The Primary Care Behavioral Health Model Creating Access, Impacting Populations Elizabeth Zeidler Schreiter, PsyD Behavioral Health Consultant Consulting Psychiatry Lead Access Community Health Centers Madison, WI

Access Community Health Centers Federally Qualified Health Center (FQHC) 3 clinic locations in Madison, WI William T. Evue Clinic and Wingra Family Medical Clinics have Patient Centered Medical Home Certification Medical, Dental, Pharmacy and Behavioral Health Services Over 26,000 residents seen in 2013 (over 80,000 office visits) Over 10,000 behavioral health visits

10-50% Chronic Disease Obesity Smokers Referral Completion Rate When asked, patients say they prefer their care here Surgeon Generals Report 80% visit PCP in a given year Chronic Disease Obesity Smokers 10-50% Referral Completion Rate Primary Care “De Facto” Mental Health System

Severe Depression, Multiple somatic complaints Provider Area Exam Rooms Hallway Severe Depression, Multiple somatic complaints = PCP = BHC

Time Activity 9-9:20 9:20-9:35 9:45-10:10 10:10-10:30 10:30-10:50 Consult: Depression 9:20-9:35 Consult: Weight loss 9:45-10:10 Downtime 10:10-10:30 Consult: Panic attacks 10:30-10:50 Consult: Diabetes management 10:50-11:10 11:10-11:30 Consult: ADHD 11:30-11:45 Consult: Parenting Issues 11:45-12:15 Notes What a consultant does: brief consultations focused on quality of life and daily functioning increase skills of providers via curbside consults provide assistance for medication management & adherence Phone-based consultation for patients & Assistance with behaviorally related calls to triage/ call center manages other related services such as care management and consulting psychiatry exerts leadership in areas such as patient-doctor communication, crisis management, staff response to difficult patients Curbside Consult Scheduled f/u Warm hand-off

PCBH: The Benefits of Integration Aims to meet the primary care needs and support PCPs De-fragments and De-stigmatizes care Allows collaboration in the moment Reduces psychological and social barriers Promotes cross-education and reciprocal learning Supports use of evidence based treatment Provides population based care Increases access to care

Consulting Psychiatry Population based approach which maximizes the skills of the psychiatrist to enhance the skills of the PCP BHC & some PCPs present patients to the psychiatrist at weekly meetings, receiving verbal and written recommendations Psychiatrist then works with BHC to select patients on a weekly basis to see for ‘one-time’ evaluations PCP retains prescribing role & is cross-trained in primary care psychiatry through this process (as are the BHCs)

Steps Toward Implementation-Consulting Psychiatry Behavioral Health Consultation and Consulting Psychiatry started at Access in 2007 Administrative backing Population care focus thus emphasis on verbal and written consultations in addition to face-to-face encounters Psychoeducation for medical providers Space for psychiatry consultant to work (e.g. exam room) Finding a psychiatrist ready, willing, and able to thrive in this environment Utilization of Behavioral health consultant to assist with triaging need and appropriate allocation of resources Increased access by written consults, if unable to be seen within 2 weeks written recs are requested. PCP always retains prescriptive authority Collaborative Family Healthcare Association 12th Annual Conference

Care Management Quarterly reviews of patients in 4 categories (depression, ADHD, pediatrics, consulting psychiatry) Registry is populated with over 3,000 patients Results in thousands of phone calls annually to engage patients along with cues to the medical team

PCBH In Action at Access 1 in 5 medical patients annually sees a BHC Over 400 consulting psychiatry chart reviews and 208 face-to- face consults in 2013 Over 3000 care management chart reviews 5.5 FTE Psychologists/Social Workers; .25 FTE Consulting Psychiatrist Train 5-10 psychology and social work trainees annually & 8 psychiatry residents annually BHC are Generalists-Not focused on one disease category, but more support across all health and behavior conditions

Research Supports PCBH Ray-Sannerud et al. (2012) Patients significantly improved using global measure of mental health functioning two years post contact with BHC Corso et al. (2012) Patient self-report of therapeutic alliance with BHC exceeded outpatient specialty mental health alliance Reiss-Brennan et al. (2010) Intermountain Health System shows high patient satisfaction, improved utilization and quality outcomes

Recommended Resources Robinson, P., & Reiter, J. (2006). Behavioral Consultation and Primary Care: A Guide to Integrating Services. Springer. Serrano, N. (Ed.) (2014). The Implementer's Guide To Primary Care Behavioral Health. iTunes Store. Access Community Health Centers. Access Community Health Centers (Access) Integrated Primary Care Consulting Psychiatry Toolkit 2013. Available from: http://www.hipxchange.org/Access. Collaborative Family Healthcare Association (www.cfha.net) Email Contact: elizabeth.zeidlerschreiter@accesshealthwi.org