1. BEHAVIORAL HEALTH LAB

2. MIRECC – VISN 4 ACSIR Goals of the BHL Instill Hope

3. MIRECC – VISN 4 ACSIR How?  Provide »the right care »at the right time »at the right place  With Empathy and Compassion

4. MIRECC – VISN 4 ACSIR Research to Practice: Behavioral Health Laboratory  BHL is designed to provide clinical services to support providers in Primary Care and Behavioral Health  It is intended to be analogous to Clinical Chemistry or Radiology Laboratories  The BHL is an automated telephone assessment, triage, and monitoring service for patients identified by primary care providers as having depressive symptoms or at-risk drinking.  The BHL conducts a brief telephone (20-30 minutes) assessment generating a report for the PCP including diagnosis, severity, and general treatment recommendations.

5. MIRECC – VISN 4 ACSIR How it works at the PVAMC  Mechanisms for requesting an assessment »Screening Annually – PCPs are required to screen for depression and at-risk alcohol use (2 question screen for depression – 3 for at-risk alcohol use). For patients who screen positive, the clinician is responsible to assess the need for immediate care. However, a consult request is automatically generated. »Referral A BHL assessment can be ordered with any frequency by primary care providers. »Disease management A package of assessments related to a new episode of treatment  The BHL receives a printed consult request.  The BHL reports findings, provides interpretation, and recommendations.  Where appropriate, BHL staff facilitate referral.

6. MIRECC – VISN 4 ACSIR What does the Service Provide?  Assessment of major illnesses – depression, anxiety, substance use  Screening for other domains – cognition, smoking, psychosis, mania  Initial Treatment recommendations  Patient engagement  Monitoring of initial treatment for depression – adherence, adverse effects, symptoms

7. MIRECC – VISN 4 ACSIR The BHL as a Platform of Care  Watchful Waiting  Referral Management  Disease Management (e.g. depression, alcohol, suicide)  Research

8. MIRECC – VISN 4 ACSIR A Platform for other activities  Telephone disease management for problem drinking »Supported by VA HSR&D  Developing watchful waiting strategies »Supported by Robert Wood Johnson Foundation  ExTENd – Use of naltrexone in managing alcohol dependence »Supported by NIAAA – R01  DIADS – depression of Alzheimer’s disease »Supported by NIMH R01  Family caregiver Support  Depression Treatment Monitoring  PTSD  Referral Management

9. MIRECC – VISN 4 ACSIR Roll out over several different settings PVAMCCBOCsCoatesvilleRalstonFamily Practice 2 years1.5 years1 year4 months1 week ~2000~ 1000~20~51 Systematic Screening No Screening ELM VA Penn 4 clinics3 clinics4 clinics1 clinic

10. MIRECC – VISN 4 ACSIR Referrals

11. MIRECC – VISN 4 ACSIR 5 Month Referral Success TotalReferred for Depression Referred for Alcohol Referred for Depression & Alcohol p value Sample sizeN=605N=472N=75N=58 Percentage of total cases100.078.012.49.6 Completed Interviews (% within category) 74.075.264.077.60.263 Age >65 (% )20.823.316.06.90.008 Gender (% male)95.095.693.31000.161

12. MIRECC – VISN 4 ACSIR Characteristics of Patients Referred for Depression Referred for Alcohol Depression & Alcohol p value N=355N=48N=45 Age (% > 65)21.414.68.9.091 Race (% White)45.927.126.7.004 MDD45.025.655.8.014 Alcohol dependence7.139.651.1.000 Anxiety disorder (Panic or PTSD)21.56.331.1.010 Psychosis13.610.426.7.044 Mania7.92.117.8.020 High Risk Suicide14.511.620.9.439 In MH/SA care (last 12 months)27.314.622.2.379 On antidepressant38.123.3.036

13. MIRECC – VISN 4 ACSIR Does the BHL change practice?  25% reduction in the number of patient not screened for depression  10% increase in the screen positive rate for depression  Significant increase in the identification of patients with suicidal ideation  Possible improvement in EPRP measures for depression

14. MIRECC – VISN 4 ACSIR Engagement in Care OverallRequired an appointment Requested an appointment p value Patients needing an appointment (% of total # of assessments) N=254 (44.3%) N=200 (35.0%) N=54 (9.3%) Patients refusing appointment12.5% Proportion seen in MH/SA care within 3 months of the BHL assessment N=119 (55.0%) N=92 (52.6%) N=27 (50.0%) 0.741 Proportion seen in primary care within 3 months of BHL assessment N=117 (51.1%) N=87 (49.7%) N=30 (55.6%) 0.453

15. MIRECC – VISN 4 ACSIR Barriers to service  Skepticism regarding validity of assessments  Skepticism regarding treatment  Limited treatment choices anyway  Low frequency of patient problems - 1 or 2 patients/week  Novelty  Doesn’t meet needs  Interventions for mild behavior/disease may not be accepted  ?

16. MIRECC – VISN 4 ACSIR Two Ways of thinking about screening and treatment initiation Systematic Screening Clinical Exam Initial Assessment And Triage Treatment Z Outcome Monitoring Treatment Adjustments Treatment Q Outcome Monitoring Treatment Adjustments

17. MIRECC – VISN 4 ACSIR BHL Flow Annual ScreeningDirect consultNew treatment for depression Consult request Full Assessment Referral to BHC Recommendations to PCP and Patient Enroll in Depression monitoring Referral to Specific Research No Treatment Recommended Brief Intervention Watchful Waiting – 8 weeks Referral Management

18. MIRECC – VISN 4 ACSIR Starting a New Practice  Identify a thought leader / Champion »Define practice specific needs – screening, referral, resources  Define practice specific procedures  Announce the availability of the service »Face-to-face »Email »Letters / Brochures

19. MIRECC – VISN 4 ACSIR Other Initial Practices  Business cards for patients  Business cards for providers  ELM interface  Listing of providers  Staff in practice / Screening of patients  877 number  ?

20. MIRECC – VISN 4 ACSIR Ongoing or new stuff  Pens  Sticky pads  Business size card for computer  Monthly email reminders  Clinic feedback  Inservice by staff on MH topics  Website  ?

21. MIRECC – VISN 4 ACSIR Conclusions  BHL is a flexible, evidence based program »Fills gaps in the VHA system »Provides valid information and documentation Acceptable to veterans Valued by provider »Can function at low cost across diverse settings »Useful for outreach »Can provide coordination as well as assessment Disease Management Referral Management »Valuable as a tool for improving system performance