Integrated Behavioral Health 101 for Nursing Care Transformation Collaborative of R.I. Nelly Burdette, Psy.D. 5/5/15

Integrated Behavioral Health Care from a practice team of primary care and behavioral health clinicians working together with patients and families using a systematic and cost-effective approach to provide patient-centered care for a defined population. 3 May address mental health and substance abuse conditions, health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stress-related physical symptoms, ineffective patterns of health care utilization. 3

Why does it matter to me? Impact In New England, nearly 1 of every 5 adults has a mental health need.2, 4, 5 Behavioral health drives 60-80% of all visits to the PCP, especially as chronic diseases increase 4,5 Cost Financial: Comorbid behavioral health conditions can cost 2-3 times more 2, 5 Mortality: substantially shorter life expectancies than the average person 2, 5 Substance Use 20 million Americans with alcohol or illicit drug dependence do not receive treatment 6 Rarely screened for within primary care, but when treated ED visits can be reduced with significant cost savings and health improvements. 6

Depression & Physical Health Depression one of top 10 drivers of medical costs 2 History of depression = 4x likely suffer heart attack and to die within six months of having a heart attack compared to those without history of depression/current depression 2 Depression care management for Medicaid enrollees can reduce overall healthcare costs by $2,040 per year with impressive reductions in emergency department visits and hospital days. 2

Depression Cycle JAMA. 2012;308(9):909-918. doi:10.1001/2012.jama.10690

Diabetes and Depression Diabetes is very common in primary care, and many patients with diabetes also suffer from depression. 5 Type 2 Diabetes nearly doubles an individual’s risk of depression and depression is associated with poor glycemic control, increased risk of complications, functional disability and overall higher healthcare costs 2 Patients receiving integrated care had significantly greater decreases in hemoglobin A1c levels, depression scores, and LDL-cholesterol than patients receiving usual care. 5

What is a NCM’s role? You are the care coordination face of integrated care Perfectly positioned to be involved in depression care management When a patient screens positive on a mental health screening (such as depression on PHQ9), it is critical that you be able to understand how care management can benefit Not a one-size fits all approach.

NCM for Depression in Spain 1 Initial nursing visit Within one week of meeting with PCP PHQ9 and antidepressant education Follow-up nursing Every 4 weeks until remission medication management and adherence Repeat PHQ9, psychoeducation, treatment planning Phone or In-Person NCM does not Provide psychotherapy or make medication decisions

NCM for Depression in US IMPACT Depression Care Manager may be nurse Educates, monitors and completes a relapse prevention plan Supports antidepressant prescribed by PCP Coaches patients in behavioral activation and pleasant events scheduling Six-eight session course of Problem-Solving Treatment http://impact-uw.org/about/key.html

IMPACT Outcomes

Future Directions Every nurse is a NCM Every nurse has capacity and skill set to learn how to utilize integrated behavioral health interventions in primary care Behavioral health and substance use triage Antidepressant and referrals compliance Psychoeducation and self-management goal planning

References Arogones, E., Lopez-Cortacans, G., Baida, W., Hernandez, J.M., Caballero, A., Labad, A. and INDI Research Group. (2008) Improving the role of nursing in the treatment of depression in primary care in Spain. Perspectives in Psychiatric Care, 44 (4), 248-258. Mauer, BJ and Jarvis, D. (2010). The Business Case for Bidirectional Integrated Care: Mental health and substance use services in primary care setting and primary care services in specialty mental health and substance use settings. MCPP Healthcare Consulting. Available at: http://www.mhsoac.ca.gov/meetings/docs/Meetings/2012/Mar/OAC_032212_Morning_BusCase.pdf Peek CJ and the National Integration Academy Council. Lexicon for Behavioral Health and Primary Care Integration: Concepts and Definitions Developed by Expert Consensus. AHRQ Publication No.13-IP001-EF. Rockville, MD: Agency for Healthcare Research and Quality. 2013. Available at: http://integrationacademy.ahrq.gov/sites/default/files/Lexicon.pdf Strosahl, K. (2002). Identifying and capitalizing on the economic benefits of integrated primary behavioral health care. In Cummings, O’Donohoe & Ferguson (Eds.) The impact of medical cost offset on practice and research: Making it work for you. NV: Context Press. Tice, J.A., Ollendorf, D.A., Reed ,S.J. Shore, K.K., Weissberg, J. & Pearson, S.D. (2015). Integrating Behavioral Health into Primary Care: Draft Report. Institute for Clinical and Economic Review. Available at: http://cepac.icer-review.org/wp-content/uploads/2015/01/BHI-CEPAC-REPORT-FINAL-VERSION-FOR-POSTING-MARCH-231.pdf Urada, D., Teruya, C., Gelberg, L. & Rawson, R. (2014). Integration of substance use disorder services with primary care: health center surveys and qualitative interviews. Substance Abuse Treatment, Prevention and Policy, 9 (15). Available at: http://www.substanceabusepolicy.com/content/pdf/1747-597X-9-15.pdf

Questions Nelly Burdette, Psy.D. naburdette@providencechc.org Director, Integrated Behavioral Health, PCHC Integrated Behavioral Health Practice Facilitator, CTC MHI Faculty Advisor, HMS Center for Primary Care Faculty, Alpert Brown Medical School & University Of MA Medical School Center For Integrated Primary Care