1. Jennifer S. Funderburk, PhD
Brooke Levandowski, PhD, MPA
Marsha Wittink, MD, MBe
Session Ga
Saturday 1:15-1:40, October 15, 2016
Team Communication within Integrated Primary Care Settings In the Context of Suicide Prevention
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List EACH PRESENTER who will ATTEND the CFHA Conference to make this presentation.
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CFHA 18th Annual Conference
October 13-15, 2016  Charlotte, NC U.S.A.
Collaborative Family Healthcare Association 12th Annual Conference

2. Faculty Disclosure
The presenters of this session have NOT had any relevant financial relationships during the past 12 months.
You must include ONE of the statements above for this session.
CFHA requires that your presentation be FREE FROM COMMERCIAL BIAS. Educational materials that are a part of a continuing education activity such as slides, abstracts and handouts CANNOT contain any advertising or product‐group message.
The content or format of a continuing education activity or its related materials must promote improvements or quality in health care and not a specific propriety business interest of a commercial interest. Presentations must give a balanced view of therapeutic options. Use of generic names will contribute to this impartiality. If the educational material or content includes trade names, where available trade names for products of multiple commercial entities should be used, not just trade names from a single commercial entity. Faculty must be responsible for the scientific integrity of their presentations. Any information regarding commercial products/services must be based on scientific (evidence‐based) methods generally accepted by the medical community.
Collaborative Family Healthcare Association 12th Annual Conference

3. Learning Objectives At the conclusion of this session, the participant will be able to:
Identify the various ways the team can communicate about suicide within this healthcare organization
Identify the barriers and facilitators that are present that may impact the communication within the team
Identify potential ways for future examination on team communication and its potential impact on suicide prevention
Include the behavioral learning objectives you identified for this session
Collaborative Family Healthcare Association 12th Annual Conference

4. Bibliography / Reference
Funderburk, J. S., Sugarman, D. E., Labbe, A. K., Rodrigues, A., Maisto, S. A., & Nelson, B. (2011). Behavioral health interventions being implemented in a VA primary care system. Journal of Clinical Psychology in Medical Settings, 18(1), doi: /s y
Himelhoch, S., Riddle, J., & Goldman, H. H. (2014). Barriers to implementing evidence- based smoking cessation practices in nine community mental health sites. Psychiatric Services, 65(1), doi: /appi.ps
Johnson, M., Jackson, R., Guillaume, L., Meier, P., & Goyder, E. (2011). Barriers and facilitators to implementing screening and brief intervention for alcohol misuse: a systematic review of qualitative evidence. Journal of Public Health (Oxf), 33(3), doi: /pubmed/fdq095Reference
Continuing education approval now requires that each presentation include five references within the last 5 years.
Please list at least FIVE (5) references for this presentation that are no older than 5 years.
Without these references, your session may NOT be approved for CE credit.
Collaborative Family Healthcare Association 12th Annual Conference

5. Bibliography / Reference
Moyer, V. A. (2013). Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: US Preventive Services Task Force recommendation statement. Annals of internal medicine, 159(3),
Williams, J. M., Miskimen, T., Minsky, S., Cooperman, N. A., Miller, M., Budsock, P. D., Steinberg, M. L. (2015). Increasing tobacco dependence treatment through continuing education training for behavioral health professionals. Psychiatr Serv, 66(1), doi: /appi.ps
Continuing education approval now requires that each presentation include five references within the last 5 years.
Please list at least FIVE (5) references for this presentation that are no older than 5 years.
Without these references, your session may NOT be approved for CE credit.
Collaborative Family Healthcare Association 12th Annual Conference

6. Learning Assessment A learning assessment is required for CE credit.
A question and answer period will be conducted at the end of this presentation.
Please incorporate audience interaction through a brief Question & Answer period during or at the conclusion of your presentation.
This component MUST be done in lieu of a written pre- or post-test based on your learning objectives to satisfy accreditation requirements.
Collaborative Family Healthcare Association 12th Annual Conference

7. Overview Suicide Prevention Efforts Types of Communication
Survey of Providers
Barriers to Communication
Future development and research

