1. Integration of a Behavioral Health Curriculum into Four Different Primary Care Practices Nyann Biery, MS, Research Coordinator Teresa A. Duda, MS, MSS, LCSW, BCD, Behavioral Health Scientist Joanne L. Cohen‐Katz, PhD, Clinical Associate Professor of Family Medicine/Family Systems Associate Collaborative Family Healthcare Association 13 th Annual Conference October 27-29, 2011 Philadelphia, Pennsylvania U.S.A. Session #B3A October 28, 2011 3:30 PM

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

3. Need/Practice Gap & Supporting Resources In a 2004 report, there was a called for action to change how Family Medicine residents are educated to support the needs of the future. LVHNFMRP answered that call by participating in a national demonstration project called p4 (Preparing the Personal Physician for Practice.) A major feature of the innovation is the decentralization of the outpatient clinic into different continuity care sites (CCS), so that residents can be educated in a variety of practice models. Our teaching of behavioral medicine has been decentralized and occurs at these CCS sites as well.

4. Objectives Participants will be able to describe a training model that incorporates intensive training in primary care counseling and collaborative care into a primary care residency training program in 4 different sites Participants will be able to identify 2-3 common barriers to implementing such a program in multiple settings Participants will be able to describe at least one solution to each of these barriers Participants will be able to identify 2-3 benefits (to patients, trainees, and practices) of a collaborative training program in a primary care setting across multiple sites

5. Expected Outcome Promote integration of Behavioral Health within Family Medicine Practices Identify & Problem solve common barriers to integration in different types of practices Discuss how integration can be adapted in different sites Discuss the benefits to patients, trainees, and practices of an integrated model

6. Learning Assessment Please feel free to ask questions during the presentation. A brief Question & Answer period will be available at the conclusion of this presentation also.

7. Background Family Medicine Residency Program De-centralized Family Medicine Center into 3 additional practice sites for a total of 4 Each new site has residents of each post- graduate year Curriculum discussed last year at CFHA Focus today on implementation and adaptation to different sites

8. Behavioral Medicine Clinics Weekly half day sessions longitudinal, through PGY2 & PGY3 years Staffed by residents & Family Doc/Behavioral health preceptors Patients referred from primary care with any behavioral/mental health issue Patients co-interviewed by Family Medicine residents & behavioral health specialists, then precepted with Family Doc

9. Behavioral Medicine Clinics Behavioral Health specialists include Ph.D./LCSW (every week) and Psychiatrist 1- 2x/month Sessions live-observed by remainder of treatment team (resident/faculty) through video feed Residents see maximum of 3 patients/session BMC sees 3-12 patients overall

10. Format of BMC Resident–led session with behavioral health co-interviewing Sessions are live observed by team when pts. allow Debriefing includes team discussions with medical and behavioral health faculty Case discussions often followed by relevant didactic topic, e.g.: – Parenting issues – Psychopharmacology – Smoking cessation – Child Behavioral problems – Marital stress

11. Clinic – Lehigh Valley Family Health Center Original Family Medicine Clinic Network owned Urban, large Spanish speaking population 7 residents Faculty: – 2 behavioral health (PhD, LCSW), weekly – 1 family physician (MD), weekly – 1 psychiatrist, 1x/month

12. Clinic – Lehigh Valley Family Practice Associates Private Practice owned by two family physicians– not within hospital network Suburban location, close to both rural and city population Prior to BMC – all patients referred out for counseling 2 residents Faculty: – 1 Psychologist (PhD), weekly – 1 Family Physician (MD), weekly – 1 Psychiatrist, 1x/month

13. Clinic – The Caring Place Network affiliated Federally Qualified Health Center – look alike status Inner-City Large percentage of patients/providers are Spanish speaking 2 residents Faculty Members (both Spanish speaking): – Psychiatrist, 1x/month – LCSW, weekly

14. Clinic - Pleasant Valley Family Practice Network owned Rural setting (Primary Care & Mental Health HPSA) LCSW already embedded within practice 1 resident – July 2010 implementation Faculty – 1 behavioral health (LCSW), weekly – 1 family physician (DO), weekly – (1 psychiatrist), 1x/month**

