Behavioral Medicine: The Future of Behavioral Health Integration

1. Behavioral Medicine: The Future of Behavioral Health Integration

2. Sheila North, LMFT, Executive Director

3. Chris Farentinos, MD, MPH, CADC II,Chief Operating Officer

4. Behavioral Medicine • Behavioral Medicine (BM) is an interdisciplinary field of medicine concerned with the development and integration of behavioral and biomedical science knowledge and technics relevant to health and illness, and the application of this knowledge and technics to prevention, diagnosis, treatment and rehabilitation. (Yale Conference on Behavioral Medicine Schwartz and Weiss, 1978)

5. Behavioral Medicine • BM has expanded its area of practice to interventions with providers of medical services • Provider behavior influences patient outcomes • Quality of relationship and communication between clinician and patient • Other areas: Clinicians attitudes; bias toward illness as opposed to wellness

6. Society of Behavioral Medicine (SBM) • “Better health through behavioral change” • 34th annual meeting in San Francisco in March 2013

7. Society of Behavioral Medicine 2013 • Adherence – theoretical and practical methods for adherence • Behavioral treatments for chronic diseases – improved self-efficacy and self-regulatory skills • Bio-behavioral mechanisms (psychoneuroimmunology, psychophysiology such as cardiovascular reactivity) • Health communication

8. Jon Kabat-Zinn • Professor of Medicine and Director of the Stress Reduction Clinic and the Center for Mindfulness in Medicine, Health Care, and Society at the University of Massachusetts Medical School • Kabat-Zinn is student of Zen Buddhism. • He integrates Buddhist teachings Western science. • A mindfulness based stress reduction program created by Kabat-Zinn is offered at medical centers, hospitals, and HMOs.

9. Health Literacy Conference (Legacy) March 2013, Portland OR • Health care reform and health literacy • Health disparities • “Plain language” • “Teach back”: two-way communication • Community health workers and health literacy • Health communication in cultural competence

10. Balancing Budget • Cut people from care • Cut provider rates • Cut services • “We either improve or we cut” (Don Berwick, former Director for CMMI)

11. Triple Aim(Quadruple Aim) Better Health Better Care - Improve Patient Experience Reduce Costs Equity 11

12. Inverting the Cost Pyramid Current Configuration Desired Configuration

14. Cost of Behavioral Health 25% of CareOregon’s patients account for 83% of CareOregon’s adult medical costs. This group’s most common health problems (CareOregon data, 2011): 1) 35% Asthma 2) 30% Drug and Alcohol Problems 3) 24% Diabetes 4) 17% Complex Mental Illness 5) 14% Chronic lung disease and Congestive Heart Failure

15. Cost of Substance Use Disorders Individuals with SUD incur between two (Parthasrathy et al., 2001) and three (McAdam-Marx et al., 2010; Thomas et al., 2005) times the total medical expenses of people who do not have SUD.

16. Payment Reform • Fee for service • Pay per volume • Pay for value • Pay for performance

17. (OHA) Oregon Metrics and Scoring Committee – CCO PerformanceMichael Bailit October 10, 2012 • CAHPs Composite (7Qs) • Rate of PCPCH enrollment • ED Utilization (HEDIS) • Initiation and Engagement of AOD • Follow-up after hospitalization for mental illness • Composite measure: mental health and physical health/assessment for children in DHS custody • Screening for clinical • Depression and follow-up plan

18. (OHA) Oregon Metrics and Scoring Committee – CCO PerformanceMichael Bailit October 10, 2012 (Continued) Prenatal care Developmental screening by 36 months (hybrid) Colorectal Cancer Screening (hybrid) Alcohol and Drug misuse, screening, brief intervention and referral for treatment (SBIRT) Optimal Diabetes Care (D3) Controlling Hypertension Adolescent Well-Care Visit EHR Composite measure

19. Behavioral Medicine: Rediscovering the Neck

20. Practitioners EBP Guidelines Skilled Communication Relationship Patient Satisfaction Patients Targeted Behavior Change

21. What is Treat to Target? • The concept gained traction in diabetes and rheumatology care, but it is now achieving wider applications in all health care • Treating to achieve a measurable and agreeable target (practitioner and patient), and changing the care plan when the interventions are not achieving the target • Common sense (but common sense is not that common)

22. Treat to Target • Some examples: • Hemoglobin A1C in Diabetes • Disease activity markers in Rheumatology • Days of use in Substance Use Disorders • Symptom Reduction in Mental Health : ACORN

23. Motivational Interviewing and Patient Centered Care • Big demand on training new and current medical and BH practitioners workforce in Motivational Interviewing skills • Addresses Motivation and Behavioral Change • Hand and glove with Treat to Target • Hand and glove with patient activation, patient self-regulation and self-efficacy enhancement • Hand and glove with patient satisfaction

24. MI efficacy on treatment adherence • In a majority of controlled studies (12 of 21) MI was found to produce significant adherence effects (Miller and Rollnick, Motivational Interviewing, second edition page 306, 2002) • Nicotine cessation: MI has shown to impact outcomes of nicotine cessation efforts when coupled with NRT • Example of adherence studies: • MI and effectiveness in facilitating transition of clients from one level of care to the another (Swanson, Pantalon and Cohen 1999) • Six studies found effects on measures of attendance, treatment commitment, readiness for change, and task completion, and medication compliance

