1. www.pspbc.ca Adult Mental Health Module An Organized Approach to Mental Health Issues in Realistic Time Learning Session 1 2015 www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources

2. 2 Psychiatrists and Mental Health Clinicians  Learn/understand module  Share resources  Comment/advise  Tell colleagues/Root for the PCPs Support Team Advisor Roles www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources

3. 3 Office Assistants:  Understand module  Take course on Mental Health First Aid  Organize office scheduling, materials   Flag patient issues › Support Team Advisor Roles www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources

4. 4  Nurses  Absorb these tools through your own lens.  Think about your own scope of practice.  Present your ideas during the action period planning and strategize with your doc how you will implement today’s training Support Team Advisor Roles www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources

5. 5  GP Champ, OA, nurse  Psychiatrist  Mental Health Clinicians  PSP Coordinators  Data Analyst  PSP Tech Group  Bounce Back Coaches Adult Mental Health Module Team

6. 6  Anyone NOT wishing their name and EMR information shared with our PSP Technology Partners  please let ___ know. Request your Permission

7. 7  Faculty’s Name  Relationship with Commercial Interest  Faculty’s Name  Relationship with Commercial Interest Faculty/Presenter Disclosures

8. 8 Housekeeping www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources

9. 9 Welcome 1. Roles 2. Survey feedback 3. Funding, CME credits 4. What are we trying to accomplish Context, aims, goals, module pathway, CBT, QI, Results 5. Physician, patient advocate testimonial 6. Break 7. Algorithm scavenger hunt 8. Tools intro, tips, PL, RL, PLAP Separate: MOAs billing and scheduling 9. BB 10. Billing 11. Action planning, Evaluations

10. 10 Thank you for your responses to the following questions. 1.What are your challenges or frustrations supporting patients with mental health concerns? 2.How do you currently support these patients & how is this working? 3.What are you hoping to get out of the PSP Mental Health module? 4.Are you familiar with the PHQ 9 screening tool 5.Are you paper based or do you have an EMR? 6.Are you with a group practice or alone? Where You are Now  Where You Would Like to Be www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources

11. 11 Results of pre-course assessment survey N=36 What are your challenges and frustrations? www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources

12. 12 How do you currently support MH patients? www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources

13. 13 What do you hope to get from PSP training? www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources

14. 14 Familiarity with the PHQ9 screening tool? www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources

15. 15 Paper or EMR? www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources

16. 16  Want to provide the best care for your patients with MH problems  Concerned about time efficiency in your practices  Doing a lot of MH care already  Some don’t feel confident in MH care they provide and some feel emotionally drained by it  Would like clearer and more timely access to mental health specialists for your patients  Here to learn skills and tools to help with diagnosis and in-office management as well as learn about helpful resources What did we learn about you? www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources

18. 18

19. 19  10.5 Mainpro M-1 credits based on  Attendance hours at all learning sessions (LSs)  Fewer if not all sessions attended  IN ADDITION  10.5 Mainpro C bonus credits based on  Completion of all 3 LSs plus an Action Period and post  reflective survey (we will contact DocBC 3 months after LS3  and AP1 completion to request them to send your Reflective  Questionnaire)  Details are found on all PSP Sessional Forms in bottom right box Mainpro Credits for Primary Care Physicians

20. 20 “This event is an Accredited Group Learning Activity eligible for up to 10.5 (3.5 per session) Section 1 credits as defined by the Maintenance of Certification Program of the Royal College of Physicians and Surgeons of Canada. This program has been reviewed and approved by the UBC Division of Continuing Professional Development.” MOC for Psychiatrists

21. 21 M 1 Credits for Residents Residents can claim a maximum of 30 M-1 credits during their residency. Residents are eligible to receive M1 credits for attending learning sessions (up to and within their maximum allowance of 30 M1 credits). To obtain M1 credits please contact: cthomas@doctorsofbc.ca cthomas@doctorsofbc.ca

