Psychological Practice in Primary Care or Other Medical Settings

1. Psychological Practice in Primary Care or Other Medical Settings Robert J. Ferguson, Ph.D. Eastern Maine Medical Center & University of Maine Maine Psychological Association, Fall Conference, November 2, 2012

2. Theoretical underpinnings

3. Where is behavioral care delivered?

4. Patient Centered Care • Huh?

5. Patient Centered Care

6. Contributing Factor to Healthcare Cost Inflation: Inefficiencies due to Mental Health “Carve Out” • 50% of high utilizers psychologically distressed (Katon, et al., 1990) • 1 month prevalence of disorders in high utilizers • Mood (dysphoric) 40.3% • GAD 21.8% • Somatization 20.2% • Panic Disorder 11.8% • ETOH Abuse 5.0%

7. Contributing Factor to Healthcare Cost Inflation: Inefficiencies due to Mental Health “Carve Out” • High healthcare utilizers account for: • 29% of Primary Care Visits • 52% of all Specialty Visits • 40% of in-hospital days • 26% of all prescriptions (Katon, et al., 1990)

8. Example: Panic Disorder • Attributed Physical Causes for Panic Sx’s after ED discharge: • Heart Attack 45% • CVA, Allergy, Hyperthyroid 40% • Overall Medical Cause 85% Lerner et al., 1995 (N = 46)

9. Example: Panic DisorderCommon Medical Settings Sought by Patients with Panic Disorder

10. Why Integration?....…not just “mental health” but “health behavior.” • 60% HMO visits made by individuals with no diagnosable disorder (Cummings & Follette, 1968). • 12-25% of Healthcare use accounted for by objective morbidity (Berknovic, Telsky, & Reeder, 1981). • Review of 1,000 GIM patient records over 3 years found less than 16% of cases had detectable pathology for chief bodily complaint (Kroenke & Mangelsdorff, 1989).

11. “Health rests on daily behavioral routines” (Rotheram-Borus, 2012; Wesner, 2002) • 5 habits lead to 70% of morbidity and mortality: • How much we eat • What we eat • Exercise • Smoking • Alcohol use (de Vol& Bedrosian, 2007)

12. Delivering care for chronic illnesses resulting from these habits account for 75% of medical care costs (CDC, 2009)

13. Health Behavior and Mental Health • Why this dichotomy? • More than psychiatric or substance abuse comorbidity… • Know the contributions of behavior to health

14. Psychiatric comorbidity is not the only behavioral factor contributing to utilization inefficiencies... • Adherence to post-AMI medication regimens 45% (Carney, et al., 1995) (Behavior Change) • Diabetes self-management regimens adhered to at about 15-20 % • 1997 prevalence…798,000 new cases annually • $ 2.1 Billion allotment by CBO for 5 year Medicare self-management plan (Behavior change arm) - CDC, October, 1997

15. Crude and Age-Adjusted Percentage of Civilian, Noninstitutionalized Population with Diagnosed Diabetes, United States, 1980–2010----CDC From 1980 through 2010, the crude prevalence of diagnosed diabetes increased by 176% (from 2.5% to 6.9%). During this period, increases in the crude and age-adjusted prevalence of diagnosed diabetes were similar, indicating that most of the increase in prevalence was not because of changes in the population age structure.

16. Why Integrate ? Example: Chronic Pain • Pain is the most common chief complaint presented to Primary Care • 70 million PC visits due to pain (Lawrence & McLemore, 1981) • Behavioral-Biomedical treatment of chronic pain reduces patient distress, decreases medical costs (Caudill, et al., 1991)

17. Models of Integration… • Coordinated • pcp-screen treat, community resources used outside • Co-Located • Behaviorist and PC located in same facility • Integrated • Behaviorist and PC located in same facility, team approach with stepped care (Blount, 2003; Millbank report 2010)

18. What is Primary Behavioral Healthcare?- Distinctions In Direct Services • Specialty MH • 50 Minute hour • # Sessions free to vary or based on research validated methods • formal intake assessment tx planning • high intensity tx • visits not related to PCP • long term f/u encouraged for most • Primary Behavioral Healthcare • 15-30 minute hour • 1-3 visits in typical case • Informal: revolves around PCP goals • low intensity; between session interval longer • visits coordinated with PCP • long term f/u rare; reserved for “high risk”

19. What is Primary Behavioral Healthcare? – Distinctions • Specialty MH • Deliver primary treatment to resolve condition • Coordinate with PC Physician “At arms length” • Teach patient core self-management skills • Manage more serious disorders over time as primary provider • Primary Behavioral Healthcare • Support PCP decision making • Build on PCP interventions • Teach physician “core” MH skills • Educate patient in self-management skills • Improve pt.-PCP relationship • Monitor with PCP “At Risk Patients” • Assist in Team Building

20. Our patientnot “your patient…”

21. How to Integrate? • Identify your skill set– Inventory what rapid assessment and treatment offerings you have • Identify the practice and the liaison/leader/practitioner who is like-minded

22. Stepped Care Specialty ReferralFamily or Individual Consultations, brief visits Shared Medical Appointments, Workshops, ClassesCurbside Consultation/Conjoint Visit, Coaching PCP

23. Clinical Behavior: For PC Colleagues • Again… “our patient” say these words… • Coach the smooth handoff, coach the language of stating the problem clearly (the “referral question”) • Know the staff, ask how you can make their job better, how they can contribute, praise when all is smooth, not just for extra effort…

24. Introduction and quick rationale: • Hi, I am____ I am part of your primary care team • Our job is to help change behavior in practical ways to help people be as healthy as they can be– no matter what the condition • Dr. ___ indicated you are dealing with (headaches, anxiety, sleep problems, depression, hypertension…” • Motivational Interviewing