25. What are the active ingredients? • Practitioner empathy – MI teaches active listening and empathic responses • MI trained practitioners do less of non empathic interactions such as directing the conversation, not listening, not collaborating, and confronting • Practitioners who are better in MI have patients who respond with more “change talk” and change talk predicts behavioral change

26. Patient Centered Care Clip 5 min • http://www.youtube.com/watch?v=dm-rJJPCuTE

27. Challenges and Opportunities • Find a partner in the audience. • Take a few minutes to jot down what do you think the transformation towards behavioral medicine will look like? • What are the challenges? • What are the opportunities?

28. Models for Integration

29. What is “Primary Care Integration”? MINIMAL BASIC At a Distance BASIC On-Site CLOSE Partly Integrated CLOSE Fully Integrated Coordinated Co-located Integrated Collaboration between SUD and MH service providers and primary care providers (e.g., FQHC’s, CHC’s) Collaboration can take many forms along a continuum* *Source: Collins C, Hewson D, Munger R, Wade T. Evolving Models of Behavioral Health Integration in Primary Care. New York: Millbank Memorial Fund; 2010.

30. Minimal Coordination The Primary Care System SUD Care System MH Care System • BH and PC providers • work in separate facilities, • have separate systems, and • communicate sporadically.

31. Basic AT A DISTANCE The Primary Care System SUD Care System MH Care System • BH And PC providers • Engage in regular collaboration and communication about shared patients leading to improved coordination

32. At a Distance Example De Paul Treatment Centers counselor attends interdisciplinary team meetings at Legacy Pain Management Center (pharmacist, physicians, nurse, social worker). Patients with chronic pain and SUD are referred to De Paul’s chronic pain tx. program (DBT and CBT). Information exchanged bi-directionally throughout treatment. De Paul expert provided patient centered care training for practitioners at Legacy

33. Basic On Site (co-location of services) The Primary Care System Referral SUD Care System SBI Counseling Counseling Referral MH Care System MH Services • BH and PC providers • Still have separate systems, or share some systems (EMR access, scheduling) • Allows for face to face between providers

34. Co-location Example Legacy Good Sam clinic care team: Outreach caseworker from CareOregon, social worker, nurse case manager, pharmacist, SUD counselor from De Paul. Behavioral health clinicians are co-located at the primary care clinic. Behavioral health and primary care providers share patients and coordinate care. Specialty mental health or SUD referrals happen but most BH treatment happen in primary care. The patients experience MH and SUD counseling as part of PC

35. Integrated The Primary Care System MH Care System SUD Care System • BH and PC providers • share the same facility, patient experiences BH tx as part of PC • have systems in common (e.g., financing, EMR, management) • regular face-to-face communication, treatment plan and treat to target plans are shared and coordinated

36. CCO’s Leadership and Management New Core Competencies CCO’s need leaders and managers who are skilled in: • Leadership • Innovation and change management, • How health care and behavioral health operates, • How to incorporate evidence based prevention and innovation to reduce preventable disease (obesity, tobacco, eating, exercise, depression, risky drinking and drug use) • And can embrace payment reform.

37. Several New Team Members Care Manager/ BH Consultant • Behavioral activation • Health literacy • Health education • Case management • Coaching • Follow up Consulting MH Expert • Caseload consultation for PCP and CM • Diagnostic consultation in difficult cases • EB guidelines for referrals to specialty Peer mentor • Recovery • Wellness Community Health Worker • Promote health • Trusted community members • Address social determinants • Remove barriers to health • Advocacy and education • Health literacy SUD counselor • Recovery management • EB guidelines for referrals to specialty • Case management • Health literacy

38. What about the Physicians???

39. Physicians • Have big demands on their time • Vary on “health care transformation readiness” • Are glad to have a BH experts on care team to do a warm hand off • Seldom have expertise or skills to deal with MH and SUD • Depend to a large extent on their communication skills to be successful • Training on “Patient Centered Care”

40. What about the BH providers?

41. BH Providers • Have big demands on their time • Vary on “health care transformation readiness” • Would be glad to collaborate with doctors on patient care but feel unskilled in the medical field • Training on basic concepts of chronic disease management (such as diabetes, hypertension, asthma etc.) • Are skilled on improving client self-efficacy and self regulatory skills using Motivational Interviewing and Brief Therapy

42. Behavioral Health Field Transformation • Less long-term – “fern and lamp” – 50 min session therapies • Shorter inpatient and outpatient lengths of stay • More short term, brief intervention, Treat to Target treatment – increase on the “back door” • More treatment at non-traditional settings; e.g., primary care, mobile van, housing site, community based, school and home • More access to primary care at BH facilities

43. Medicine will look more like BH and BH will look more like medicine = Behavioral Medicine

44. Contacts • sheilan@depaultreatmentcenters.org • chrisf@depaultreatmentcenters.org