1. Contemporary Issues in IBHC: Implications for Rural Colorado Practices
Updates
Contemporary Issues in IBHC: Implications for Rural Colorado Practices

2. Disclosures
The speaker has no conflicts of interest to disclose

3. Learning Objectives
Participants will identify two contemporary issues in integrated behavioral health care.
Participants will identify two ways to overcome the constraints and concerns of rural integrated care practice.
Participants will discuss and create pathways to enhance accessibility to integrated behavioral health care.

4. Speaking to the Choir

5. Benefits of Integrated Care
Healthcare professionals work together as members of an inter-professional team to improve patient outcomes and self-management

6. Behavioral Health and Primary Care Outcomes
Depression
Panic Disorder
PTSD
Generalized Anxiety D/O
Social Anxiety Disorder
Tobacco Use
Alcohol Misuse
Diabetes
Obesity
Primary Insomnia
Chronic Pain
IBS
Somatic Complaints
Behavioral Health and
Primary Care Outcomes
1. Butler et al., Integration of Mental Health/Substance Abuse and Primary Care. AHRQ Publication No. 09- E003. Rockville, MD. AHRQ
 2. Craven et al., Better Practices in Collaborative Mental Health Care: An Analysis of the Evidence Base. Canadian Journal of Psychiatry, 2006;51:1S-72S.
 3. Gilbody et al., Collaborative Care for Depression: A Cumulative Meta-analysis and Review of Longer-term Outcomes. Archives of Internal Medicine, 2006;166:
 4. Williams et al., Systematic Review of Multifaceted Interventions to Improve Depression Care. General Hospital Psychiatry, 2007; 29:
 5. Roy-Byrne et al., Delivery of Evidence-Based Treatment for Multiple Anxiety Disorders in Primary Care: A Randomized Controlled Trial. JAMA, 2010;303:
 6. Cigrang et al., Treatment of Active-Duty Military With PTSD in Primary Care: Early Findings. Psychological Services, 2011;8:
 7. Fiore et al., Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline, Rockville, MD: U.S. Department of Health and Human Services, Public Health Service.
 8. Whitlock et al., Behavioral Counseling Interventions in Primary Care to Reduce Risky/Harmful Alcohol Use by Adults: A summary of the evidence for the U.S. Preventive Services Task Force. Annals of Internal Medicine, 2004;140:
9. The Diabetes Prevention Program Research Group: The 10-Year Cost-Effectiveness of Lifestyle Intervention or Metformin for Diabetes Prevention: An Intent-to-Treat Analysis of the DPP/DPPOS. Diabetes Care, 2012;35:
 10. Funnell et al., National Standards for Diabetes Self-Management Education. Diabetes Care, 2008;31Supp1:S97-S104
 11. Wadden et al., A Two-Year Randomized Trial of Obesity Treatment in Primary Care Practice. NEJM, 2011;365:
 12. Leblanc et al., Effectiveness of Primary Care-Relevant Treatments for Obesity in Adults: A Systematic Evidence Review for the U.S. Preventive Services Task Force. Annals of Internal Medicine, 2011;155:
 13. Edinger et al., A Primary Care “Friendly” Cognitive Behavioral Insomnia Therapy. Sleep, 2003; 26:
 14. Goodie et al., Using Behavioral Health Consultants to Treat Insomnia in Primary Care: A Clinical Case Series. Journal of Clinical Psychology, 2010;65:
 15. Ahles et al., A Controlled Trial of Methods for Managing pain in Primary Care Patients With or Without Co-Occuring Psychosocial Problems. Annals of Family Medicine, 2006;4:
 16. Dobscha et al. Collaborative Care for Chronic Pain in Primary Care: A Cluster Randomized Trail. JAMA, 2009;301:
17. Cigrang et al., Evaluation of a Collaborative Mental Health Program in Primary Care: Effects on Patient distress and health care utilization. Primary Care and Community Psychiatry, 2006;11:
18. Bryan, et al., Impact of Behavioral Health Consultant Interventions on Patients symptoms and Functioning in an Integrated Family Medicine Clinic. Journal of Clinical Psychology, 2009;65:
19. Bryan, et al., Severity of Mental Health Impairment and Trajectories of Improvement in an Integrated Primary Care Clinic. Journal of Consulting and Clinical Psychology, 2012;80:
1. Butler et al., AHRQ Publication No. 09- E003. Rockville, MD. AHRQ
2. Craven et al., Canadian Journal of Psychiatry. 2006;51:1S-72S.
3. Gilbody et al., British Journal of Psychiatry, 2006;189:
4. Williams et al., General Hospital Psychiatry, 2007; 29:
5. Hunter et al., Integrated Behavioral Health in Primary Care: American Psychological Association, 2009

