Patients Seen, and Interventions Used by Behavioral Health Providers Working in Different Models of Integrated Healthcare in Primary Care Clinics Across the VA Jennifer S. Funderburk, Ph.D. Stephen A. Maisto, Ph.D. Anne Dobmeyer, Ph.D. Christopher Hunter, PH.D.

Acknowledgements This study was funded by the Center for Integrated Healthcare pilot grant This study could not have been completed without the generosity and hard work of behavioral health providers across the VA, leadership, and fellow research staff

Objectives Describe the different integrated healthcare models behavioral health providers reported working in across the VA nationally Describe the types of patients seen and clinical interventions used regularly across different integrated healthcare models. Discuss the implication of these results on the clinical practice of BHPs within integrated primary care settings. Discuss potential avenues for future clinical intervention research.

Purpose of the Study National prospective descriptive web-based study examining the types of patients seen and interventions used by VA behavioral health providers (BHPs) integrated into primary care

Method Recruitment ▫Contacted implementation coordinators of PCMH (N=143) to obtain addresses for BHPs in their VA  92 coordinators responded (71% response rate) ▫33 forwarded recruitment to BHPs ▫8 scheduled a teleconference to present research to BHPs ▫40 provided BHP names and addresses to researchers ▫Some provided listservs which included non-BHP staff ▫Sent 3 recruitment s to each BHP asking them to contact us if they were interested

Method Procedure: Interested BHPs replied to the recruitment and scheduled a 5-minute telephone call, where they completed informed consent, learned how to use the web-based questionnaire, and scheduled a day to complete the study BHPs completed online questionnaires on one randomly assigned day of clinical service

Method Measures: ▫ Demographics & Background (filled out only once):  BHP’s background & clinical training  Integrated healthcare setting elements ▫ Appointment Questionnaire (filled out after each patient on day of study):  Patient Information: gender, age, presenting symptomatology  Types of Clinical Interventions Performed

Participants: BHPs 159 BHPs completed the study ▫ 21 VISNs represented ▫452 eligible BHPs contacted ▫Overall 35% response rate  Impacted by over-inclusive listservs  Slightly higher than typical response rate 33% (Shih & Fan, 2009)

Participants Integrated Healthcare Models ▫Coordinated Care (N=4)  Medical and behavioral health providers largely function independently in separate facilities  Maintain separate records, treatment plans, and standards of care. ▫Co-located (N=39)  Medical and behavioral health providers are located in same physical space and may share administrative personnel ▫Care Management (N=9)  Model of care typically focused on a discrete clinical problem (e.g., depression), incorporating specific pathways using a variety of components

Participants Integrated Healthcare Models (continued) ▫Co-located Collaborative Care (CCC; N=75)  Population health-based model of care focused on all patient populations  Medical providers and BHPs share patient information, medical record, treatment plan, and standard of care  BHP is embedded within the primary care team, acts as a consultant to PCP ▫Blended--Care Management / CCC (N=28)  Incorporates embedded care management aspect of CCC model  Care manager and behavioral health consultant are part of primary care team  BHC is typically responsible for supervision of the care manager ▫Blended--Co-located / CCC (N=4)  Medical providers and BHPs are located in the same physical space, share patient information, medical record, treatment plan, and standard of care

Results: BHP Demographics & Clinical Background by Model Co-located (N=39 BHPs) CCC (N=75 BHPs) Blended-CCC+CM (N=28 BHPs) Mean (SD) RangeModeMean (SD) RangeModeMean (SD) RangeMode Provider age 41(9) (10) (9) Yrs. of clinical experience in primary care 4(4)0-1714(4)0-2113(3)0-181 No. of hrs/wk seeing patients 27(10) (12) (11) Office distance from PCP (ft) 17(19) (60) (20)0-755

Results: Provider Type by Model Other: MS in Psychology, Psychology Interns, NPs, Advanced Practice Nurses

Co-locatedCCCBlended- CCC+CM Shared medical record 100% Patients use same waiting area as primary care 90%92%93% Offices located within primary care clinic 90%85%86% Daily open slots for same-day appointments 87% 89% BHPs attend primary care staff meetings 69%77%82% Same staff schedules BHP appointments as primary care* 41%*67%*36%* BHPs regularly present at primary care staff meetings† 36%†52%†61%† PCP regularly asks BHP to join them on patient appointments 23%29%32% Results: Integrated Care Elements by Model * p <.05, † p <.10 in X 2 analysis

