Integrating Behavioral Health into Primary Care Sara Honn Qualls, Ph.D. University of Colorado Colorado Springs

WHAT’S ALL THE BUZZ IN INTEGRATED CARE ABOUT?

Older adults… Have similar rates of most mental disorders as other adults (20-25% Dx % Sx) Seek MH services in MH settings far less frequently Prefer MH services in primary care Prefer non-pharmacological interventions Have high rates of co-morbidity with other health conditions that influence MH

 Cognitive and psychological problems fail to be diagnosed in 66% of primary care patients*  Yet psychological problems result in poorer engagement in health self-care 4 Psychological Problems are not well recognized

Some impressive findings on depression… IMPACT PROSPECT PRIME-MD

Setting Matters Prevalence Mental Health Salience Mental Health Provider Role Assessment Tool Selection Intervention Approach Evaluation of Impact

Some local experience in Colorado Springs…

CU Aging Center Mental Health and Family Services Since 1999, near Senior Center, in neighborhood Operated by UCCS Psychology department, Clinical Geropsychology Ph.D. program Core Internal Programs  Psychotherapy  Neuropsychological Evaluations  Memory Clinic  Aging Families and Caregiver Program

UCCS Integrated Care Partnerships Partner AgencyIntegrated Care Team Silver Key Senior ServicesHome Based Services Team Peak Vista Community Health Senior Clinics FQHC Primary Care with Integrated Behavioral Health Program of All-Inclusive Care of the Elderly (PACE) Adult Day Health Managed Primary and Long Term Care The Resource ExchangeDisabilities Services (Supportive Living Services, Primary Care) Palisades at Broadmoor Park – Senior Housing Campus Wellness Center Integrated Care (Primary care, physical wellness, psychosocial wellness)

Biopsychosocial Frame Physiological aging – systemic changes – Illnesses – functional change Social contexts – Aging social stimulus value – Social structures (or lack of) in later life in particular societies – Roles and role transitions, social support Psychological aging – Cognitive changes – Emotional processing changes – Stress and coping responses 10

Screening Evaluation Intervention Menu Consultation with staff Program design and evaluation What do we bring to our partners?

Individual Assessments Integrated Team Care Plan Individual Intervention APA, Blueprint for Change: Integrated Care for an Aging Population

In fragmented service systems, each agency has protocols for assessment of ONE FACET of the Care Recipient – Diseases/Medications – Functioning – Care Preferences – Aging and End-of-Live Values – Resources Needed The WHAT: Assessment and Evaluation

Even as professionals we can only learn about the part of the elephant we can see… We might want to know what the family member sees on a daily basis, what has changed recently, and whether the current care structure is stable or fragile.

Rule In vs Rule Out

Mr. Howard Thomas is a 72-year-old retired African American veteran living in the rural Midwest with his wife of 46 years. He had triple by-pass surgery three months ago and was seeing his primary care provider, a family physician, for a follow-up visit. He was accompanied by his wife, who shared concerns that he was spending all of his time alone in the den watching TV. Mr. Thomas completed a variety of screening measures given on an annual basis in his primary care clinic. These tools were reviewed by the clinic nurse, who informed the physician that Mr. Thomas scored in the depressed range on the PHQ-9. The physician reviewed Mr. Thomas’ health status to assure that new or unresolved medical and neurological issues were not responsible for his depressive syndrome. Additional questions about Mr. Thomas’ mood and activities revealed decreased interest in previously pleasurable activities such as reading the newspaper and woodworking. With that information, the physician invited the behavioral health consultant (a psychologist) into the meeting with the explanation that she was a member of the care team who specialized in helping patients cope with medical illnesses and other life stressors. The physician further emphasized his confidence in the consultant’s ability to help Mr. Thomas address his recent difficulties.

