Successful Integration of Behavioral Health into Medical Hypertension Management University Family MedicineDenver Health Lowry Family Health Center Hypertension Clinic Verena Roberts, Ph.D. Session I5 – Tapas Saturday, October 29, 2011

Learning Objectives Learn how to successfully integrate behavioral health into medical management of hypertension Learn innovative approaches to management of patient health Learn how to deliver brief evidence-based practices on hypertension in a time- limited Learn how to adapt an integrated approach to your clinic structure

Denver Cares Correctional Care Denver Health Medical Center 911 Community Health Services (CHS) Regional Poison Center & Nurseline Denver Health Medical Plan School- based Health Centers Rocky Mtn Center for Medical Response to Terrorism Public Health Rocky Mtn Regional Trauma Ctr Denver Health/CHS

Lowry Family Health Center Medical Director/Team Leader (MD) Program Manager (RN) 3 FT/3 PT MD Attendings 2 F-NPs Family Medicine Residents 2 Behavioral Health Consultants (PsyD & PhD) 2 RNs PT Patient Navigator 6 Medical Assistants a/k/a Health Care Partners (HCPs) PT Pharmacy Dispensary Technician PT Family Planning Educator 3 Laboratory Technicians Clerical Supervisor 5 Clerks Residency Coordinator

From Idea to Implementation How we got started: PCHM project Clinic split into two teams Each team chose a topic Hypertension (HTN) Weekly HTN Clinic focused on medical HTN management of patients with HTN who were already diagnosed by their PCP, but blood pressure was uncontrolled 1 provider sees only HTN patients in 1 afternoon session Medication assessment Educational handout NO BEHAVIORAL HEALTH

Aim Statement We aim to improve the identification and management of patients with hypertension in Lowry Family Health Center. The process begins with the correct diagnoses of hypertension. The process ends with each patient having an individualized care plan. By working on the process, we expect: - improved health - decreased visits for patients - improved outcomes - patient and employee satisfaction - medication compliance - increased access - decreased cost. It is important to work on this now due to: 1. Access issues 2. Expensive to health care system 3. Decrease mortality and morbidity in patients.

Behavioral Health Integration Metamorphose of the Lowry HTN clinic Idea was introduced to team during monthly PCMH meeting After initial yes – more detailed proposal Logistics Content Continued discussion with medical provider who was conducting the HTN clinic Develop and research evidence-based treatments that can be adapted to short primary care visits

Integrated Hypertension Clinic Key Features Half-day scheduled with 8-10 HTN patients Visit limited to hypertension issues All patients seen by medical and behavioral health provider either together or one after another Medication adjustment for hypertension Self-management goal-setting/ Motivational Interviewing Follow-up during HTN clinic only Clinic is provider-driven

Clinic Flow Patient navigator selects patients from registry or PCPs refer patients - Patients have to have HTN dx - appointment is made by navigator or HCP Clerk checks patients in – HCP gets vitals and blood pressure, rooms pt. PCP and BH see patient together Or alone, but tag team, so that each patient is still seen by both, PCP and BH - Use Vocera to communicate & manage flow Check out via HCP (if non-English) or clerk and follow-up appointment is made

Extending the Team Work Clerks and HCPs manage visit flow and assist with check out and follow-up Patient navigator finds patients via registry and makes calls Other PCPs make referrals to HTN clinic Remember – this is not a 2 person pony show, but a team approach

Action Plan Sheet

Challenges to Integration Data collection Clinic flow Turf protection Follow-up Provider driven

Key Factors to Integration Get your clinic on board! Talk to leadership Use PCMH as starting point Start small Be flexible Be persistent Show providers and patients how behavioral health can help Have a plan Do not take no for an answer, but come up with solutions – or better – think of possible problems that may occur and have an answer Build positive relationships with providers Regroup after each clinic – what works, what doesnt? Give positive feedback and point out your successes! Involve the entire team as needed

Adaptations Talk to PCPs about behavioral health seeing patients with significant HTN issues via integrated care visits (PCP & BH present at same visit) Each day, scout out patients and huddle with PCPs regarding which patients are appropriate for BH integrated visits Advertise how BH can help PCPs with HTN patients If you happen to be unavailable, have patient see BH in individual visit or schedule future integrated visit

Questions/Discussion