1. Behavioral Health Lab: Building a Strong Foundation for the Patient- Centered Medical Home Johanna Klaus, PhD, Director, Behavioral Health Lab Sara Kornfield, PhD, Post-doctoral fellow Erin Ingram, BA, MIRECC Research Coordinator Dave Oslin, MD, MIRECC Director, ACOS MH Collaborative Family Healthcare Association 13 th Annual Conference October 27-29, 2011 Philadelphia, Pennsylvania U.S.A. Session #E1 October 28, 2011 11:15AM

2. Faculty Disclosure We have not had any relevant financial relationships during the past 12 months.

3. Need/Practice Gap & Supporting Resources Primary care mental health (PCMH) integration has blossomed at facilities throughout the VA, and is consistent with the adoption of the Patient Centered Medical Home. However, the implementation of evidence based protocols for the collaborative treatment of depression, anxiety, and alcohol misuse and the consistent use of assessment to evaluate treatment and program effectiveness (i.e. measurement based care) has been slower in adoption. Systematic use of informatics tools to support evidence-based and measurement-based care can help address this gap.

4. Objectives Describe how the Behavioral Health Lab is consistent with the principles of the Patient-Centered Medical Home including improved access, care coordination, team-based care, and partnering with the patient. List the Behavioral Health Lab services and target populations and how the program can be adapted for changing or individual clinic needs. Describe the importance of measurement-based care with collaborative care programs for triage, patient education and symptom monitoring, and program quality improvement. Identify the use and features of the BHL software system that can assist in implementation of a PCMH approach, including screening of behavioral health problems and ongoing tracking of care.

5. Expected Outcome Consider the benefit of a flexible informatics platform to help implement evidence based protocols in primary care to inform both patient treatment outcomes and program effectiveness.

6. VISN 4 MIRECC 6 Patient Centered Medical Home Replaces episodic care based on illness and patient complaints with coordinated care and a long term healing relationship  The Primary Care Team Takes collective responsibility for patient care Responsible for providing all the patient’s health care needs Arranges for appropriate care with other specialties as needed  Enhanced Access  Enhanced communication between Patients Providers Staff  Continuous Improvement in our work 6

7. The spectrum of mental health problems Mild-to-Moderate Severe Large Numbers “Sub-optimal” functioning Depression Anxiety Alcohol misuse Brief Interventions Primary Care Providers Smaller Numbers Major Impairment Severe depression, anxiety Personality disorders Schizophrenia or bipolar disorder Complex interventions Specialty Care Providers

8. VISN 4 MIRECC 8 Philadelphia VA Integrated Care program – Behavioral Health Lab  A platform for the delivery of collaborative care in primary care  A public health focus on non-complex patients  A partnership with PC  A bridge to specialty care  Patient centered care – incorporating convenience and preference  A program that stresses self- management and collaborative decision making  Measurement-based care  Ever evolving…

9. VISN 4 MIRECC 9 Clinical Process Patient Identification Screening / Clinical Assessment / Casefinding Initial Assessment Consultation Or Referral Mgt Treatment Recommendations Brief Treatment & Care Management No treatment & Refusal of care Patient Education and Promote Self-Care Watchful waiting & Brief Interventions Specialty CareEvidence based protocols Prevention / Health Promotion BHL software – provides the platform

10. VISN 4 MIRECC 10 Behavioral Health Laboratory: components A clinical management program focused on:  Identification: screening, pharmacy based, direct to consumer, etc  Seek out patients  Assessment and triage to appropriate level of care  Care Management / Brief treatment/ Health Promotion and Prevention  Using Specialty Care and facilitating engagement  Tracking: software program

11. VISN 4 MIRECC 11 Behavioral Health Laboratory: components A clinical management program focused on:  Identification: screening, pharmacy based, direct to consumer, etc  Assessment and triage to appropriate level of care  Care Management / Brief treatment/ Health Promotion and Prevention  Using Specialty Care and facilitating engagement  Tracking: software program