22. CME and Compensation: Who to Contact? PSP Modules Mainpro C and M1 credits Fax all Learning Session and Action Period Invoices to Doctors of BC (604.638.2939) Contact: Physician Forums Mainpro M1 credits MUST sign in so we can send your name to VIHA Physician Compensation for both reimbursement and CME tracking Contact:

23. 23 Who sees MH patients in Canada? Pan Canadian Survey 2011

24. 24 Hypothesis  Family docs need:  time efficient skills to increase their comfort and confidence in treating their mental health patients  fee codes that fit this mental health work www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources

25. 25  CBIS manual – cognitive behavioral interpersonal skills manual. This formed the core of the BC provincial practice support program adult mental health module Weinerman R et al, Improving Mental Healthcare by Primary Care physicians In British Columbia. Healthcare Quarterly, 2011. 14:1, 36-38 MacCarthy,D;Weinerman,R:Kallstrom,L;Kadlec,H;Hollander,M;Patten,S;Mental Health Practice and Attitudes Can be Changed. The Permanente Journal, 2013, Summe; 17(3);14-17. Developed Training tools www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources

26. 26 1.Screening scales: ie PHQ9 2.CBIS Screening Assessment tools: ie Diagnostic Assessment Interview (DAI) 3.Three Supported Self-Management Cognitive Behavioural Therapy (CBT) skills options  CBIS Manual  Bounce Back  Antidepressant Skills Workbook Key Components of the Adult Mental Health (AMH) Module www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources

27. Results n=525 physicians

28. Further Results

29. 29  Provide PCPs with effective tools to screen, diagnose, engage, partner with, manage their MH patients  Improve PCPs’ comfort, confidence and satisfaction  Improve patient experience and outcomes  Reduced healthcare provider stigma Hope/Aim/Goals www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources

30. 30 Depression used as Lens (Anxiety too) High prevalence in isolation/comorbid and comorbid with chronic disease Lifetime prevalence of  Major Depressive Episode: 12.2%  Past-year episodes: 4.8%  Past-month episodes: 1.3% *  * Descriptive Epidemiology of Major Depression in Canada. Patten, SB; Wang, JL; Williams, JVA et al. Canadian Journal of Psychiatry; Feb 2006; 51, 2; 84.  ** Twelve-month and lifetime prevalence and lifetime morbid risk of anxiety and mood disorders in the US. Kessler, RC, Petukhova, M, Sampson, NA, Zalavsky, AM, Wittchen, H-U. Int J Methods Psychiatr Res. 2012 Sep:21(3) 169-184 Ranked by frequency **  Major depressive disorder  Specific Phobia  Social phobia  PTSD  GAD  Separation anxiety  Panic  Bipolar  Agoraphobia  OCD

31. 31 Focus of this module Patients that present with: 1.fatigue, depression, anxiety, panic, insomnia, psychosomatic symptoms 2. chronic pain, headache, chronic illness, 3. depressed demeanor, worrier a thick chart and trigger you to generate a mental health screening.

32. 32  Plan: Ride my bike to work Bike ride Improvement Ramp I was late I was sweaty Bike was rusty I was stiff Rain/wind Forgot soap Still late Too many hills On time!! Felt good!! I Can do this! Get up Get ready Get bike Go Fix bike Stretch Leave early Take clothes/shower at work Attempt #3 Check google for bike time Got poncho/glasses Brought shampoo Find straighter route Leave earlier Done!! Attempt # 1 Attempt # 2 Always go back to why is this important! Get exercise Save on gas & wear/tear on car Contribute to carbon footprint Promote exercise/wellness in community Lessen traffic flow by one car………

33. Confirm patient population Locate tools on algorithm Begin trying out tools Review use of MH Log Sheet Confirm MOA role Billing questions/tech assistance Review Log Sheet progress Use of DAI Use of other resources Discuss optimal office flow (include MOA) Overview of aims, CBIS, ASW Bounceback and practice finding the tools (Scavenger Hunt) Log sheet/AP requirements Billing and EMR optimization Develop an action plan Share experiences (good & bad) w peers Use of tools DAI role play Log sheet/AP requirements Update action plan Share experiences Community Resource Cafe Troubleshoot issues for sustainability & improvement Sustainability Plan AP1AP2Pre-visit Month 0Month 7-8 Sustain Survey-barriers, desires Orientation to Algorithm, Review use of MH Log Sheet Location of tools on algorithm Confirm use of EMR Ongoing Support CME Post Module Reflective Questionnaire (mid-March) Module Pathway

