1. Behavioral Health Skills for Primary Care Team Members: Increased capacity to meet the need Larry Mauksch, M.Ed Senior Lecturer, Family Medicine, Univ of Washington Consultant

2. Presentation Objectives

3. Behavioral Health Role(s): Integration Steps Referral to BH offsite No collaboration BH part of team Disease mgmt for Complex patients Supervision of BH care management Referral for BH offsite Shared records Referral to BH onsite No collaboration Referral to BH onsite Shared records Referral to BH onsite Shared records, shared planning Team Training and System Transformation

4. Mental Disorders in Primary Care J of Fam Practice 200150(1), 41-47

5. Primary Care Realities

6. Teamwork The solution

7. Patient Centered Medical Home: Two interdependent components Rogers, PCMH Movement: Promise and peril for family medicine. JABFP, 2008 21(5) Larry Mauksch, M.Ed University of Washington Department of Family Medicine

8. Why Are High Functioning Teams Essential To Primary Care

9. Role versus Function Toward transdisciplinary teamwork

10. Continuum of Role Function

11. Behavioral Health Functions

12. Transdisciplinary Functions and Roles in Primary Care Role Function PCPNurseMedical Assistant PharmBehavioral health Care Management Relationship555555 Agenda setting and activation 435244 Self management- simple 434322 Self management- complex 342345 Primary care counseling 341254 Plan confirmation and care integration 344345 Proactive follow-up and stepped care 354334 Intensity: 5 =always; 4= often; 3 = periodic; 2 = support; 1 = reinforce and connect Larry Mauksch, M.Ed UW Family Medicine

13. Mastering a Skill Domain

14. Common Training Sequence Larry Mauksch, M.Ed University of Washington Department of Family Medicine

16. Observation Form Purpose and Training

17. PCOF Use Larry Mauksch, M.Ed University of Washington Department of Family Medicine

18. PCOF Categories

19. Relationship Communication and Efficiency: Creating a model from a literature review Mauksch, Dugdale, Dodson, Epstein 2008, Arch of Intern Med

20. UW Family Medicine Residency (Mauksch et al Families Systems, Health, 2001) Community RCT Brock, Mauksch et al JGIM, Nov 2011 10 Residents; 7 faculty 162 patients48 physicians, 1460 patients; two systems Brief reading, video, written learning confirmation, skill reinforcement 2 hr training w/demo & practice; handout, 2 hrs coaching/wk for 4 weeks, no reinforcement for 6 months Higher patient satisfaction More MD prioritization MDs charted more problems More f/u requests No difference in visit lengths EF MDs showed more upfront elicitations (“something else”*) EF patients more likely to say “that’s it” EF Patients & MDs had fewer “oh by the ways” in phase 3 Shorter visits 90 seconds (NS) No diff in pt / MD satisfaction

21. Agenda Creation

22. Agenda Refinement Then ask “What is going on in your life that causes stress and feeling down?”

23. Upfront Agenda Setting: Impressions Larry Mauksch, M.Ed University of Washington Department of Family Medicine

24. Self Management-Complex (Integration of Goal Setting and Action Plan, Patient Activation and Motivational Models)

25. Complexity Care Influences and Collaborators  Minnesota Complexity Assessment Model  Peek, Baird, Coleman  Bill Gunn, PhD and colleagues in Concord, NH  UW colleagues work on a Picker Foundation support pilot Study:  Kavitha Chunchu, MD., Carol Charles, MSW, Valerie Ross, MS., Judy Pauwels, MD  Family Care Network in Whatcom County, Wa  Berdi Safford, MD, Marcy Hipskind, MD. David Lynch, MD

26. Collaborative Complexity Care Assessment, Goals and Action Plans

27. Patient Centered Care Plan or Collaborative Care Plan

28. Patient Centered Goal Setting

29. Goal Setting Chart review PCCP 51 yrs;60%F Controls 55 yrs; 40% F Goal documented.96 %.43 % Ongoing activity.89.34 Specific activity.78.41 How often.68.07 When.68.07 Barriers.75.01 Confidence.71.00 What can help with confidence.53.00

30. Continued work