Learning Objectives

2. Learning Objectives • To provide an overview of racial/ethnic behavioral health disparities • To provide an overview of integrated behavioral health services in a primary care setting. • To provide an overview of one model of integration-CommuniCare Health Centers. • To define roles of integrated team members.

3. Health Disparities Health status of ethnic populations Diabetes Cardiovascular disease HIV/AIDS Mental health and behavioral health disorders Health Care Disparities Access to care Lack of interpreters Un- and underinsured populations Under-diagnosis of diseases Lower referral rates Health Disparities vs. Health Care Disparities

4. A Supplement to Mental Health: A Report of the Surgeon General, Department of Health and Human Services, 1999

5. Executive Summary • Themes of Report • Mental health and mental illness require the broad focus of public health approach. • Mental disorders are disabling conditions. • Mental health and mental illness are points on a continuum. • Mind and body are inseparable. • Stigma is a major obstacle preventing people from getting help.

6. Executive Summary • Message from Surgeon General • Mental health is fundamental to health. • Mental illnesses are real health conditions. • The efficacy of mental health treatment is well documented. • A range of treatments exists for most mental disorders.

7. Purpose of the Supplement Report • To understand better the nature and extent of mental health disparities; • To present the evidence on the need for mental health services and the provision of services to meet those needs, and • To document promising directions toward the elimination of mental health disparities and the promotion of mental health.

8. Striking Disparities in Mental Health Care • Racial and ethnic minorities: • have less access to and availability of mental health services. • Are less likely to receive needed mental health services. • In treatment often receive a poorer quality of mental health care. • Are underrepresented in mental health research.

9. Main Messages From Report • Culture Matters • Personal Health Recommendation • Seek Help

10. Prevalence of Mental Disorders Among Hispanics • Lower rates of depression in Hispanics than for non-Hispanics (in particular in Mexican and Cuban Americans) • Higher rates of Major Depression in Whites than Blacks than Hispanics • Higher rates of Dysthymia in Whites than Blacks than Hispanics Vega, Alegria, Latino Mental Health and Treatment in US, 2001; Riolo, et al, Am J Pub Health, 2005; Kessler, et al, Arch Gen Psychiatry, 2005

11. Mental Disorders in Hispanic May Go Undetected in Primary Care Settings • Primary Care providers identified only 21% of Hispanic patient with depression. • Elderly Medicare recipients who were Hispanic had a .72 odds ratio for diagnosed depression compared with Caucasian patients. Borowsky, et al, J Gen Intern Med, 2000; Schmaling, et al, J Health Care Poor Underserved, 2005

12. Health Factors That May Affect Patient’s Mental Health • Obesity • Regular leisure time exercise • Diabetes • Tobacco use • Alcohol use • Illicit drug use • Prescription drug abuse CDC, National Health Interview Survey, 2005; SAMHSA, National Survey on Drug Use and Health, 2005

13. Rationale for Integration of Physical and Behavioral Health • Most patient seek help for behavioral health problems in primary care. • Behavioral health problems often go undetected or untreated in primary care. • Patients with medical disorders like diabetes have higher rates of behavioral health problems. • Treating behavioral health problems in primary care presents opportunity for early intervention and prevention of more disabling conditions.

14. Why Do Patient Seek BH Services In Primary Care Settings? • Patient may be un or under insured. • Patient’s insurance may not cover BH services. • Limited access to public MH services. • Lack of availability of MH services, especially in rural areas. • Cultural beliefs and attitudes.

15. Conceptualizing Care Across Integrated Systems • The four quadrant system of care conceptualizes frameworks for designing integrated programs. • The four quadrant model is built on the type of care people need and where that care is best delivered depends on severity of needs. • The systems of care model recognizes that patient are likely to interact with many systems of care.

16. The Four Quadrant Clinical Integration Model Low -Behavioral Health Risk -High Low -Physical Health Risk-High

17. Definition of Integrated Behavioral Health • Defined as the systematic coordination of physical and behavioral health services. • Collaborative care adopted by the Wagner’s chronic care model. • Integrated services will provide the best results. • Integrated services are patient center.

18. Collaborative Care’s Key Ingredients • Care management- Patient education & empowerment, ongoing monitoring, co-management. • Evidence based treatment. • Expert consultation for patients who are not improving. • Outcome tracking.

19. Overview of Chronic Care Model • Health Care Organization and Leadership • Linkage to Community Resources • Support of Patient Self-Management • Coordinated Delivery System Design • Clinical Decision Support • Clinical Information Systems

20. CommuniCare Health CentersOur Mission CommuniCare Health Centers has been serving the community since 1972. Our mission is "to provide comprehensive, affordable, quality health care while responding to the changing needs of the community and respecting the dignity, values and culture of the individual."

21. About Us • CommuniCare Health Centers offer comprehensive primary health care services in Bexar and Hays counties. Our services include: • Medical • Family Medicine • Pediatrics • Women’s Health • Dental • Behavioral Health • Pharmacy & Laboratory We pride ourselves for being a one-stop service facility for all of your primary health care needs.

22. Health Care Organization and Leadership • Leadership within organization and within the department that supports this model is key. • Organizational environment that systematically supports and encourages chronic illness care. • Results in successful quality improvement activities.

