1. Behavioral health integration as a catalyst for practice transformation: A case study Joanne L. Cohen‐Katz, PhD, Clinical Associate Professor, Dept. of Family Medicine Nancy C. Gratz, MPA, Practice Facilitator, Dept. of Family Medicine Penny Keim, Practice Manager, LVFPA Collaborative Family Healthcare Association 13 th Annual Conference October 27-29, 2011 Philadelphia, Pennsylvania U.S.A. Session G5 October 29, 2011 1:30 PM

2. Need/Practice Gap & Supporting Resources What is the scientific basis for this talk? Behavioral health integrators continue to grapple with the issue of gaining leverage to support on site integration. Aligning the integration movement with other larger trends in primary care, and adding to the research on the value added by on-site behavioralists are key strategies for increasing leverage. The Patient Centered Medical Home movement provides this opportunity, as recent research on the PCMH suggests that physicians and practices need to change in ways that behavioralists are ideally suited to provide.

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

4. Objectives Participants will be able to: – Identify the key features of the Patient Centered Medical Home (PCMH) movement – Identify what the evidence says about the ways that healthcare providers and practices will need to change in order to transform into PCMH’s – Identify 2-3 ways that behavioral health integration is ideally suited to promote these types of transformation – Identify 1-2 ways this work can be applied into their own healthcare settings

5. Expected Outcome What do you plan for this talk to change in the participant’s practice? Promote better understanding of the PCMH movement, and the key ways in which practices and providers need to change to adapt to a PCMH model Catalyze key stakeholders to expand their research efforts on the effects of behavioral health integration to include these changes as outcome variables. Provide key stakeholders with additional rationales for integrated primary care, given these necessary changes

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. What is Required for a high functioning PCMH? 1.Patient-centered (personal relationship) 2.Comprehensive care 3.Coordinated care 4.Superb Access to care 5.Systems-based approach to quality & safety Agency for Healthcare Research & Quality (AHRQ)

8. PCMH Research & Evaluation National Demonstration Project – Positive attributes emerge from synergy of PCMH “Pillars of Primary Care” – Lessons Learned: Requires Transformation Technology Needs Personal Transformation of Physicians Developmental Change Process

9. Practice Transformation Whole practice Fundamental redesign – New coordination – New access schedules – More point-of-care services – Team-based care Continuous process of change

10. Personal Transformation of Physicians Team Approach Facilitative leadership Population-based Partnerships

11. Change Process Magnitude and consistency of change Developmental – Start - Strong Structural Core – Build Adaptive Reserve

12. Recommendations Realistic expectations Assure adequate resources Assist physicians with transformation TAILOR APPROACH TO PRACTICE

13. Lehigh Valley Family Practice Associates Private Practice – not within hospital network Suburban Started 25 years ago by two independent family physicians Now employs 2 F.T. physicians, 2 P.T. nurse practitioners, 1 P.T nurse manager, 2 nurses, 2 front office personnel, 1 office manager Began educating residents as part of the LVHN Family Medicine program, P4 initiative Primary practice for 3 Family Medicine residents and 1 Family Medicine faculty

14. Lehigh Valley Family Practice Associates: Behavioral Health Eduation Collaborative care clinic (BMC): – Two year, longitudinal training program for residents – Clinic meets once a week, resident attends approximately 2x/month on avg. – Collaborative care of patients with behavioral issues as primary concern – Resident–led session with behavioral health specialist (psychologist or psychiatrist 1x/month) co-intervieweing – All sessions also precepted with Family Physician

15. Collaborative Care Clinic 2010-11 38 patients seen 58% Anxiety 58% Depression 1% no show rate

16. Impact of Collaborative Care Clinic on Culture of the Practice Assessed by Qualitative Interviews – Conducted by student research scholar of key stakeholders: Practice Manager Nurse Manager Two physicians (founding physician plus F.M. faculty) Nurse Practitioner Behavioral health specialist

17. Findings Unanimous agreement that on site clinic has been positive for patients Especially helpful for pediatric behavioral patients, who were often referred out and had long waiting times.

18. Findings Collaborative Care clinic has been helpful for staff members as well – “Helpful to have somewhere to send my patients.” (NP, Physician) – “We feel like we have something to offer now to our patients who call in and are often so desperate for help that can be so hard to find.” (Nurse manager)

19. Other Findings (cont.) Surprised at the volume of patients requesting services Interested to see patients’ almost unanimous preference for staying on-site for care Need for more services now that the “floodgates are opened.”

20. Findings At clinician’s request, a session on “difficult patients” with consulting psychiatrist was held with all employees (physician, nurse, front office, practice manager) present Reactions to the session included: – We loved it, we want more – It was amazing to see how every single person struggles with patients in one way or the other. – It’s great to vent, we need more of that. – I was surprised that every single person came. Desire for more sessions to talk about difficult patient Plans to develop more regular staff meetings that focus on team functioning and staff well-being

21. Findings In order to accommodate increased demand, behavioral health specialist met with founding physicians to discuss options Physicians chose a training model option, because it would fit best with the culture of the practice September, 2011, Psychology doctoral student started practicum placement Attends Collaborative care clinic and sees patients 2 days/week

22. Behavioral health integrators.. Uniquely positioned to: – build adaptive reserve of practice, through offering balint or other type sessions – help with issues of team functioning – Indirectly improve morale in the practice by taking pressure off of front line providers In addition, patient care outcomes are improved.

23. Conclusion Research into the effectiveness of behavioral health integration should also investigate change at the practice level, including variables such as: – Physician and other provider wellness – General adaptive reserve – Team functioning

24. Your Experiences? What have you noticed about practice transformation as a result of behavioral health integration, from your own experiences as “integrators” or observers of integration.

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

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