8. Suicide In PC SI is present but not often discussed1
PCPs inconsistently ask2, 3
Patients may not disclose4
Positive depression screens precede structured SI screens5
Structured screens
Gather information to determine risk6
Develop safety plan6
1 (Vannoy et al., 2011); 2 (Feldman et al., 2007);
3 (Hooper et al.; 2012); 4 (Ganzini et al., 2013);
5 (Dobscha et al., 2013); 6 (Grant et al., 2015)
Collaborative Family Healthcare Association 12th Annual Conference

9. Suicide Prevention Efforts
VA’s integrated primary care setting allows for suicide prevention
Annual depression screening using Patient Health Questionnaire (PHQ-2)
Use of PHQ-9
Presence of Integrated Behavioral Health Provider (BHP)
Templates within EMR for suicide risk assessment
Flag EMR
Prevention coordinator for high risk pts
National Crisis Line
Mandated Educational Program
Research
Nurse
PCP
Integrated BHP
Patient
Support Specialist

10. Communication Among Team Members
Direct
Team Huddles
Feedback/Consultation
Indirect (EMR)
Additional signer on notes
Templates
Flags
Collaborative Family Healthcare Association 12th Annual Conference

11. Purpose Quality Improvement evaluation
Obtain a better understanding how communication occurs among team members
Identify potential barriers/facilitators
Focus groups
Online anonymous survey
Among those members of the primary care team: PCP, nurses, integrated behavioral health provider
Focus groups with nurses, integrated behavioral health providers, and primary care providers identified several themes such as: important role of integrated behavioral health providers helping to assess and communicate about suicide within primary care, less discussion about the specific role of PCP unless they serve as a conduit to BHP, the role of nurses as identifying when things have changed for the patient, the diffusion of responsibility, the shared responsibility of suicide prevention
We conducted an online survey of primary care staff within all VA primary care clinics within the Upstate New York region. After sending out three recruitment s to primary care staff listserves, a total of 139 completed the anonymous survey. A total of ?? Integrated providers, ?? PCPs, and ?? Nurses with at least one individual from each primary care clinic participating. Within these primary care clinics, all of them had an embedded behavioral health provider working in a service delivery model most similar to the Primary Care Behavioral Health model.
91 total number in final dataset—15 PCMHI; 32 PCP; 39 RNs; 5 SPC, representing all large medical centers as well as small clinic outpatient clinics associated with those medical centers
Collaborative Family Healthcare Association 12th Annual Conference

12. SURVEY SAYS… 1-2 3-4 5-6 7-8 9-10 >10
1-2
3-4
5-6
7-8
9-10
>10
How often do integrated behavioral health provider attend huddle in past month?
PCP
Nurse
How often do PCP talk to integrated behavioral 1
1-3
>3 -
Health provider in past week?
Least Likely to Initiate Contact with the PCMHI Provider
PCP
Nurse
When a patient has a new medical diagnosis
When I have a concern about med interactions or side effects
When I disagree with the treatment plan
When a patient has had a significant change in life circumstances
When I refer a patient to the PCMHI provider
When a patient is in acute mental health crisis situation
Collaborative Family Healthcare Association 12th Annual Conference

13. Direct Communication SURVEY SAYS…
1-2
3-4
5-6
7-8
9-10
>10
How often do integrated behavioral health provider attend huddle in past month?
PCP
61%
13%
16% 3% - 6%
Nurse
56%
26% 9%
How often do PCP talk to integrated behavioral 1
1-3
>3
Health provider in past week?
Least Likely to Initiate Contact with the PCMHI Provider
PCP
Nurse
When a patient has a new medical diagnosis
When I have a concern about med interactions or side effects
When I disagree with the treatment plan
When a patient has had a significant change in life circumstances
When I refer a patient to the PCMHI provider
When a patient is in acute mental health crisis situation
Huddles are one place where information about suicide risk may be discussed; however, integrated behavioral health providers don’t attend them regularly. Missed opportunity.
Collaborative Family Healthcare Association 12th Annual Conference

