Integrated Models of Care: Examples from HBPC and Cardiology Steven Lovett, Ph.D.

Program Descriptions Home Based Primary Care (HBPC) Home Based Primary Care (HBPC) –Primary care delivered in the home. –3 teams with their own NPs, RN, SW, OT –Shared Medical Director, Pharmacist, Dietitian, Psychology. –Goal = return patients to clinic or avoid institutionalization.

Program Descriptions – cont. Cardiac Transplant Clinic Cardiac Transplant Clinic –Serves vets who are candidates for, or, –have had a heart transplant. –Regional program. –Patients followed for life.

Integration: Treatment Goals Assist medical providers in reaching program’s treatment goals. Assist medical providers in reaching program’s treatment goals. Identify undiagnosed psychological problems. Identify undiagnosed psychological problems.

Integration: Treatment Setting Fast paced clinics. Fast paced clinics. Reduced privacy. Reduced privacy. Specific accomplishments for each visit. Specific accomplishments for each visit. Relatively infrequent visits. Relatively infrequent visits.

Psychological Services Provided Triage for psychological issues. Triage for psychological issues. Adherence issues: Adherence issues: –Knowledge –Skills –Resources –Motivation

Psychological Services Provided – cont. Health behaviors. Health behaviors. Somatic issues: Somatic issues: –Sleep disturbance –Pain Psychological distress: Psychological distress: –Depression / anxiety –Stress

Psychological Services Provided – cont. Cognitive screening / capacity assessment. Cognitive screening / capacity assessment. Caregiver / Family issues. Caregiver / Family issues. End of life issues. End of life issues. Provider consultation. Provider consultation.

Therapeutic Modalities Single session intervention. Single session intervention. Phone follow-up. Phone follow-up. Referrals / case management. Referrals / case management. Individual therapy, as needed & feasible. Individual therapy, as needed & feasible.