7. Behavioral Health and Primary Care Outcomes
Reduced specialist utilization
Lower ED utilization
Lower hospital admissions
Lower overall costs per patient
Improved cost savings
Improved referral acceptance in-house
Improved attendance with transitional care and referrals
Improved satisfaction for patients and providers
Behavioral Health and
Primary Care Outcomes
1. Butler et al., Integration of Mental Health/Substance Abuse and Primary Care. AHRQ Publication No. 09- E003. Rockville, MD. AHRQ
 2. Craven et al., Better Practices in Collaborative Mental Health Care: An Analysis of the Evidence Base. Canadian Journal of Psychiatry, 2006;51:1S-72S.
 3. Gilbody et al., Collaborative Care for Depression: A Cumulative Meta-analysis and Review of Longer-term Outcomes. Archives of Internal Medicine, 2006;166:
 4. Williams et al., Systematic Review of Multifaceted Interventions to Improve Depression Care. General Hospital Psychiatry, 2007; 29:
 5. Roy-Byrne et al., Delivery of Evidence-Based Treatment for Multiple Anxiety Disorders in Primary Care: A Randomized Controlled Trial. JAMA, 2010;303:
 6. Cigrang et al., Treatment of Active-Duty Military With PTSD in Primary Care: Early Findings. Psychological Services, 2011;8:
 7. Fiore et al., Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline, Rockville, MD: U.S. Department of Health and Human Services, Public Health Service.
 8. Whitlock et al., Behavioral Counseling Interventions in Primary Care to Reduce Risky/Harmful Alcohol Use by Adults: A summary of the evidence for the U.S. Preventive Services Task Force. Annals of Internal Medicine, 2004;140:
9. The Diabetes Prevention Program Research Group: The 10-Year Cost-Effectiveness of Lifestyle Intervention or Metformin for Diabetes Prevention: An Intent-to-Treat Analysis of the DPP/DPPOS. Diabetes Care, 2012;35:
 10. Funnell et al., National Standards for Diabetes Self-Management Education. Diabetes Care, 2008;31Supp1:S97-S104
 11. Wadden et al., A Two-Year Randomized Trial of Obesity Treatment in Primary Care Practice. NEJM, 2011;365:
 12. Leblanc et al., Effectiveness of Primary Care-Relevant Treatments for Obesity in Adults: A Systematic Evidence Review for the U.S. Preventive Services Task Force. Annals of Internal Medicine, 2011;155:
 13. Edinger et al., A Primary Care “Friendly” Cognitive Behavioral Insomnia Therapy. Sleep, 2003; 26:
 14. Goodie et al., Using Behavioral Health Consultants to Treat Insomnia in Primary Care: A Clinical Case Series. Journal of Clinical Psychology, 2010;65:
 15. Ahles et al., A Controlled Trial of Methods for Managing pain in Primary Care Patients With or Without Co-Occuring Psychosocial Problems. Annals of Family Medicine, 2006;4:
 16. Dobscha et al. Collaborative Care for Chronic Pain in Primary Care: A Cluster Randomized Trail. JAMA, 2009;301:
17. Cigrang et al., Evaluation of a Collaborative Mental Health Program in Primary Care: Effects on Patient distress and health care utilization. Primary Care and Community Psychiatry, 2006;11:
18. Bryan, et al., Impact of Behavioral Health Consultant Interventions on Patients symptoms and Functioning in an Integrated Family Medicine Clinic. Journal of Clinical Psychology, 2009;65:
19. Bryan, et al., Severity of Mental Health Impairment and Trajectories of Improvement in an Integrated Primary Care Clinic. Journal of Consulting and Clinical Psychology, 2012;80:
1. Butler et al., AHRQ Publication No. 09- E003. Rockville, MD. AHRQ
2. Craven et al., Canadian Journal of Psychiatry. 2006;51:1S-72S.
3. Gilbody et al., British Journal of Psychiatry, 2006;189:
4. Williams et al., General Hospital Psychiatry, 2007; 29:
5. Hunter et al., Integrated Behavioral Health in Primary Care: American Psychological Association, 2009

8. Improvements in 2-3 visits
Symptom
Functioning
Quality of Life
Wellbeing
2 Year Sustained

9. National Quality Strategy: The Triple & Quadruple Aim
Promote Effective Chronic Care Management
Make Care Safer
Promote Community / Population Health
Promote Effective Care Coordination
Integrated Team Based Care
Strengthen Patient & Family Engagement
Make Full Care Accessible
National Quality Strategy:
The Triple & Quadruple Aim
Institute for Healthcare Improvement & Bodenheimer

10. Definition & Inclusivity Expansion
Primary Care
Urgent Care
Dental Health
Health Literacy & Education
Nutrition
Family Planning
Personal Wellbeing
Social Wellbeing
Lifestyle
Substance Use
Mental Health

11. Drank the Kool-Aid

12. Rarity

13. INTEGRARTION is the standard
How do we integrate than should we integrate?

15. Rural

16. Knowledge Check LEGAL AND ETHICAL CONSIDERATIONS IN INTEGRATED CARE
COMMUNICTION PITFALLS
CHILDHOOD BEHAVIOR PROBLEMS
PEDIATRIC ASSESSMENTS
INTEGRATED CARE BILLING CODES
SOMATIZATION
STRATEGIES FOR SUCCESSFUL WARM HANDOFFS
What did you learn?
What did you contribute?
How does integrated care help?
What was new?
What was challenging?