34. 34 Cognitive Behavioural Therapy (CBT): Setting the Stage www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources

35. 35  Level 1 Evidence based. CBT prevention endures beyond tx cessation. If both CBT and meds stopped after successful acute treatment, patients who received CBT have lower rates of relapse **  Behavior/Activation oriented  Helps patients learn to change thought patterns/behaviors that negatively affect mood  Gives patients a sense of power and control  Retrains the brain!  You are the coach not the therapist **CANMAT Clinical Guidleines for the management of major depressive disorder in adults: Kennedy SH, Lam RW, Prikh SV, Patten SB, Ravindran AV What is a Cognitive Behavioral Approach? www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources

36. 36 How does CBT and CBT skills work? Use this to introduce CBT skills Situation www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources

37. 37 37 SITUATIONS Loss Conflict Isolation SITUATIONS Loss Conflict Isolation THOUGHTS Harsh self- criticism Over-pessimistic Catastrophic about future THOUGHTS Harsh self- criticism Over-pessimistic Catastrophic about future PHYSIOLOGY  Altered sleep  Low energy  Δ brain chemistry PHYSIOLOGY  Altered sleep  Low energy  Δ brain chemistry ACTIONS  Withdrawal  Reduced activity  Poor self-care ACTIONS  Withdrawal  Reduced activity  Poor self-care EMOTIONS  Sadness  Despair  Numbness EMOTIONS  Sadness  Despair  Numbness Problem Solving Behavioural Activation Realistic Thinking How does CBT and CBT skills work? Use this to introduce CBT skills

38. 38 Helps on its own Mild or moderate depression, mild and moderate anxiety disorders such as GAD, social anxiety, panic, stress, anger, self esteem, some personality disorders As an adjunct with medications in primary care or collaborating with secondary care Severe depression, anxiety disorders, obsessive compulsive disorder, bulimia, post- traumatic stress disorder, personality disorders, stable bipolar disorder and stable psychosis Engages, empowers patients to work towards their recovery Provides patients with coping skills & a sense of control A non-pharmaceutical option/adjunct for treatment that is enduring and prevents relapse The benefits of using CBT skills? www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources

39. 39 “Before just jumping into pharmaceuticals you can start with other things like re-training your brain, I have some strategies involving some homework to help you, what do you think about trying this?” Dr. Howard Bright, Chilliwack An alternate approach….consider saying to your patient…. www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources

40. Results n=525 physicians

41. 41  Giving practitioners and patients more coping tools reduced healthcare provider stigma against AIDS **  Family docs feel unequipped to deal with mental health issues *** Novel hypothesis Providing tools for practitioners, patients to use will reduce healthcare provider stigma against mental health issues ** Brown, L. Trujillo, L., Macintyre, K.; (2001)Interventions to Reducde HIV/AID Stigma: What have we learned?, Horizons Program/Tulane School of Public Health and Tropical Medicine, New Orleans, Louisiana, *** Clatney, L., MacDonald, H., & Shah, S.M. (2008). Mental health care in the primary care setting: Family physicians’ perspectives. Canadian Family Physician, 54, New Hypothesis www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources

42. 42 OMS-HC Total average scores: Both groups

43. 43 *Wilcoxen rank sum test was used to measure between group change from pre-test to follow- up, p<.001 **Wilcoxen sign rank test was used to measure within group change. Intervention group pre- test to post-test change, p=.002; post-test to follow-up change, p=.017. Control group, not significant.

44. 44  Why this module will change everything! Dr. Fiza video

45. Perspective www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources

46. 46 Break

47. www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources Let’s Do it!

