1. Integrating Mental Health into Primary Care: The BHL Model VISN4-Healthcare Network Department of Veterans Affairs

2. UPENN / VISN 4 MIRECC 2 Where is Mental Health / Depression Care Delivered  Depression: FY 2002: 64% of all outpatient depression visits for elderly occur in primary care (only 25% by psychiatrists) (Harmon et al 2006)  Nearly half of all antidepressants, sedatives, and hypnotics were prescribed by a primary care provider (20% of all antipsychotics) (cdc.gov/nchs/data/series/sr_13/sr13_157.pdf)

3. UPENN / VISN 4 MIRECC 3 Alcohol Use Disorders Grant BF et al. Arch Gen Psychiatry. 2004;61:807-816. SAMHSA, Office of Applied Studies. Substance Dependence, Abuse and Treatment Tables; 2003 IMS - MAT March 2006

4. UPENN / VISN 4 MIRECC 4 How is Care Provided?  Key Facts: Depressive disorders are common (10-15% prevalence) Less than 50% of patients have treatment initiated Less than 50% are adequately treated Rates of follow-up to new treatments (HEDIS) ~20%

5. UPENN / VISN 4 MIRECC 5 The Patient’s Perspective Integrated Care Referral Care Odds Ratio Depression75 %52 %2.86 [2.26,3.61] Anxiety71 %56 %1.93 [0.69, 5.40] At-risk Drinking61 %34 %3.09 [2.07, 4.63] Overall71 %48 %2.84 [2.35, 3.43] Engagement = at least one contact with the mental health specialist.

6. UPENN / VISN 4 MIRECC 6 The BHL Program

7. UPENN / VISN 4 MIRECC 7 So What’s the BHL Program?  A clinical program providing prevention and treatment services designed around the following principals: An emphasis on use of structure assessments and algorithms An emphasis on the use of care management modules Patient centered care – incorporating convenience and preference A focus on both patients and providers as the stakeholders A population based approach to care A focus on self- management and collaborative decision making A focus on open access

8. UPENN / VISN 4 MIRECC 8 What are the (potential) parts?  Specialty Care (usually PhDs and MDs) Consultative Brief therapies  Care Management (BHSs usually RNs, SW) Depression, Alcohol,(abuse and dependence), Anxiety, Pain, Smoking Cessation, Referral Management (optimizing specialty care) PTSD, Bipolar, Dementia  Prevention and Health promotion (mix RNs, SW, PhDs, counselors, etc) Watchful Waiting for subsyndromal symptoms Problem solving therapy Caregiver and family support MOVE for weight Education Adherence

9. UPENN / VISN 4 MIRECC 9 Step 1 1.Identification and triage Primary care screening Primary care assessment Self-referral Outreach Prescribing Driving principal – we take anyone you are concerned about.

10. UPENN / VISN 4 MIRECC 10 Initial Assessment Module Philadelphia BHL data from 1/2008 to 1/2010 5626 referred 79% had a complete assessment –PTSD (85%) –Depression (81%) –MH and SA problems (79%) –Alcohol problems (76%) –Drug problems (71%) Only 7% refuse!

11. UPENN / VISN 4 MIRECC 11 Impressions from Initial Assessment  Enormous range of psychopathology  Greatly appreciated by patients  Phone vs face to face – access or provider comfort  Greatly appreciated by primary care providers  A great tool for research recruitment

12. UPENN / VISN 4 MIRECC 12 Step 2 – Treatment Options Patient Identification Screening / Clinical Assessment / Case-finding Initial Assessment Initial triage / treatment plan No treatment & Refusal of care Patient Education and Promote Self-Care Specialty CareCare ManagementPrevention / Health Promotion

13. UPENN / VISN 4 MIRECC 13 Optimizing Specialty Care Referral Management Different methods of case finding lead to different rates of complex patients.  30-50% of patients may have psychosis, PTSD, Illicit drug use, Severe depression, bipolar disorder, suicidal ideation  Limited evidence for treating these patients in primary care Problem: Low rates of MH/SA treatment engagement (30 – 40%) Zanjani F, Oslin D (2005). Telephone Based Referral-Care Management. Grant Supported by Philadelphia Veteran’s Affairs: Mental Illness Research Education and Clinical Center (MIRECC)

14. UPENN / VISN 4 MIRECC 14 Referral Management  Brief workbook based intervention designed to enhance engagement in specialty MH/SA services  Focus Enhancing motivation Addressing practical issues Preparing the patient

15. UPENN / VISN 4 MIRECC 15 Referral Management Module Attended 1 st Appointment Motivational Session70% Control Group32% Zanjani F, Oslin D (2005). Telephone Based Referral-Care Management. Grant Supported by Philadelphia Veteran’s Affairs: Mental Illness Research Education and Clinical Center (MIRECC) p =.006

