1. 1 Primary Care and Behavioral Health Integration within the Free Clinic Setting: Developing a PCBH Model of Care Alysia Hoover-Thompson ahoover7@radford.edu Radford University Presented at the Mental Health Roundtable Virginia Health Care Foundation, Richmond, VA August 16, 2011

2. 2 Radford University Psy.D. Program  First cohort began providing services to community in 2008 as part of training program  Students provide mental health services to local community organizations  Many of these organizations are not-for-profit  Program emphases Rural practice Rural practice Cultural diversity Cultural diversity Social justice Social justice Evidence-based practice Evidence-based practice

3. 3 Free Clinics  “Free clinics are volunteer-based, safety- net health care organizations that provide a range of medical, dental, pharmacy, and/or behavioral health services to economically disadvantaged individuals who are predominately uninsured” (National Association of Free Clinics, 2008)

4. 4 Free Clinic of the New River Valley  On site Medical Medical Dental Dental Pharmacy Pharmacy Dermatology clinic Dermatology clinic  Who Qualifies? Adults without health insurance Adults without health insurance “Low income” based on 2010 Federal Poverty Guidelines “Low income” based on 2010 Federal Poverty Guidelines  Mental Health Association of the New River Valley Provides pro-bono counseling services to MHA clients at an office located in the Free Clinic Provides pro-bono counseling services to MHA clients at an office located in the Free Clinic

5. 5 Why Integrated Care?  Up to 70% of visits to primary care offices are related to behavioral health needs  Many common medical problems that are treated by PCP involve health and behavioral habits that influence symptoms (Hunter, Goodie, Oordt, & Dobmeyer, 2009)  In 2008, the American Psychological Association launched the Primary Care Initiative

6. 6 Developing an Integrated PCBH Site  Psy.D. Program Director approached by Free Clinic Director Program students had previous experience providing traditional mental health services at site through Mental Health Association Program students had previous experience providing traditional mental health services at site through Mental Health Association  Joshua Bradley was the first Psy.D. student from Radford to complete a practicum there Developed forms and documents for integration Developed forms and documents for integration Developed comprehensive 360 degree evaluation procedure to assess integration into the system and performance Developed comprehensive 360 degree evaluation procedure to assess integration into the system and performance

7. 7 Integrating PCBH Services into an Established System  Emphasize that you are there to support existing services  Try to accept as many referrals as possible in order to show usefulness  Get to know all people in the clinic  Explain what you do Have a prepared explanation and examples Have a prepared explanation and examples Create a handout Create a handout

8. 8 Systemic Contextual Considerations  Names and Faces Virginia College of Osteopathic Medicine residents Virginia College of Osteopathic Medicine residents On site physician On site physician Nurse practitioners Nurse practitioners Nurses Nurses Front office staff Front office staff Volunteers Volunteers

9. 9 Patient Contextual Considerations  Given the low-income client base, there may be relevant considerations related to intervention options Clients may lack financial resources to make significant changes to their diet or join a gym Clients may lack financial resources to make significant changes to their diet or join a gym Transportation may be a problem Transportation may be a problem High frequency of significant financial and environmental stressors High frequency of significant financial and environmental stressors Literacy rates may be lower Literacy rates may be lower Other contextual factors will undoubtedly become apparent as the BHC becomes more familiar with the client base Other contextual factors will undoubtedly become apparent as the BHC becomes more familiar with the client base  This speaks to the importance of being aware of cultural and contextual factors when working within an integrated care system

10. 10 Primary Care Environment  Fast paced Adjust clinical note taking Adjust clinical note taking  Space limitations At least 7 different rooms At least 7 different rooms Move from room to room frequently Move from room to room frequently  Finding medical charts Several places they can be Several places they can be  New faces Remembering names Remembering names

11. Patient Referrals  Self-Referred Request to see Mental Health Counselor at appointment with physician/NP Request to see Mental Health Counselor at appointment with physician/NP  Physician/NP Referred Request for BH evaluation/intervention Request for BH evaluation/intervention  Warm Hand-off Occurs in exam room Occurs in exam room 11

12. 12 Additional Activities  Consultation with medical staff Example: Patient is in abusive relationship and medical resident asks about treatment options. BHC explains options such as Women’s Resource Center, Mental Health Association, etc… Medical resident presents options to patient Example: Patient is in abusive relationship and medical resident asks about treatment options. BHC explains options such as Women’s Resource Center, Mental Health Association, etc… Medical resident presents options to patient  Presentations to clinic staff Safety in medical settings Safety in medical settings Behaviors that increase appointment/treatment adherence Behaviors that increase appointment/treatment adherence  Case management

13. The First Year  201 Total Contacts 21 warm hand-offs 21 warm hand-offs 54 referrals 54 referrals 126 follow-up appointments 126 follow-up appointments  111 Cancellations/No Shows  Primary Complaints Depression (64), Anxiety (44), Depression (64), Anxiety (44), Diet/Exercise (38), Relationship problems (32) Diet/Exercise (38), Relationship problems (32) 13

14. The Second Year  Two students and two days/week Mondays, Wednesdays and Fridays at the Free Clinic in Christiansburg Mondays, Wednesdays and Fridays at the Free Clinic in Christiansburg Wednesdays at Giles satellite office Wednesdays at Giles satellite office  Want to increase warm hand-offs Will increase number of patients seen Will increase number of patients seen  Utilize 360 evaluation 14

15. 15 Adjusting to Environment  “Client” versus “patient”  Transportable office  Medical terminology  Brief encounters (as short as 5 minutes)  Case management  Educator/Presenter  In-house mental health representative

16. 16 Conclusion  Different paradigm  Multiple treatment setting considerations  Need to be flexible  Fit into system  Requires more directness and behavioral focus because of time limitations