Actions? Brief (20-30 min) assessment – Mental status – IN TACT – Depression - YES – Cognitive functioning – NO PROBLEMS – Suicidal thought, plan, intent – NO INTENT OR PLAN

Action? Share findings (include wife) – Assessment results – Education about depression and cardiac illness – Offer Tx options Wife: hesitant about medications Patient: open to medication but prefers not – Schedule 3 behavioral intervention sessions Adjustment to chronic disease Behavioral activation

Action? Confer w PCP on assessment findings and Tx plan Chart plan Include in chart results of ongoing assessments

Bypass the need for – Professionals to notice underlying problems – Elders to have insight and courage to self-identify Screens must cover common areas of mental health problems in older adults, AND fit work flow of primary care – Cognitive problems – Depression and Anxiety – Sleep Disorders, Substance Abuse, Pain Strategy #1: Screen Elders for MH

Case finding Brief Screen Depth of psych info Contextual info Multidisciplinary info Diagnostics Heavy on context info Intervention design User-friendly Outcome focused Brief Outcome assessments 21

6.5 million have Alzheimer’s Disease with or without another form of dementia Plassman et al (2007) CI is a leading cause of functional decline in older adults Costs? – 4.9 million unpaid caregivers – $183 billion/year societal cost in US Cognitive Impairment: Hidden Epidemic?

23 How does it look in your office? Frustration and anger Vague responding and excuses for errors Slow responses Personality changes Memory Difficulty with complex tasks Inappropriate responding Reduced rate of behavior (lack of initiation) Benign agreement but no follow-through

– Poor historian – long term or recent – Medication mismanagement Medications not taken at all Medications taken on alternate time schedule Multiple medication administrations Arbitrary dosages – Appointment follow-up Appointments not made, or forgotten Person arrives at appointment without instructions as to why they are there – Activity, diet, therapy instructions – Inability to read instructions – Inability to report symptoms Risks to Quality of Care

Disconnect ….. Health System Family Challenges “Why won’t they talk to me…I’m the one who has to take care of her??” “Why didn’t they tell me that ____ was an option?” “I just thought it was normal aging.” “Families can’t be included because of HIPAA” “If the family was just taking better care, she wouldn’t be so depressed.” “Why won’t the family let us do our job?”

Concept – starting age 50… personal baseline Controversial so no standards set yet Medicare’s new Annual Prevention Visit – Requires cognitive screening – Requires depression screening Challenges – High sensitivity/specificity measures take minutes which is not feasible in primary care – Computerized tools reduce labor but typically do not provide information on multiple domains of cognition or alternative causes Require some familiarity with computers, vision, English language Screening

Mental status exam Collateral report on daily functioning – Basic Activities of Daily Living: bathing, dressing, etc – Instrumental Activities of Daily Living: appointments, financial management, transportation, cooking Medical rule-out When suspicious of CI

Neuropsychological Evaluation -> cognition – Attention – Executive Function – Memory – Language – Problem-Solving/Reasoning – Psychological/Psychiatric conditions Depression Anxiety Substance Abuse Pain or Sleep disruption or pain Medical Rule-out of delirium causes Sx are Evident

Dx is known Re-assess regularly Engage family – Learn about the life context in order to make judgments about safety – driving, finances, housing – Inquire about surrogate decision-makers – Respect the critical role of family in the unfolding of this disease – caregiver self-care Ensure that the elder with dementia has emotional support 29

MoCA SLUMS Screen Dementia Rating Scale CogniStat Profile for General Planning Neuropsychological Evaluation Diagnostic Decisions Neuropsychological Evaluation Legal Capacity 30 Example: Cognitive Impairment

Mr. Johns Today Mr. Johns clearly did not recall what you discussed just a week ago, even after you prompted him. His labs suggest he may not be responding well to his medication regimen. Although he does not recall your instructions from last week, he was delighted to see you, and seemed earnestly interested in implementing the advice you gave today. Mental status exam showed him oriented x3, recalling 2 of 3 objects, and able to create a clock although he couldn’t recall the exact time you asked him to draw. 31

WHO-5 PRIME-MD Screen SCID – research level Clinical INterview Diagnostics Pleasant Events Scale Suicidal Beliefs Intervention Design GDS-15 item Staff observer scale for dementia Outcome Assessments 32 Example: Depression

Strategy #2 Gather information from collateral Concerns Observed behavior changes Daily functioning Health beliefs Care burden

1Memory Aggressive Behavior Concentration Suspiciousness Planning Personality Changes Decision-making Finances Follow through on plans Medical Care Mood Safety Issues Anxiety/Worry Household Tasks Irritability Self-care/Hygiene Sadness Appointments Depression Driving Apathy Medical Problems Suicidal Thoughts Falls/Balance Homicidal Thoughts Nutrition Social Relations Appetite Isolation Incontinence Withdrawal Sleep Inappropriate behavior Energy Level Other: Other: Behavior Problem Checklist In what areas do you find your family member having difficulty? Please rate the degree of problems your family member is experiencing by circling the appropriate number in each of the following areas on a scale from 1(no problem) to 7 (frequent problem or intense problem). Place a check beside the areas of functioning that have changed with in the past four to six months.