48. Today: Start with Algorithm and 4 Basic tools CBIS Manual Bounce Back Coaching/ DVD Anti- Depressant Skills Workbook PHQ9/ GAD7

49. Updated Algorithm Available ‘Google’ this: www.gpsc bc.ca Click PSP www.gpsc bc.ca Click PSP Scroll to this: Scroll down Click Adult Mental Health Select Algorithm for Mental Health (pdf) Right click select "Save target" to download to your desktop

50. Algorithm Scavenger Hunt (locating the tools quickly)

51. 51 MH Tools Scavenger Hunt  Form groups of 2-3, each with at least one laptop with downloaded MH Algorithm OR Google www.gpscbc.ca click PSP, scroll down click Adult Mental Health Module, select Algorithm, right click save target www.gpscbc.ca

52. 52 Format  Each Pair:  Will review 2 Case Studies (Anxiety, Depression)  Must complete each task to receive next task  One person to bring completed task to Coordinator  Each Group Member:  Will receive an Action Period log to fill in (keep at your table until the end of the Scavenger Hunt)  Bonus Tasks = Prizes Coordinators will be circulating to provide assistance

53. Algorithm Scavenger Hunt Discussion and “Treasures”

54. 54 MOA Tasks to discuss  Reschedule MH patients in blocks  Organize relevant resources – forms, booklets, other materials  Provide patient follow-up calls  Identify how Action Period logs will be completed and faxed  Complete the CMHA Mental Health First Aid course  Contact the Practice Support Team for support  Ensure Algorithm is loaded on each computer

55. Today: Start with 4 Basic tools CBIS Manual Bounce Back Coaching/ DVD Anti- Depressant Skills Workbook PHQ9/ GAD7

56. 56 PHQ-2 & PHQ-9 www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources

57. 57 Need one or both questions endorsed as “2” or “3” (“More than half the days” or “Nearly every day”)

58. 58 PHQ-9 Scoring Major Depressive Disorder: Need 5 or more questions endorsed as “More than half the days” or “Nearly every day” (i.e. in shaded areas) 18 89 1

59. 59 PHQ-9 Scoring Is functional impairment endorsed as “Somewhat difficult” or greater? 18 89 1 www.gpscbc.ca/psp-learning/ adult-mental-health/tools-resources

60. 60 DSM 5 Confirming Diagnosis of Major Depressive Episode Criteria A: reflected in PHQ9 nine questions 1 symptom is either depressed mood or loss of interest or pleasure (PHQ9 1 st 2 questions) 5/more symptoms present in same 2 week period/change of function Criteria B:  Reflected in PHQ9 function question Criteria C:  episode is not due to a substance or other medical condition

61. 61 Bereavement  May resemble a major depressive episode  Use your clinical judgment depending on your knowledge of the individual and their cultural norms

62. 62 Manual Overview Assessment Flow  DAI  Problem List  Action Plan  Resource List  SAQ  Anxiety Dx Skills  Activation  Cognition  Relaxation  Lifestyle  Anxiety

63. 63

64. 64  Tools – use according to your needs  Be selective  Use all, some, now, later  Be strategic Flexibility of Use - Key Strategy www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources

65. 65 Shift in How we Work  Shift to shared patient responsibility  Chronic problems  No quick fix  All tools to engage  Build partnership

66. 66 General  Breathe, relax  No right or wrong  PDSA  Can’t hurt  Negotiate, demonstrate and soft sell  Validate, encourage and praise

67. Skills Activation - first Cognition – prepare Relaxation/Anxiety – demonstrate Lifestyle – always good Anxiety disorders -

68. 68 Organizing Tips  Handouts available  One at a time  Small goals  Chart homework given  Regular follow-up  Practice

69. 69 Problem List

70. 70 Resource List (Reslience)  About the patient  Shift to strength  Challenging  Help  Internal and external  Wellspring

71. 71 Problem List Action Plan  All known  Patterns, not solutions  Chaos organized  Being heard  Validated  Prepares for action

72. 72 Ask patient: What action do you think would be helpful for this problem…. ? Activation ? Relaxation ? Thought changing ? lifestyle changes ? medications ? referrals to other resources Small Group Activity – Problem List Action Plan 10 min

