1. A Day in the Life of a Behavioral Health Consultant Jeffrey T. Reiter, PhD, ABPP Co-Director, Primary Care Behavioral Health Service, HealthPoint Community Health Centers Seattle, WA Collaborative Family Healthcare Association 13 th Annual Conference October 27-29, 2011 Philadelphia, Pennsylvania U.S.A. Session # F2b October 28, 2011 1:30 PM

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

3. Need/Practice Gap & Supporting Resources Integration of primary care and behavioral health is increasing, with use of various models A consultant model (aka PCBH) is utilized in many organizations, but is not widely understood This talk will delineate the consultant model from other models using real world examples and clinical tools Strosahl, K. (2005). In O’Donohue et al. (Eds.) Behavioral Integrative Care: Treatments that Work in the Primary Care Setting. Routledge (Chapter 1) Robinson, P. & Reiter, J. (2006). Behavioral Consultation and Primary Care: A Guide to Integrating Services. Springer: New York

4. Objectives – Identify the basic components of a consultant model – Explain how a consultant model differs from a therapy model – Outline strategies for conducting consultative visits of varying lengths – List the most important components of consultative feedback for a PCP

5. Why a Consultant Model? Overwhelming number of behavioral issues in PC – The specialty (case-focused) model will be insufficient PCPs poorly trained in behavioral interventions PCPs will use more behavioral interventions if exposed to them regularly (Robinson, 1996)

6. Consultants and Therapists DimensionConsultantTherapist Primary consumerPCPPatient/Client Care contextTeam-basedAutonomous AccessibilityOn-demandScheduled Ownership of carePCPTherapist Referral generationResults-basedIndependent of outcome ProductivityHighLow Care intensityLowHigh Problem scopeWideNarrow/Specialized Termination of carePt progressing toward goalsPt has met goals

7. Context of a Consultative Visit Timing can vary – Before PCP visit: prep for PCP visit – During PCP visit: for support; help with assessment or intervention; or due to time constraints – After PCP: answer specific question or augment care Purpose can vary – Medication-focused (Meds indicated? Which class?) – Functionally-focused (“Please help with____”) – Other specific question (suicide risk?, meds risk?, etc.)

8. Goals of a Consultative Visit Goal is to optimize PCP care, efficiency – For specific questions Primarily answer the referral question – For medication-focused referral Provide a diagnostic category Obtain medication history (response, SE) and current preferences – For functionally-focused referral Listen for important history the PCP did not have Provide behavioral recommendations for pt, PCP

9. Content of a Consultative Visit – General content Role introduction History of the presenting problem – Including psych tx history, if applicable Overview of functioning – Work/School, Family, Social, Physical, Recreational – Look for relationships b/w problem and function » Often forms the basis for the intervention – Substance use (etoh, tob, caffeine, drugs) » If indicated » Past history, current use Recommendations for pt and PCP (including f/u plan)

10. Sample Clinic Day 9:00 PCP wants meds rec – 52 y/o homeless, ? ADHD vs bipolar 9:30 Question re disability expiring – 64 y/o Russian-speaker, depression 10:00 PCP says “I don’t know her problem” – 62 y/o, psychiatrist d/c’d, on 3 meds from 3 Drs 10:30 Open→WH w/ PCP in exam room – 12 y/o autism, ADHD, recently showing tics, hall’s

11. Sample Clinic Day (cont’d) 11:00 N/S→WH in exam room, PCP- prep – 6 y/o ADHD, insomnia, enuresis 11:30 Planned f/u from 1 week earlier – 20 y/o Spanish-speaker, depressed w/ SI 1:00 Team mtg (15-min talk on pain, 5-min on tobacco cessation) 2:00 Cx→same-day appt for NRT refill

12. Sample Clinic Day (cont’d) 2:30 Open→WH for CSA – 60 y/o severe etoh, chronic arm pain 3:00 Planned f/u after 2 weeks – 47 y/o homeless, MDD w/ psychosis, acute SI due to meds 3:30 Planned f/u after 1 month – 45 y/o homeless, MDD, trying to get disability 4:00 Cx→WH for PCP prep on new pt – 16 y/o expelled from school, needs risk assessmt 4:30 Open→Same-day f/u after 4 mos – 20 y/o seeking disability for PTSD, dep

13. Keys for Flexibility Be open to shorter than usual visit (e.g., 10 mins) Be mindful of your schedule – Does the next pt need a full 30 minutes? – Can the WH pt wait? – Do you have an opening later to catch up? Perspective – Primary goal is to improve PCP’s care and efficiency – “A bird in the hand is worth two in the bush.” – Positive interaction and f/u plan may reduce no-show

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