15. Statistics for AY 2011 Location# Patients# visits per patient (range) % Anxiety% Depression% referred out long-term therapy # Residents FHC651 - 72053237 TCP2 LVFPA381 - 857.9 182 PV210 - 261.942.9241

16. Barriers High No show rate – PV67%ruralnetwork – TCPurbanFQHC – FHC10%urbannetwork* – LVFPA 1%suburbanprivate Insurance issues Unmet clinical need revealed by BMC Residents’ concern that model is unrealistic for primary care

17. Barriers & Solutions: FHC Insurance – Help patients apply for network’s reduced cost care High No show rate – Fill open slots with medical sick visits, but cap the number of sick visits Inability of BMC to meet clinical need – Search for full-time behavioral health specialist with bilingual, multicultural skills

18. Barriers & Solutions: FHC Concerns by residents that BMC is unrealistic model for PC – Faculty retreat to clarify how to keep teaching primary care-friendly “What would you do in a 15 minute session in this case?” Encourage patients with lifestyle change needs Uniform implementation of “teaching pearls”

19. Barriers & Solutions: TCP Spanish speaking population – Recruited a bi-lingual behavioral health faculty and psychiatrist No show rate – Creating alternative models of treatment Group visits for Depression Citizens’ Healthcare Project focusing on how to best use the BMC time

20. Barriers & Solutions: TCP No insurance – Sliding fee scale Awareness of unmet clinical need magnified by BMC – Hired psychiatric nurse specialist Reviewing other models of care such as proactively scheduling all patients to have initial interview with social worker – With FQHC look alike status, pursuing contract with independent mental health group (on-site) – Creation of Citizens’ Health Project

21. Barriers & Solutions: LVFPA Presence of BMC created high demand by patients & practice staff for more services – Physicians decided among several models for expanding services, chose a co-training model – Fall, 2011: Psychology practicum student added Co-trains in BMC with Family Medicine residents, producing rich interactions

22. Barriers & Solutions: LVFPA Since BMC, residents treating more complex psychiatric problems than previously treated in practice – Residents may have different comfort levels than preceptors – Solution: Ongoing discussions, supporting residents having a good rationale for their plans Involving preceptors in discussions with psychiatrist & psychologist to help their comfort level

23. Culture Change: LVFPA Presence of behavioral health specialists revealed a need within the practice for more time to focus on providers’ stress – “Difficult patient” session held for entire practice by behavioral science faculty – Plans to develop meetings that allow for more team building, care of providers, etc.

24. Barriers & Solutions: PV No show due to lack of transportation & inclement weather (rural area) – Co-interview for acute medical visits, but cap number of visits Insurance – Help patients apply for network’s reduced cost care

25. Barriers & Solutions: PV Due to presence of embedded provider, clinical needs were not a significant barrier – Outside of BMC, behavioral health scientist co- interviews patients identified by resident or faculty Embedded provider also provides help with difficult doctor-patient relationships

26. Overall Feedback: Benefits of Integration to Patients Staying in the medical home where they are comfortable Reduced overutilization & ED visits Better medication control, increased access to psychiatry for some patients Addressing of biopsychosocial issues by team of care providers working together Providers more aware of available community resources

27. Overall Feedback: Benefits of Integration to the Resident Learn how to treat whole person; mind, body, and spirit, in a site that better matches their future practice goals Recognize the full range of biopsychosocial factors contributing to illness Comfort in management of psychotropic medication More in-depth exposure to other forms of biopsychosocial treatment Develop comfort level assessing how and when to refer to a behavioral health specialist Learn how to co-manage patients with behavioral health scientist

28. Overall Feedback: Benefits of Integration to the Practice Doctors feel they can offer better access to mental health care for their patients Potential increase in practice morale, as providers feel they are taking care of their patients better Potential increase in practice morale, as presence of behavioral health providers opens up new options for provider self-care

29. Take Home An educational intervention promoting behavioral health integration often faces similar challenges regardless of the primary care setting – Each setting may find unique solutions to addressing these barriers – These solutions can enhance the resident, patient and practice experience

30. Take Home An educational program such as this can result in unexpected transformation within the practices where they live. – Educators and clinicians working on these programs need to stay open to these possibilities…

31. Questions? Please feel free to contact Joanne Cohen-Katz, PhD Joanne.Cohen-Katz@lvhn.org

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