Primary Care and Behavioral Health Integration within the Free Clinic Setting: Developing a PCBH Model of Care

1. Primary Care and Behavioral Health Integration within the Free Clinic Setting: Developing a PCBH Model of Care Alysia Hoover-Thompson ahoover7@radford.edu Radford University Presented at the Mental Health Roundtable Virginia Health Care Foundation, Richmond, VA August 16, 2011

2. Radford University Psy.D. Program • First cohort began providing services to community in 2008 as part of training program • Students provide mental health services to local community organizations • Many of these organizations are not-for-profit • Program emphases • Rural practice • Cultural diversity • Social justice • Evidence-based practice

3. Free Clinics • “Free clinics are volunteer-based, safety-net health care organizations that provide a range of medical, dental, pharmacy, and/or behavioral health services to economically disadvantaged individuals who are predominately uninsured” (National Association of Free Clinics, 2008)

4. Free Clinic of the New River Valley • On site • Medical • Dental • Pharmacy • Dermatology clinic • Who Qualifies? • Adults without health insurance • “Low income” based on 2010 Federal Poverty Guidelines • Mental Health Association of the New River Valley • Provides pro-bono counseling services to MHA clients at an office located in the Free Clinic

5. Why Integrated Care? • Up to 70% of visits to primary care offices are related to behavioral health needs • Many common medical problems that are treated by PCP involve health and behavioral habits that influence symptoms (Hunter, Goodie, Oordt, & Dobmeyer, 2009) • In 2008, the American Psychological Association launched the Primary Care Initiative

6. Developing an Integrated PCBH Site • Psy.D. Program Director approached by Free Clinic Director • Program students had previous experience providing traditional mental health services at site through Mental Health Association • Joshua Bradley was the first Psy.D. student from Radford to complete a practicum there • Developed forms and documents for integration • Developed comprehensive 360 degree evaluation procedure to assess integration into the system and performance

7. Integrating PCBH Services into an Established System • Emphasize that you are there to support existing services • Try to accept as many referrals as possible in order to show usefulness • Get to know all people in the clinic • Explain what you do • Have a prepared explanation and examples • Create a handout

8. Systemic Contextual Considerations • Names and Faces • Virginia College of Osteopathic Medicine residents • On site physician • Nurse practitioners • Nurses • Front office staff • Volunteers

9. Patient Contextual Considerations • Given the low-income client base, there may be relevant considerations related to intervention options • Clients may lack financial resources to make significant changes to their diet or join a gym • Transportation may be a problem • High frequency of significant financial and environmental stressors • Literacy rates may be lower • Other contextual factors will undoubtedly become apparent as the BHC becomes more familiar with the client base • This speaks to the importance of being aware of cultural and contextual factors when working within an integrated care system

10. Primary Care Environment • Fast paced • Adjust clinical note taking • Space limitations • At least 7 different rooms • Move from room to room frequently • Finding medical charts • Several places they can be • New faces • Remembering names

11. Patient Referrals • Self-Referred • Request to see Mental Health Counselor at appointment with physician/NP • Physician/NP Referred • Request for BH evaluation/intervention • Warm Hand-off • Occurs in exam room

12. Additional Activities • Consultation with medical staff • Example: Patient is in abusive relationship and medical resident asks about treatment options. BHC explains options such as Women’s Resource Center, Mental Health Association, etc… Medical resident presents options to patient • Presentations to clinic staff • Safety in medical settings • Behaviors that increase appointment/treatment adherence • Case management

13. The First Year • 201 Total Contacts • 21 warm hand-offs • 54 referrals • 126 follow-up appointments • 111 Cancellations/No Shows • Primary Complaints • Depression (64), Anxiety (44), Diet/Exercise (38), Relationship problems (32)

14. The Second Year • Two students and two days/week • Mondays, Wednesdays and Fridays at the Free Clinic in Christiansburg • Wednesdays at Giles satellite office • Want to increase warm hand-offs • Will increase number of patients seen • Utilize 360 evaluation

15. Adjusting to Environment • “Client” versus “patient” • Transportable office • Medical terminology • Brief encounters (as short as 5 minutes) • Case management • Educator/Presenter • In-house mental health representative

16. Conclusion • Different paradigm • Multiple treatment setting considerations • Need to be flexible • Fit into system • Requires more directness and behavioral focus because of time limitations