12. VISN 4 MIRECC 12 Initial Triage  All patients entering the program complete standard initial assessment  Completed via phone or in person (patient preference)  Includes array of behavioral health symptoms and substance use and overall functioning  Helps determine next step in treatment  Completion rate of 80%  BHL Software output: clinical report, patient letter

13. Initial Triage Assessment Demographics Current MH care Financial status Social support Blessed Orientation-Memory-Concentration (>55 yrs or head injury) Mini International Neuropsychiatric Interview (psychosis, mania, GAD, panic) Depression assessment: PHQ-9 PTSD Checklist (PCL-c) Anxiety assessment: GAD-7 (optional) Brief Pain Inventory Interference scale Current Psychotropic/Pain medications 5-item Paykel scale for suicidal ideation Alcohol use (7 day follow-back) Illicit substance use Depression history Work Limitations questionnaire (optional) SF-12 (optional)

14. Communicating with PC team

15. Characteristics of Veterans who completed the BHL pre-assessment Demographics and BackgroundN = 3348 Age (M, SD) (N=4163)52.6 (16.1) Race non-Hispanic White1617 (49%) Employed946 (28%) Married/Partnered Separated Divorced 1462 (44%) 298 (9%) 728 (22%) Finances “Can’t make ends meet” “Just enough to get along” 1016 (31%) 1672 (50%) Served in Iraq/Afghanistan post 9/11815 (25%) SF-12 Physical component score Mental component score 41.0 (12.9) 38.6 (13.6)

16. Mental Health and Substance Use DiagnosesN, % PTSD PCL-c (M, SD); N=2066 1368 (43%) 51.8 (17.5) Major Depression Other depression PHQ-9 (M, SD) 1422 (43%) 433 (13%) 12.4 (7.0) Panic Disorder, current190 (6%) Generalized Anxiety Disorder1206 (38%) Mania183 (6%) Psychosis91 (3%) At-risk Alcohol Use/Abuse Alcohol Dependence 467 (15%) 361 (11%) Used street drugs, ever Marijuana use, past 3 months 1895 (57%) 394 (12%) Clinically significant MH or SA symptoms1603 (50%)

17. VISN 4 MIRECC 17 Behavioral Health Laboratory: components A clinical management program focused on:  Identification: screening, pharmacy based, direct to consumer, etc  Assessment and triage to appropriate level of care  Care Management / Brief treatment/ Health Promotion and Prevention  Using Specialty Care and facilitating engagement  Tracking: software program

18. VISN 4 MIRECC 18 Behavioral Health Lab Interventions  Evidence based (or we are working on it) and stepped care approach  Longitudinal but brief treatments (can be by telephone – patient choice)  Promote patient self-management  Collaborate with PCP  Pharmacological support  Measurement based

19. VISN 4 MIRECC 19 Evidence Base for primary care delivered interventions Robust Evidence Base  Depression Care management  Alcohol Brief Interventions (alcohol misuse)  Referral management Growing Evidence Base  Alcohol care management (alcohol dependence)  Watchful waiting  Anxiety care management  Pain care management

20. VISN 4 MIRECC 20 Measurement Based: BHL Software  Built in interview for tracking follow-up contacts for care management/brief treatment  6 optional domains: Depression: PHQ-9 Anxiety: GAD-7 PTSD: PCL-c Pain: BPI for pain interference Alcohol: 7-day time line follow-back Referral Management: to track engagement in specialty care

21. VISN 4 MIRECC 21 BHL Software support: patient level feedback Tracking structured assessments: Ability to provide feedback to both the provider and the patient Progress reports generated by BHL software

22. VISN 4 MIRECC 22 BHL Clinician: the Glue Primary Care Clinician Mental Health Supervisor BHL clinician Patient

23. VISN 4 MIRECC 23 Behavioral Health Laboratory: components A clinical management program focused on:  Identification: screening, pharmacy based, direct to consumer, etc  Assessment and triage to appropriate level of care  Care Management / Brief treatment/ Health Promotion and Prevention  Using Specialty Care and facilitating engagement  Tracking: software program