14. Direct Communication SURVEY SAYS…
1-2
3-4
5-6
7-8
9-10
>10
How often do the integrated behavioral health provider attend huddle in past month?
PCP
61%
13%
16% 3% - 6%
Nurse
56%
26% 9%
How often do PCP talk to integrated behavioral 1
1-3
>3
Health provider in past week?
19%
28%
41%
29%
32%
Least Likely to Initiate Contact with the PCMHI Provider
PCP
Nurse
When a patient has a new medical diagnosis
When I have a concern about med interactions or side effects
When I disagree with the treatment plan
When a patient has had a significant change in life circumstances
When I refer a patient to the PCMHI provider
When a patient is in acute mental health crisis situation
A majority of PCPs and nurses speak with integrated providers less than 3 times per week---some opportunities for communication but likely not enough
Collaborative Family Healthcare Association 12th Annual Conference

15. Direct Communication SURVEY SAYS…
1-2
3-4
5-6
7-8
9-10
>10
How often do integrated behavioral health provider attend huddle in past month?
PCP
61%
13%
16% 3% - 6%
Nurse
56%
26% 9%
How often do PCP talk to integrated behavioral 1
1-3
>3
Health provider in past week?
19%
28%
41%
29%
32%
Least Likely to Initiate Contact with the PCMHI Provider
PCP
Nurse
When a patient has a new medical diagnosis
53%
31%
When I have a concern about med interactions or side effects
20%
25%
When I disagree with the treatment plan
17%
When a patient has had a significant change in life circumstances 7% -
When I refer a patient to the PCMHI provider 3% 6%
When a patient is in acute mental health crisis situation
When a patient has a new medical diagnosis; when I have a concern about medication interactions or medication side effects
Other Option for Least Likely that was not endorsed:
2, b. when a patient is exhibiting an increase in symptoms
Collaborative Family Healthcare Association 12th Annual Conference

16. Indirect Communication
Electronic Medical Record
Flag Chart
Violence or suicide
Suicide Risk Assessment Template
Add Additional Signers on note
Presence of the note indicates that provider saw the patient
Content of the note can convey information about work doing together
Flags added by providers to indicate a high level of risk after a patient has had a suicide attempt or event indicating high risk---NOT just simple ideation
Collaborative Family Healthcare Association 12th Annual Conference

17. Electronic Medical Record
% Agree
% Disagree
Integrated BHP
PCP
Nurse
I’ve used suicide template in EMR in the past 6 months 93 61 36 7 39 64
Template suicide risk assessments are impersonal 57 - 43
I find the alerts helpful for identifying violent pts
I find the alerts helpful for identifying suicide pts
I value electronic alerts EMR when other providers saw pt
I find it hard to identify relevant info in other providers notes
I value information in progress notes from other providers
Other providers often adds me as an additional signer
Providers use the suicide risk assessment EMR template with both PCMHI and PCPs finding the template impersonal
Likely impacts their ability to use it well
Collaborative Family Healthcare Association 12th Annual Conference

18. Electronic Medical Record
% Agree
% Disagree
Integrated BHP
PCP
Nurse
I’ve used suicide template in EMR in the past 6 months
Template suicide risk assessments are impersonal
I find the alerts helpful for identifying violent pts 93 91 87 7 9 13
I find the alerts helpful for identifying suicide pts
100 94 90 6 10
I value electronic alerts EMR when other providers saw pt
I find it hard to identify relevant info in other providers notes
I value information in progress notes from other providers
Other providers often adds me as an additional signer
I feel comfortable initiating conversations about suicide
Like the electronic flags
Collaborative Family Healthcare Association 12th Annual Conference

19. Electronic Medical Record
% Agree
% Disagree
Integrated BHP
PCP
Nurse
I’ve used suicide template in EMR in the past 6 months
Template suicide risk assessments are impersonal
I find the alerts helpful for identifying violent pts
I find the alerts helpful for identifying suicide pts
I value electronic alerts when other providers saw pt 86 97 - 14 3
I find it hard to identify relevant info in other providers notes 29 41 71 59
I value information in progress notes from other providers
100 96 4
Other providers often adds me as an additional signer 47 78 53 22
Although the providers value being informed that the patients are engaged in care and the information within the notes, they find it hard to figure out what information is trying to be conveyed.
Although all of these team members are involved in this patients care, they don’t always include each other on their notes. More common for PCMHI to report not being included on notes from the PCP----may not know that there is relevant information in the chart, may not know that the PCMHI is involved with the patient currently
Collaborative Family Healthcare Association 12th Annual Conference