23. Linkage to Community Partnerships • Methodist Health Care Ministries • Electronic Health Records- BH Module • Center for Health Care Services • Crisis Unit and Care Management • University Health System • Psychiatric ER and Adult Inpatient Unit • Clarity Child Guidance Center • Child Inpatient Unit • United Way Referral Agencies • Haven for Hope • Independent School Districts • Early Childhood Intervention

24. Maslow’s Hierarchy of Needs

25. Support Patient Self-Management • Problem Focused Therapy • Cognitive Behavioral Therapy • Motivational Interviewing and Therapy

26. Clinical Decision Support • American Academy of Child and Adolescent Psychiatry Treatment Guidelines • American Psychiatric Association Treatment Guidelines • Substance Abuse Mental Health Service Administration Treatment Improvement Protocols • American Association of Family Physicians • US Department of Health and Human Services: Treating Tobacco Use and Dependence Clinical Practice Guidelines

27. Standard Screening Instruments • Patient Health Questionnaire (PHQ)- 9 • Beck Depression & Anxiety Inventory (BDI & BAI) • Mood Disorder Questionnaire (MDQ) • Vanderbilt Attention Deficit Hyperactivity Disorder (ADHD) Scale • Edinburgh Post-Partum Depression Scale • Fagerström Tobacco • Michigan Alcohol Screening Test-Short form

28. Clinical Information Systems • Access to adequate database software. • NexGen Health Information System • Generate treatment plans and provide these to patients at part of appointments. • Handouts and messages to facilitate self-care.

29. Roles of the Integrated Team • Psychiatrist • Social Workers • Psychologist • Psychiatric Nurse Practitioner • Medical Assistant • Mental Health Technician

30. Interprofessional Behavioral Health Staff • Frank Bryant Clinic • Dr Clarissa Aguilar, PhD • Rulynne Ballinger, LCSW • Tandra Rathey, PNP • Barrio Family Health Center • Thelma Rivera, LCSW • Sandra Trevino, LCSW • Christina Wei, PNP • San Marcos Clinic • Donna Murphree, LCSW • Kyle Clinic • Michele Purvin, LCSW

31. “NONE OF US IS AS SMART AS ALL OF US.” Japan Proverb; Kenneth Hartley Blanchard.

32. INTERPROFESSIONAL TEAMS • More effective and efficient patient care. • Patient benefit from receiving care from professions with various areas of expertise. • Team work provides coordination of all aspects of patient care. • Professional growth and job satisfaction. • Enhances breadth of knowledge and appreciation for skills and knowledge of other health professionals, above and beyond their roles in team work.

33. Patient Health Questionnaire-2 • Over the past 2 weeks, how often have you been bothered by any of the following problems? • Little interest or pleasure in doing things?* • Feeling down, depressed or hopeless?* *Responses are not all the time, several days, more than half the days or nearly every day. Kroenke, K, et al, Medical Care 2003.

34. PATIENT FLOW WHEN BH STAFF IN PRIMARY CARE POD Patient Vitalized by Medical Assistant ↓ ↓ PHQ-2 Positive PHQ-2 Negative ↓ ↓ Patient seen by BH staff PHQ-2 labeled and scanned into chart ↓ PHQ-9 completed and scored ↓ ↓ Positive Negative ↓ ↓ Patient scheduled for Provide information about BH Program Intake appt and anticipatory guidance

35. Beck Scales • Depression Inventory • Mean 29.4 (Severe) • Median 29 • Range 4-53 • Minimal 14 (13%) • Mild 14 (13%) • Moderate 24 (22%) • Severe 56 (52%) • Total 109 • Anxiety Inventory • Mean 28.8 (Severe) • Median 28 • Range 14-63 • Minimal 7 (6%) • Mild 11 (10%) • Moderate 28 (26%) • Severe 63 (58%) • Total 108

36. Behavioral Health Initiatives • Post Partum Depression • ADHD Children • Smoking Cessation Initiative • Alcohol Abuse Intervention

37. PEDIATRICS POST PARTUM DEPRESSION FLOW CHART Mother presents infant (patient) for first visit ↓ MA ask mother to complete PHQ-2 → Negative → No further action ↓ Positive → Mother Not CommuniCare patient → Depression Handout ↓ Mother CommuniCare patient ↓ Pediatrician to ask patient to complete Edinburgh Post Partum Depression Scale → Negative* → Anticipatory guidance ↓ Positive* ↓ Refer to Behavioral Health for appointment

38. Ms. Smith Medications Medications • Promethazine 25 mg • Prednisone 20 mg • Hydroxychloroquine 200 mg • Meclizine 25 mg • Naproxen 500 mg • Methotrexate 2.5 mg • Folic acid 1 mg • Cyclobenzaprine 10 mg • Butalbital/apap/caf • Azithromycin 150 mg • Citalopram 20 mg • Proair • Propo-n/apap 100-650

39. Future Plans • Expand staffing to include: • Pharm D as consultant • Expand Screening and Evaluation tools • Panic Disorders • Enhance existing programs with BH needs • FUN Clinic • Smoking and Alcohol Abuse • Mother Infant Attachment Assessments • Expanding Community Partnerships • Hospital Emergency Rooms

40. Closing Thoughts • The Integrated Model allows opportunities for Behavioral and Physical Health Prevention and Health Promotion. • The Integrated Model developed at our site is a hybrid of many models to address our patient populations needs. • Integrated Models are patient centered.

41. Learning Objectives • To provide an overview of racial/ethnic behavioral health disparities • To provide an overview of integrated behavioral health services in a primary care setting. • To provide an overview of one model of integration-CommuniCare Health Centers. • To define roles of integrated team members.

42. Questions