1. Primary Care Psychology &the Behavioral Health Lab Memphis VAMC Robert Baldwin, Ph.D. Charissa Camp, Ph.D. November 1, 2012 Presentation for TPA Convention 2012

2. Background • Dr. Oslin and Philadelphia VA • “Best Practice” • Evidence and Readings Handout

3. Personnel • Memphis Main Hospital Campus • Co-Located Collaborative Care and Care Management Staff • Copper Behavioral Health (PC-MHI Psychologist Dr. Robert Baldwin) • Blue Behavioral Health (PC-MHI Psychologist Dr. Charissa Camp) • Louisville Call Center • BHL Care Management Staff • Program Director (Psychologist Dr. Beth Scheu) • 2 RNs • 1 Supervisory Health Technician • 12 Health Technicians

4. The PACT Model • Veteran Centered • Primary Care Patient Aligned Care Team • Veteran • PCP • RN • Clinical Associate • Clerical Associate • Auxiliary PACT Members • Psychologist <-> BHL • Nutritionist • Social Worker

5. Fun with Acronyms (the VA way) • Psychologist = CCC • CCC = Co-located collaborative care • BHL = CM • BHL = Behavioral Health Lab • CM = Care Management • PC-MHI = CCC + CM • PC-MHI = Primary Care Mental Health Integration

6. The Six Dispositions that follow CORE • Disease Management (Brief Counseling) • Depression Monitoring (BHL) • Watchful Waiting (BHL) • Referral Management (to MH, SA, PCT, SMI, other) • SMI Management • No Tx—Refusal of services/Not in need of services

7. PC-MHI/BHL Clinical Process Patient Identification By screening or clinical assessment in PCC ** Initial PC-MHI Psychologist Contact BHL Core Assessment Review Results + Triage (by PC-MHI Psychologist) No Treatment Indicated Refusal of Services Referral Management to MH, SA, PCT, &/or SMI services Disease Management and/or Medical Consultation BHL Watchful Waiting or Depression Monitoring ** when possible

8. In case of emergency…Access/Warm-Handoffs • Warm-Handoff • When pt is identified by PCP or self-identifies as having an urgent MH issue • PCC staff contacts Psychologist (individual teams have different methods of communication) • Pt is seen same-day, generally within 30 min or less due to protected schedule • Initial contact note is completed and initial triage made • CORE is scheduled to start parallel care management services (CORE if appropriate)

9. Core Report • Structured Interview completed by HTs • Screening assessment • -Depression - Anxiety and Panic • -Trauma - Mania • -Psychosis - Substance Abuse • -Cognitive Impairment • Report summary generated for CPRS • Reviewed and disposition made by the appropriate PC-MHI Psychologist, depending upon clinic—Copper or Blue

10. Now let’s review CCC and CM and then specifics of dispositions…Co-located Collaborative Care (CCC) • Initial Referral • Primary Care Staff refer to PC-MHI Psychologist via route agreed upon by that clinic (consults, additional signers, whatever) • Referral for BHL support • PC-MHI Psychologist sends basic info to a sharepoint to enroll Veteran in BHL for Core Assessment • Same day Assessment/Evaluation • If emergency or positive clinical reminders • Triage and Referral • Determine the recommended and Veteran directed level of care – refer as indicated (back to BHL or to specialty MH services) • Brief Therapy • Typically 1-6, 30 min visits • Goal directed/action oriented/MI or SMI management • Referral Management • Motivational interviewing is utilized to assist Veteran in referral process to specialty care such as MHC, PTSD, CDC, SMI programs

11. Care Management (CM) • Health Technicians (HTs) in Louisville • Conduct the BHL phone services (structured interviews at intervals determined by protocol and/or clinical recommendation) • PC-MHI Psychologists (also the CCC provider in the Veteran’s Primary Care Clinic • Reviews all collected data and drafts of CORE reports edits them in CPRS with a disposition • Communicates with PC medical providers via CPRS or in person about dispositions and status of Veteran’s mental health issues

12. The Dispositions:Disease Management (Brief Counseling/Brief Interventions) • Brief Therapy (1-6 sessions) • Cognitive Behavioral • Solution Focused • Motivational Interviewing • Use of Action Plans • Often concurrent with Depression Monitoring when the patent is placed on an Antidepressant by their PCP • Lose the couch  and (maybe) the do not disturb sign

13. Depression Monitoring (DM) • PCP prescribed • new Antidepressant per MH-PC service agreement • Significant changes in their Antidepressant • Phone calls at week 2, 6, 9, by Health Techs to administer follow-up screeners • PHQ-9, Sub Abuse • If PCP is not comfortable prescribing necessary medication, patient is placed in Referral Management to psychiatry

14. CM/BHL for Depression Monitoring • HT will alert psychologist that contact has been completed • Psychologist will review report, make edits, make treatment adjustments, and place the report in CPRS • If trend is static or depressive symptoms increase, psychologist contacts Veteran for phone contact/assessment or have their Prescribing Provider consultant look at case and make recommendations for PCP or PCP may refer to psychiatrist • Final Depression Monitoring report, paste into CPRS with determination • Often the psychologist will contact the Veteran to confirm determination is consistent with pt needs/desires • Closing summary note is completed if appropriate

15. Watchful Waiting (WW) • Mild cases of mental health symptoms • Patients not willing/able to engage in treatment • 8 weekly phone calls: Health Techs will call to complete follow-up screening • PHQ-9, Sub Abuse • If conditions worsen, can be referred for disease management or referral management

16. CM for Watchful Waiting • HT will alert psychologist of the completion of this contact (often with encrypted email as well) • Psychologistlogs into BHL software to review trend in PHQ-9 scores and substance abuse report • If trend is static or depressive symptoms/SA increases, psychologist contacts Veteran for phone contact/assessment • Final WW will elicit a BHL software report; access and edit similar to Core and paste into CPRS with determination • Often the psychologist will contact the Veteran to confirm determination is consistent with pt needs/desires • Closing summary note is completed if appropriate

17. Referral Management (RM) • Facilitate transition between Primary Care and Specialty Mental Health Services • Offer interim appts/contacts as needed • VA system consults to specialty services as indicated • If high risk, psychologist will follow-up by phone or in person during interim and coordinate with Suicide Prevention Team as needed

18. SMI Management • May or may not have CORE • Monthly supportive meetings for persons with serious mental illness that are not appropriate for other categories

19. Let’s Review the Steps • Referral from PACT to PC-MHI Psychologist • CORE/Initial meeting with psychologist • Review of CORE and determine disposition(s) (6 possible) • Follow procedure for disposition(s) selected • Close As with PCP, Veteran/patient may be seen again in future as primary care psychology need arises.

20. Questions???Thanks for your attention!Robert.Baldwin@VA.govCharissa.Camp@VA.gov