16. UPENN / VISN 4 MIRECC 16 Care Management Modules  Care Management is algorithm driven care delivered by a Behavioral Health Specialist as an adjunct to primary care. Depression Panic Disorder Generalized Anxiety disorder Alcohol Dependence Pain ?PTSD

17. UPENN / VISN 4 MIRECC 17 Disease Management Disease Management Percent of Patients Achieving Remission

18. UPENN / VISN 4 MIRECC 18 Change in Depressive Symptomatology over the Course of Monitoring (n=140)

19. UPENN / VISN 4 MIRECC 19 First 12 weeks  Issues addressed early 26% report non-adherence to treatment 12% report significant side effects  22% managed (dose change or med change)  53% symptom remission

20. UPENN / VISN 4 MIRECC 20 Alcohol Care Management  Two components Non dependent  Brief alcohol intervention - Time-limited (20 minutes in 1-3 brief sessions) and targets alcohol misuse Dependent  Pharmacotherapy  Referral management

21. UPENN / VISN 4 MIRECC 21 Alcohol Care Management  BHS meets with patient for 16 sessions over 6 months  Collaborates with PCP to: Increase motivation to abstain Be supportive and optimistic Naltrexone Encourage AA attendance Provide education (health risks and detrimental outcomes)

22. UPENN / VISN 4 MIRECC 22 What patients said  “I’ll take the chance on getting the nurses help”  “I have no interest in going back to the ARU, I am not that sick”  “I could use a med to help with my cravings”

23. UPENN / VISN 4 MIRECC 23 Preliminary Outcomes  ACM 90% (55/61) had at least 1 face to face visit mean #visits = 10.2 (range 0-28)

24. UPENN / VISN 4 MIRECC 24 Prevention Services  Sub syndromal anxiety and affective disorders Most common treatment is an SSRI but no evidence of efficacy Psychotherapy is time consuming and not without risks Limited research on problem solving therapy and other brief focused interventions

25. UPENN / VISN 4 MIRECC 25 Close Monitoring  8 Weeks of prospective monitoring by telephone using the PHQ-9  Patient choice for treatment engagement is also allowed  Those with persistent symptoms or who choose are enrolled in depression disease management

26. UPENN / VISN 4 MIRECC 26 Study Results  223 Subjects randomly assigned to WW (130) or usual care (93)  In the WW arm 81 (62%) no further treatment required Improved MH outcomes Improved Physical functioning

27. UPENN / VISN 4 MIRECC 27 What are the keys to success?  A plan – including training, supervision, etc  BHL software to promote measurement based care and to provide decision support and tracking  Great staff

28. UPENN / VISN 4 MIRECC 28 Panel management

29. UPENN / VISN 4 MIRECC 29 Patient History

30. UPENN / VISN 4 MIRECC 30 Summary of Interview

31. UPENN / VISN 4 MIRECC 31 Patient and chart documents

32. UPENN / VISN 4 MIRECC 32 Implementation Factors  Facility Small clinics may be collocated and collaborative just by size Location – more rural clinics manage more BH in primary care  Leadership – very important to resource management  Access to Specialty care – factors into how complex cases are managed  Staff – highly variable on all sides  Scope – the more limited typically the less useful or hard to use  Method of case finding – screening, clinical exam, self referral leads to very different case mixes and thus different program needs  Marketing and program description – what you are known for.  Resources and reimbursement

33. UPENN / VISN 4 MIRECC 33 Conclusions  Depression and anxiety care management Works! By telephone or face to face Reduced mortality Reduced symptoms But not for complex patients  Close monitoring Works! For subsyndromal depressive symptoms waiting and targeting care management is effective  Referral management Works! For complex patients with affective illnesses, substance abuse or more other complex presentations.  A Brief alcohol intervention Works! For patients without alcohol dependence  Alcohol Care Management Very Promising! For patients with alcohol dependence

34. UPENN / VISN 4 MIRECC 34 Thank You David Oslin, MD Johanna Klaus, PhD Elena Volfson, MD Steve Sayers, PhD Shahrzad Mavandadi, PhD Health Specialists Lisa Dragani, BSN, RN Suzanne DiFilippo, RN Trisha Stump, BSN, RN Shani Simmons-Wilson, BSN, RN Janet Sherry Cocozza, MA, RN, APN.C Coordinator Erin Ingram, BA Health Technicians – Megan Aiello, BS Lauren Witte, BA Victoria Farrow, BS Kelly Stracke, BA Natacha Jacques, MS Chris Cardillo, BS Henry Quattrone, BS Lindsey Reid, BA Brian Cox, BS a host of others Funders: NIH, VA, BCBS

35. UPENN / VISN 4 MIRECC 35