25. PDQ Motivational Interviewing • Summary/Reflection • Stating the Extreme • Reconciling Disparate Sides of the Conflict • http://www.nova.edu/gsc/forms mi_rationale_techniques.pdf

26. Daily work

27. Daily Work: The schedule • Primary care providers may typically work 55 hours per week • The intent is to move a lot of people a little way, not a few a long way (specialty care) • As such, patients are scheduled on 15 or 30 minute blocks in some settings, 20 min in others • Behaviorists fit the PC schedule

28. Always coach the smooth handoff

29. Some handoff script tips: • “a recommended step is to meet with Dr./Ms./Mr.___ who is an expert in this problem and can help you manage this.” • “they can help you change that health habit –and stick to it-- with practical methods…” • “he/she has expertise to help you meet the challenge…boost emotional strength…” • “he/she is a coach for health behavior change…” • AVOID: “you need to talk to someone…” • “This is psychological, you need psych…” • “talking with ____ will help you resolve this…” • “you need mental health… this is a mental thing…”

30. Daily Work: Conjoint visits • A brief meeting with the patient and PCP, usually in an exam room • Intended to “break the ice” (begin to establish rapport and therapeutic alliance) • Can happen unexpectedly, on a moment’s notice and rapidly. Be prepared. • If you see distress, anger, resentment, simply state, “I understand, you don’t have to make any decision, but know I am here and the door is open…” “talk more with Dr. __ if you wish… call with questions….”

31. Daily Work: Tracking activity • Why? To identify the needs of practice • What to track: • Track provider behavior: • Frequency of… • How many times each provider “refers” per month • How many times each provider curbsides • Track problems: Of patients- billing/diagnostic records, categorize

32. Daily Work: Tracking activity • Outcomes Monitoring • Will depend on the preferences of the practice • Do you want to track program outcomes? • Do you want to track general health of the panel served? • This can be time consuming and expensive • Will you use commercially available or public domain measures? • Usually a psychologist in charge: Is he or she being paid for the time it takes? • Who will manage the data base? Enter the data? Analyze the data? Who will oversee data safety and monitoring plan?

33. Problems Seen In Collaborative Primary Care in GIM (‘97-99)

34. Daily Work: Tracking outcomes • Public domain resources: • Patient Reported Outcomes Measurement Information System www.nihpromis.org/ • Functional Assessment of Chronic Illness Therapy (FACIT.org) www.facit.org/

35. Daily Work: Framing the behavioral health visit 1. Warm introduction • State purpose of the visit: evaluate the and make a plan • Indicate when the visit will end • Give a 5 minute warning

36. Daily Work: The initial interview • After the frame… • Rapid assessment • Use the referral question and previous note of PCP to identify the problem • Use reflection, summarization and Socratic questioning to validate the person’s experience • Use the template of questions of specific problem (discussed later)

37. Daily Work: The initial interview • After rapid assessment… • Set a specific, measurable goal • (daily activity schedule, approach supervisor, ask friend for assistance, call specialty service) • Establish a follow-up visit

38. More motivational interviewing methods 1) “Asking permission” • “do you mind if we talk about…?” • “so now that you are here, should we talk about ?” 2) “Eliciting change talk” • “what would you like to see different about your situation” or “what makes you think you need to change? 3) “Exploring importance/confidence” “- What would it take to move from – to --?” “- How would you life be different?”

39. Daily Work: Scheduling the follow-up • Assure an appointment is made upon leaving • Set up the system to do this • It should be identical to any other PC appointment! • All staff must be aware of this system– good, helpful, customer service with enthusiastic social skills • “When is a convenient time to check in– a week would be good for behavioral momentum but what is preferred… ?” 10 days?”

40. Daily Work: Documentation and other unsettled challenges • Privacy • Each institution is different in policies • Integrated care IS primary care ROI is for outside entities (e.g., if seeing someone on one day in specialty MH, then release is needed at that facility) • HIPAA (Health Insurance Portability and Accountability Act of 1996) • http://www.hhs.gov/ocr/privacy/hipaa/understanding/index.html • The act continuously changes and balances the tension between continuity of care and privacy of private health information(PHI)

41. Daily Work: Documentation and other unsettled challenges • Documentation-- considerations that others have used • Assumption: notes on medical record • Keep them succinct • Avoid “states secrets” • Assure compliance with your compliance officer • Document: • Time begin, end, date • Status of the patient– were they able to understand, participate? • What was the procedure • Diagnosis, assessment • Plan THIS IS SUBJECT TO YOUR INSTITUTIONAL PRACTICE POLICY

42. What can be done in primary (integrated) care? • Shared Medical Appointments (aka, “drop-in”“group..”) • Not group therapy– billed with a medical code • Alternative, addition to 1:1 medical appointment • Leverages physician and other provider time • Patients– more time with Dr. • Increases physician, patient, staff satisfaction • Not for everyone (40%??) • Requires set-up, buy-in with ALL staff

43. Headache • Workshops: Penzien, et al. • See http://www.apa.org/pubs/videos/4310731.aspx • See also Jonathan Borkum, Ph.D. “Chronic Headache: Biology, Psychology and Behavioral Treatment”

44. Medical Problems • Chronic Non-malignant pain • Headache • Coping with and managing chronic illness • Adherence to medical regimens • Anti coagulant clinics, e.g. Coumadin (warfarin) • Cancer Survivorship • Medical checks, imaging, blood work, medical vulnerabilities (cardiac, metabolic, cognitive) • Essential Hypertension

45. The Path Ahead