17. Rural Needs & Challenges
5 Steps: Financials, Legislative, Regulatory, Service Delivery/Coding, & Licensure
Accessibility
Acceptability
Availability
Funding
Quality & Care Coordination
Culture Focus & Ethics
Rural Needs & Challenges

18. Rural Innovations
Population Health & Redesigned/Delivered Medical Visits
Telehealth & Technology
Learning Collaboratives
Expanded Roles & Responsibilities
Transformed Teams
Government Support & Advocacy
Ecological Perspective: Community & Capacity Building

20. Final Questions

21. For Further Information
Dr. Lesley Manson
Arizona State University
Doctor of Behavioral Health
Assistant Chair of Integrated Initiatives
Consultant for Integrated Care Sustainability and Planning
Phone: (602)

22. References
Smalley, B.K., Warren, J.C., & Rainer, J.P. (2012) Rural Mental Helath: Issues, policies, and best practices. Springer Publishing: New York. Corso, Hunter, Dahl, Kallenberg, and Manson (2016). Integrating behavioral health into the medical home: A rapid implementation guide. Greenbranch: Phoenix, Maryland. Kilbourne, A. M., Keyser, D., & Pincus, H. A. (2010). Challenges and opportunities in measuring the quality of mental health care. Canadian Journal of Psychiatry, 55(9), Burt, J. D., Garbacz, S. A., Kupzyk, K. A., Frerichs, L., & Gathje, R. (2012). Examining the utility of behavioral health integration in well-child visits: Implications for rural settings. Families, Systems, & Health, 32(1), Gouge, N., Polaha, J., Rogers, R., & Harden, A. (2016). Integrating behavioral health into pediatric primary care: Implications for provider time and cost. Southern Medical Journal, 109 (12), doi: /SMJ Meadows, T., Valleley, R., Haack, M. K., Thorson, R., & Evans, J. (2011). Physician "costs" in providing behavioral health in primary care. Clinical Pediatrics, 50(5), doi: / Hunter, C., Goodie, J.L., Oordt, M.S., and Dobmeyer, A. (2016). Integrated behavioral health in primary care. Second edition. American Psychological Association (APA), WA. Adams, S. J., Xu, S., Dong, F., Fortney, J., & Rost, K. (2006). Differential effectiveness of depression disease management for rural and urban primary care patients. Journal of Rural Health, 22(4), doi: /j x Aguilar-Gaxiola, S. A., Zelezny, L., Garcia, B., Edmondson, C., Alejo-Garcia, C., & Vega, W. A. (2002). Trans- lating research into action: Reducing disparities in mental health care for Mexican Americans. Psychia- tric Services, 53(12), doi: /appi.ps Bird, D.C., Dempsey, P. & Hartley, D. (2001). Addressing mental health workforce needs in underserved rural areas: Accomplishments and challenges. Portland, ME: Maine Rural Health Research Center, Muskie Institute, University of Southern Maine. Blank, M. B., Fox, J. C., Hargrove, D. S., & Turner, J. T. (1995). Critical issues in reforming rural mental health service delivery. Community Mental Health Journal, 31(6), doi: /BF Borders, T. F., & Booth, B. M. (2007). Research on rural residence and access to drug abuse services: Where are we and where do we go? The Journal of Rural Health: Official Journal of the American Rural Health Association and the National Rural Health Care Association, 23 Suppl, doi: /j x Borgenicht, L. (2008). Serving the underserved: Personal, social, and medical challenges. In P. M. Dalinis (Ed.), Ethical issues in rural health care. ( pp ). Baltimore, MD US: Johns Hopkins University Press. Retrieved from direct=true&AuthType=ip,url,uid,cookie&db=psyh&AN= &site=ehost-live; Rural AND Mental Health between 1970 an 2011 in English Human and Professional & Research Peer Reviewed Briddell, L. O. (2010). Rurality and crime: Identifying and explaining rural/urban differences. ProQuest Infor- mation & Learning). Dissertation Abstracts International Section A: Humanities and Social Sciences, 71(3 -) Retrieved from direct=true&AuthType=ip,url,uid,cookie&db=psyh&AN= &site=ehost-live; Rural AND Mental Health ( ) Hauenstein, E. J., Petterson, S., Rovnyak, V., Merwin, E., Heise, B., & Wagner, D. (2007). Rurality and mental health treatment. Administration and Policy in Mental Health and Mental Health Services Research, 34 (3), doi: /s Hayslip Jr., B., Maiden, R. J., Thomison, N. L., & Temple, J. R. (2010). Mental health attitudes among rural and urban older adults. Clinical Gerontologist, 33(4), doi: /