Instrumental/ Activities of Daily Living Assessment Form Please rate the degree of problems your family member is experiencing by circling the appropriate number in each of the following areas on a scale from 1(no assistance) to 7 (full assistance). Place a check beside the areas of functioning that have changed with in the past four to six months. 1Ambulation Laundry Bathing Medication Administration Dressing Food Preparation Transfers Heavy Chores Toileting Telephone Eating Financial Management Grooming Household Tasks Transportation Appointment Management Shopping Access Resources

Patricia travels to Florida for a week each quarter to help her parents who live in a condo there. In the past 6 months, however, her mother has been hospitalized 4 times for uncontrollable heart irregularities. Pat’s father is well meaning but rarely communicates accurate or complete information to Pat about medical treatment or decisions. She realizes he is beginning “to slip a little”. Her mother is sharp when she is not heavily medicated, but this series of illnesses have made her thinking a bit fuzzier than normal. Pat has caught a couple of times when her mother’s report from the doctor was inaccurate. She can’t travel any more often and keep her job, but also can no longer rely on her parents’ reports of what is happening in the hospital or at home.

Strategy #3 Assessment feedback Describe findings Educate about disorders Link information about MH and Physical health Explore health beliefs Explain Tx options (Pharm/Non-Pharm) Offer Tx source options (primary or MH)

38 Cognitive Impairments Impact … Executive Function – time, sequencing, impulse control Problem-solving Memory Language – expressive/receptive/pro cessing Attention

WHO is relevant? Medical Model

WHO is relevant? Individualistic Model

WHO is relevant? Familistic Model

42 Selling Family Involvement to Patient “Your family needs to know more about your health before there is a crisis and you can’t tell them” [Information only model] “You deserve to have some help with the detail work of managing your all of these medical details, while you direct the overall picture” [staff person model] Now is a great time to figure out how you want your family to work as your “team” [restructuring model]

43 Selling Increased Involvement to Family Your ____________ is concerned that no one knows the details of his/her health and thinks it is time to share information with you Your ____________ is finding it more and more challenging to handle the details of day- to-day management of medications, nutrition, and other aspects of health Your ____________ would like to invite you to become more involved in managing his/her health

Strategy #4 Apply findings to Daily Life Context Key Q: How do findings inform daily life? Apply to engagement in health and life Determine role of patient vs others in implementing recommendations Establish benchmarks/milestones Anticipate next transitions Use community resources

Interventions Criteria: -Evidence-based -Brief; focus in quickly on problem Specific options: -Problem-Solving Therapy -Brief Problem-Focused Solution -Motivational Interviewing

H & B Codes Address non-psychological disorders only Behavioral medicine Health behaviors APA

Chronic disease management= IS a behavior issue Engagement in choice to change – Information feedback – Education – Risk assessment and pro/con review – Motivational interviewing – Problem-focused, solution-focused interventions

Integration of Behavior Change into Treatment Planning Who can best deliver information and education? What data can be shared, in what format, at what pace? Coordinating the team Tracking outcomes

Practice Pragmatics

› Team membership and roles › Challenges › Hierarchical structures › Overlapping roles › Virtual teams with unknown membership › HIPAA concerns about sharing information › Consent form within unit › Specific consent for particular agency partners › Define scope of disclosure to family members carefully Where is the integration?

Individual Assessments Integrated Team Care Plan Individual Intervention APA, Blueprint for Change: Integrated Care for an Aging Population

 Facility paper charts › Find out who reads what sections › Find out who doesn’t read any section › Consider carefully who needs to know what  EHRs › Is there a comprehensive care plan? › Read carefully › Consider carefully who needs to know what  Your records › Medicare rules rule › Medical necessity, time of service, plan  Keeping family in the loop, with what? Communication

 Capacity evaluations › Only billable to Medicare IF meet medical necessity › Private payment is common (attorneys)  Family meetings › Medicare only reimburses if relates to care for elder who is patient of yours › Carriers vary, but usually, patient must be present  Staff interactions typically are not billable Watch out for special cases…

Disease organizations Alzheimer’s Association, stroke association, etc. Health provider groups Area Agency on Aging Hospitals and FQHC Public health department Local resources