73. 73

74. Summary Just do it! Jump in! Use favorites! Own it!

75. 75 Supported Self Management Cognitive Behavioral Skill Building Mood Improvement Program www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources

76. 76  Brief ‘Little Booklet’ format with less text Accessibility Alternatives Cantonese versions + Coaching also available

77. 77  To learn more about Bounce Back in general:  Visit our Website: www.bouncebackbc.cawww.bouncebackbc.ca  Bounce Back toll-free #s:  Phone: 1-866-639-0522  Facsimile: 1-877-688-3270 Additional Information www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources

78. 78 Advocate Perspective Importance of  being heard  being asked the questions  Short term more time, long term less time/gain  Stigma experience  Other experience www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources

79. 79 Discussion www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources

80. 80

81. 81 CBIS tools DAI 2 counseling visits 00120 x 2 1 counseling visit finish with MH planning fee 00120, 14043 Problem List Action Plan Counseling visit 00120 Skills Office Visit 00100 Tel Fup 14079 MSP Compensation

82. 82 Impact of using the tools: Dr. Egan’s Renewed Practice Visit 1 PHQ9/GAD & PL/RL Bill 0010 or if >20 minutes, bill 00120 worth 1.5 of a 00100 up to 4 times a year Visit 2 Review PL/RL & create Action Plan, choose Skill sheet Bill 0010 or if >20 minutes, bill 00120 worth 1.5 of a 00100 up to 4 times a year Visit 3 Review and add ASW (pt may choose Bounce Back too) Bill 0010 or if >20 minutes, bill 00120 worth 1.5 of a 00100 up to 4 times a year Visit 4 May need more in depth Diagnostic Assessment Interview

83. 83  Visit 4 May need more in depth Diagnostic Assessment Interview Bill 14043 MH planning fee, and after this is billed, this generates 4 more counseling visits giving access to 8 prolonged visits in one calendar year in addition to the planning visit 14043 worth $100 once a year. Plan must include a screening assessment and a planning document to keep on chart. If you take 2 sessions to do this bill 00120 for first and 14043 for second giving you the time to discuss with patient easily. More about Visit 4 83

84. Action Period Planning

85. Confirm patient population Locate tools on algorithm Begin trying out tools Review use of MH Log Sheet Confirm MOA role Billing questions/tech assistance Review Log Sheet progress Use of DAI Use of other resources Discuss optimal office flow (include MOA) Overview of aims, CBIS, ASW Bounceback and practice finding the tools (Scavenger Hunt) Log sheet/AP requirements Billing and EMR optimization Develop an action plan Share experiences (good & bad) w peers Use of tools DAI role play Log sheet/AP requirements Update action plan Share experiences Community Resource Cafe Troubleshoot issues for sustainability & improvement Sustainability Plan AP1AP2Pre-visit Month 0Month 7-8 Sustain Survey-barriers, desires Orientation to Algorithm, Review use of MH Log Sheet Location of tools on algorithm Confirm use of EMR Ongoing Support CME Post Module Reflective Questionnaire (mid-March) Plan Your Pathway

86. PSP Mental Health Log

87. Successful planning for achieving Action Period activities Successful planning for achieving Action Period activities

88. To complete Action Period 1 Replace this box:With your practice ideas Scheduling options Create/Review patient registry Select specific patient criteria…complex care, migraine, others? Organize relevant resources – forms, booklets, other materials Follow up with patients (MOA can follow up with patients on homework and goals agreed to in action plans) Identify changes to work processes and office re-design Record overall progress on log sheets

89. Paperwork Learning Session Evaluation KEEP Invoices to FAX to Doctors of BC (FAX # at lower R side)

90. 90 What is your proof that this stuff works??? How will you know that what you are doing is an improvement??? My appointments will be faster Some of my patients may not need to see psychiatry My patients will progress and respond to my approach My appointments will be proactive My income will increase My MOA will have an enhanced role and a workflow in place My MOA will have an enhanced role and a workflow in place My communications with Mental Health and Addictions will improve

91. Thanks for Attending www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources Lunch Info

92. 92