionaire: PHQ Purpose: clinically efficient screening tool for mental health disorders. Administration: Self-report < 2 minutes to review Scoring > 5 = further assessment and treatment Follow-up assessment (BSI or SCL 45) 26

+ Mood Disorder Questionaire: MDQ Purpose: Brief self-report screening for BiPolar Spectrum Disorder Consider before starting SSRI in positive depression Screen 3 Questions (Q1 -13 subquestions) -1 page – easily scores Sensitivity:.73 Specificity:.90 Recommended for use in Primary Care Settings 27

+ Other Adult Screening Tools Substance Abuse Assessment: CAGE AUDIT-C SBIRT Pregnancy Edinburgh Intimate Partner Violence 28

+ Basics of SBIRT Screening Brief Assessment Intervention Referral Treatment Screening quickly assesses the severity of substance use and identifies the appropriate level of treatment. Brief intervention focuses on increasing insight and awareness regarding substance use and motivation toward behavioral change. Referral to treatment provides those identified as needing more extensive treatment with access to specialty care. 29

+ AUDIT: Alcohol Use Disorders Identification Test Identify persons with hazardous and harmful patterns of alcohol consumption Screening for excessive drinking Assist in brief assessment Developed by the World Health Organization AUDIT-SBIRT 30

+ Pregnancy Related Depression Screen - EDPS The Edinburgh Postnatal Depression Scale (EDPS) 10 questions/one page-completed by patient Scored in 5 minutes Specificity of 80% at cutoff score of 12.5 Sensitivity range of 57-71% Most tested in 3 month post partum period No differences with PHQ-9 or BDI-II 31

Senior Mental Health Screening Tools Montreal Cognitive Assessment (MoCA) Mini Cog Mini Mental Status (MMSE) Geriatric Depression Screening Scale 32

+ Cognitive Screening: Mini-Cog Assess elderly patients who are multilingual. Three-item recall assessment and clock drawing tool together. Distinguishes patients with or without dementia, but not sensitive enough to detect mild cognitive impairment 33

+ Senior Screening: MoCA Purpose: First line detection of mild cognitive impairment (MCI). Working memory Use of mental images Attention and speed Naming Executive Function Cognitive flexibility Administration: minutes Scoring 34

+ Tools for Behavioral Health and Healthy Life - THE FUTURE Patient Activation Measurement (PAM) 13-item survey Validation in approx 1500 patient population May be valuable for future use in treatment for behavior change QOL: Quality of Life One page, Patient or Caretaker Completed Easy to use in a clinical setting 35

+ Team Roles and Communication in Screening Staff Give patient screening tool MA/Nurse Score Tool Enter into medical record Provider Review results Document follow-up Enter results into medical record Flag positive results Document Referrals Treatment Plans Quality improvement data 36 Roles Communication

+ Office Management: Clinical Flow Non-Targeted Patient completes Screening tool Registration/Previsit MA Scores Screening Tool MA enter data in EHR Triage Reviews results with patient Follow-up referral and/or assessment Enters follow-up plan Provider review practice data Design/revise protocol Quality Improvement process 37

+ Regulatory and Financial Systems Do you have permission to use a tool? ie Conners, BDI, PAM Are you sure that you can deliver appropriate follow-up? Does the patient have access to behavioral health or mental health treatment? Privacy concerns in EMR or records Can you bill for screen? Knowledge of codes Knowledge of which clinician can bill codes How do you track the billing? Who is responsible for entering the billing data? Are the screening services bundled? 38 Regulatory Financial

+ Pay for Performance Screening Guidelines/ Procedures Tobacco Screening is expected for Meaningful Use Payments/PQRI Alcohol Screening: SBIRT Depression Adults Pregnancy Developmental Screening: ASQ, PEDS. M-CHAT, BINS ADHD May be bundled or billed as separate service CPT or May add modifier -25 to E/M if performed separately Multiple screens may require - 76 modifier as well 39

+ Practice-based Quality Improvement and Screening Tools Screening tools as patient population-based data Epidemiology Monitoring treatment effectiveness Plan-Do-Study-Act (PDSA) cycles 40

+ Benefits of Integrating Behavioral Health Screening Tools into Primary Care Provide anticipatory guidance Support and Encourage healthy choices Share diagnosis and health risks Identify poor coping behaviors Link life stressors and health/mental health Advise patients on healthy psycho-social functioning Referrals for community resources, specialists 41

Summary and Discussion Applications clinical settings Limitations Benefits Future Directions