24. VISN 4 MIRECC 24 Referral Management  Problem: low attendance rates for MH/SA treatment (30-40%)  Goal: increase referral adherence in symptomatic patients with complex behavioral health care needs  Possible psychosis  Drug addiction  Mania  Severe/complicated depression or anxiety  Uses a motivational interviewing style to provide clinical support and promote problem-solving skills

25. VISN 4 MIRECC 25 Appropriate Use of Specialty Care: Referral Management Module Attended 1 st Appointment Motivational Session 70% Control Group 32% Zanjani et al, 2008 p <.001

26. VISN 4 MIRECC 26 Behavioral Health Laboratory: components A clinical management program focused on:  Identification: screening, pharmacy based, direct to consumer, etc  Assessment and triage to appropriate level of care  Care Management / Brief treatment/ Health Promotion and Prevention  Using Specialty Care and facilitating engagement  Tracking: software program

27. VISN 4 MIRECC 27 BHL Software Platform Provides structured assessments across providers and settings Programmable decision logic that is exportable across sites and testable Allows capacity to define and follow a cohort of subjects with prompts for additional clinical actions (panel management for follow ups) Allows integration across mental health conditions (not just one disorder) Creates patient material, including treatment progress Provides program level outcome data Allows rapid research engagement

28. VISN 4 MIRECC 28 Patient Tracking: Panel Management

29. VISN 4 MIRECC 29 Patient Tracking: Patient History Page

30. VISN 4 MIRECC 30 Patient Tracking– Measurement based care

31. VISN 4 MIRECC 31 Patient Level Reports  Progress Note Creation for all interviews: Treatment plan Results of all assessments  Patient letters and Progress reports Patient education Visual for treatment progress

32. VISN 4 MIRECC 32 Program Level Outcome Data OUTCOME DATA: Available at the program, clinic, Primary Care Provider and staff level

33. VISN 4 MIRECC 33 BHL as a platform: ex. Developing a Treatment for PTSD Of >17,000 BHL assessments  5,651 (33.2%) positive for PTSD; PCL-c mean = 49.8 (18.2) PTSD positive veterans: more symptomatic –66% with depression vs 29% of PTSD negative –More likely to have psychosis, mania, illicit drug use, problem drinking, other anxiety disorders  But 17% of Veterans at Philadelphia referred to specialty care because they endorsed symptoms consistent with PTSD had PCL scores < 60.

34. VISN 4 MIRECC 34 PTSD Brief Treatment  For lower level PTSD symptoms  6-8 sessions of about 30 minutes  1-4 sessions focus on psychoeducation, behavioral activation, and mindfulness  Extra sessions for anger management, sleep, alcohol misuse as needed  Current pilot; outcomes soon Effective treatment? Secondary triage? Warm-up for evidence based treatment?

35. VISN 4 MIRECC 35  Increase identification of patients needing behavioral health services (Oslin et al, 2006)  Increase engagement in specialty care (Zanjani et al, 2008)  Improve outcomes for depression and alcohol misuse (Oslin et al, 2003)  Platform for new treatments and research  Allows for efficient staffing and collaboration with PC  The triage and tracking mechanisms allow for seamless referral and the ability to reduce waiting times, prioritize care, and provide administrative support for monitoring. Behavioral Health Lab: In Summary

36. VISN 4 MIRECC 36 Patient-Centered Medical Home and the Behavioral Health Lab Key PrinciplesBehavioral Health Lab Patient-driven Team-based Efficient Comprehensive Continuous Communication Coordinated √ √ √ √ √ √ √

37. VISN 4 MIRECC 37 More information?  Johanna Klaus: Johanna.Klaus@va.govJohanna.Klaus@va.gov 215-823-5899  Erin Ingram:Erin.Ingram@va.govErin.Ingram@va.gov  Sara Kornfield:Sara.Kornfield@va.govSara.Kornfield@va.gov  David Oslin:Dave.Oslin@va.govDave.Oslin@va.gov http://www.mirecc.va.gov/visn4/BHL/bhlindex.asp

38. Session Evaluation Please complete and return the evaluation form to the classroom monitor before leaving this session. Thank you!