Results: Theoretical Orientation by Model “Other” orientations: Co-located (21%) CCC (35%) Blended (32%)

Results: Patient Demographics by Model Co-located (N=151 patients) CCC (N=311 patients) Blended-CCC+CM (N=105 patients) Patient gender96% male85% male82% male Initial session40%37%32% Session range2-47, Mode:21-96, Mode: 22-28, Mode: 2 Mean (SD) RangeModeMean (SD) RangeModeMean (SD) RangeMode Patient age 54(15) (15) (14) Visit length (min) 39(17) (16) (15)7-9030

Results: Top 3 Patient Presenting Problems by Model Next 3 Most Commonly Reported Problems: Insomnia, Chronic Pain, & Coping with a Medical Condition

Clinical Intervention Co-located (N=151) CCC (N=311) Blended- CCC+CM (N=105) Psycho-education about diagnosis70%64%71% Educate about CBT62%70%82% Discuss current techniques for relief76%89%91% Importance of interpersonal relationships 73%72%80% Pleasurable activities66%74%76% Behavioral changes50%62%63% Plan to see patient again 72%70%79% Results: Top Interventions by Model

Clinical Intervention Co-located (N=151) CCC (N=311) Blended- CCC+CM (N=105) Educate about CBT64%68%81% Problem solving skills48%60%71% Discuss medication adherence43%52%66% Relapse prevention 22%*25%53%* Discuss communication style in relationships 43%49%60% Cognitive distortions33%28%51% Results: Differences in Interventions for Depression * Largest difference in how much an intervention is used

Clinical Intervention Co-located (N=151) CCC (N=311) Blended- CCC+CM (N=105) Educate about CBT67%71%84% Problem solving skills47%58%72% Discuss medication adherence38%*44%67%* Relapse prevention 19%23%44% Educate about medications55%49%72% Behavior change48%60%68% Results: Differences in Interventions for Anxiety * Largest difference in how much an intervention is used

Results Overview: Similarities BHPs most likely to be psychologists CBT most common Aspects of integrated healthcare context: ▫Shared medical record ▫Patients use same waiting area as primary care ▫Daily open slots for same-day appointments ▫BHP offices located within primary care clinic Depression, Anxiety & Adjustment top problems Most common interventions among the models: ▫Discussing current techniques for relief ▫Importance of interpersonal relationships

Results Overview: Differences Aspects of integrated healthcare context ▫Staff scheduling BHP and primary care appointments ▫BHPs presenting at primary care staff meetings Top Interventions ▫Co-located: Plan to see patient again ▫CCC: Pleasurable activities ▫Blended-CCC+CM: Educate about CBT Depression Interventions ▫Relapse Prevention (used 22-53%) Anxiety Interventions ▫Discussion of medication adherence (used 38-67%)

Limitations Only 35% response rate from BHPs ▫Impacted by over-inclusive listservs Only examined one day of primary care ▫Could be non-representative of typical care given ▫Future studies could examine several days and create averages of the data that more accurately reflect what is happening Limited numbers of all models represented ▫Makes across-model comparisons difficult

Discussion Majority of BHPs are psychologists ▫BHPs can come from a variety of training backgrounds ▫Psychologists are increasingly being recruited to work in integrated primary care settings (Cummings, O’Donohue, Hayes, & Follette, 2001; Frank, McDaniel, Bray, & Heldring, 2004) Depressive and anxious symptomatology are most common within primary care (Funderburk et al., 2011; Bluestein & Cubic, 2009) Evidence suggests the efficacy of problem-solving & CBT interventions; could be helpful to be utilized even more (Catalan et al, 1991; Churchill et al., 2001)

Conclusions Need for effectiveness research ▫Focused on the interventions regularly used by BHPs ▫Focused on comparing the efficacy in different models of care Need for research on barriers ▫Exploring barriers to BHPs using recommended or preferred interventions (e.g., CBT, problem-solving techniques) ▫Exploring barriers to sites becoming more integrated Need for dissemination ▫Examining how to disseminate findings on evidence-based treatment to providers to help improve practices ▫Examining the current access to trainings on evidence-based treatments