20. Individual Factors Integrated BHP PCP Nurse 100 97 85 3 15 % Agree
% Disagree
Integrated BHP
PCP
Nurse
I feel comfortable initiating a conversation about depression/suicide
100 97 85 3 15
I am less concerned about a patient’s risk for suicide if they are actively involved in txt with a behavioral health provider
I depend on nurses to alert me if patient is not engaged in treatment
I depend on nurses to alert me if patient’s life circumstances has changed
I depend on nurses to alert if I should ask more about patient’s mood
I value in-person feedback regarding shared pts
Collaborative Family Healthcare Association 12th Annual Conference

21. Individual Factors Integrated BHP PCP Nurse 60 56 44 40 % Agree
% Disagree
Integrated BHP
PCP
Nurse
I feel comfortable initiating a conversation about depression/suicide
I am less concerned about a patient’s risk for suicide if they are actively involved in txt with a behavioral health provider 60 56 44 40
I depend on nurses to alert me if patient is not engaged in treatment
I depend on nurses to alert me if patient’s life circumstances has changed
I depend on nurses to alert if I should ask more about patient’s mood
I value in-person feedback regarding shared pts
Collaborative Family Healthcare Association 12th Annual Conference

22. Individual Factors Integrated BHP PCP Nurse 73 44 92 27 56 8 67 53 100
% Agree
% Disagree
Integrated BHP
PCP
Nurse
I feel comfortable initiating a conversation about depression/suicide
I am less concerned about a patient’s risk for suicide if they are actively involved in txt with a behavioral health provider
I depend on nurses to alert me if patient is not engaged in treatment 73 44 92 27 56 8
I depend on nurses to alert me if patient’s life circumstances has changed 67 53
100 33 47
I depend on nurses to alert if I should ask more about patient’s mood - 68 95 32 5
I value in-person feedback regarding shared pts
Collaborative Family Healthcare Association 12th Annual Conference

23. Individual Factors Integrated BHP PCP Nurse - % Agree % Disagree
I feel comfortable initiating a conversation about depression/suicide
I am less concerned about a patient’s risk for suicide if they are actively involved in txt with a behavioral health provider
I depend on nurses to alert me if patient is not engaged in treatment
I depend on nurses to alert me if patient’s life circumstances has changed
I depend on nurses to alert if I should ask more about patient’s mood
I value in-person feedback regarding shared pts
100 93 - 7
Collaborative Family Healthcare Association 12th Annual Conference

24. Take Away Points
Indirect communication:
EMR suicide/violence flags are valued and perceived as useful for high risk patients
Asking a provider to be an additional signer of a progress note conveys that they have seen the patient and is valued, but communication within the note may be ineffective
A mixed level of indirect communication occurs from PCP’s to integrated behavioral health providers.
Hard to know whether PCP actually know integrated provider still involved since PCBH model is brief and may not be seeing them regularly
Collaborative Family Healthcare Association 12th Annual Conference

25. Take Away Points Individual Factors Diffusion of responsibility
Direct communication:
Value In-person feedback
Missed opportunities: huddles
If have something to tell provider, direct communication may be the way to go
Diffusion of Responsibility may be a problem
Not all PCPs don’t feel that changes in medical/medications need to be shared with integrated BHP
Individual Factors
Diffusion of responsibility
Less concerned if patient in BH
50% of patients who commit suicide see their PCP within prior 12 months7
Flags appear to facilitate communication
Additional signers would further this communication
PCPs and RNs utilize PCMHI in more crisis situations
Collaborative Family Healthcare Association 12th Annual Conference

26. Future Development and Research
How do patients feel about communication about suicidal risk factors among medical home team?
Is this data characteristic of other clinics?
What does it mean if greater communication among the team to suicidal risk?
Collaborative Family Healthcare Association 12th Annual Conference

27. Session Evaluation
Please complete and return the evaluation form before leaving this session. Thank you!
This should be the last slide of your presentation
Collaborative Family Healthcare Association 12th Annual Conference