Session # H4a
October 18th, 2014
Stress, Psychological Flexibility, and Behavioral Health
Satisfaction- An Assessment and Intervention Study with
Primary Care Providers
Melissa Baker, PhD, Behavioral Health Consultant, HealthPoint (Community Health Center)
David Bauman, PsyD, Behavioral Health Consultant, Central Washington Family Medicine Faculty, Community
Health of Central Washington
Bridget Beachy, PsyD, Behavioral Health Consultant, Central Washington Family Medicine Faculty, Community
Health of Central Washington
Collaborative Family Healthcare Association 16th Annual Conference
October 16-18, 2014
Washington, DC U.S.A.
Faculty Disclosure
• We have not had any relevant financial relationships
during the past 12 months.
Learning Objectives
At the conclusion of this session, the participant will be able to:
1. Identify methods for measuring PCP work-stress,
psychological flexibility, and perceptions of behavioral
health services
a)
Understand the relationship between PCP work-stress and psychological
flexibility
2. Understand how to apply the Trident Approach to
research in primary care
3. Learn a new approach or strategy for promoting
increased teamwork, integration and BH services
Bibliography / Reference
Gray, B. H., Stockley, K., & Zuckerman, S. (2012). American primary care physicians' decisions to leave their practice:
Evidence from the 2009 commonwealth fund survey of primary care doctors. Journal of Primary Care &
Community Health. doi:10.1177/2150131911425392
Heath, B., Wise Romero, P., & Reynolds, k. (2013). A Standard Framework for Levels of Integrated Healthcare. SAMHSAHRSA Center for Integrated Health Solutions, 1-13. Retrieved May 11, 2014, from
http://www.integration.samhsa.gov/integrated-caremodels/A_Standard_Framework_for_Levels_of_Integrated_Healthcare.pdf
Levey, S. B., Miller, B. F., & deGruy III, F. V. (2012). Behavioral health integration: an essential element of populationbased healthcare redesign. Translational Behavioral Medicine, 2(3), 364-371. doi:10.1007/s13142-012-0152-5
Robinson, P. J., Gould, D., & Strosahl, K. D. (2011). Real Behavior Change in Primary Care. Strategies and Tools for
Improving Outcomes and Increasing Job Satisfaction. Oakland: New Harbinger
Robinson, P. J. & Reiter, J. T. (2014). Behavioral Consultation and Primary Care: A Guide to Integrating Services, 2 nd
Edition. NY: Springer.
Robinson, P. & Strosahl, K. (2009). The Primary Care Behavioral Health model: Lessons learned. Journal of Clinical
Psychology in Medical Settings,16, 58-71.
Substance Abuse and Mental Health Services Administration (SAMHSA, 2014). Integrated care models. In SAMHSAHRSA Center for Integrated Health Solutions. Retrieved August 30, 2014, from
http://www.integration.samhsa.gov/integrated-care-models
Learning Assessment
• A learning assessment is required for CE
credit.
• A question and answer period will be
conducted at the end of this presentation.
Who we are…
*Started BH program in
2000
*9 BHCs, 6 Pre-doctoral
interns in 11 clinics
*FQHC
Integrated Behavioral Health
Program
Integration, you say?
Shared
practice
space
Billing
Practice
Change
Clinical: Tx
plan;
Shared
EBPs
(5th & 6th)
Organization
support
Care team:
One stop
shop
(Health, Wise Romero, & Reynolds, 2013)
“Trident” Approach to Integrated
Care Research
#1 Clinical
Interventions
#2 Train/Educate
providers for
caring for “whole
person”
#3 Assist/
Support PCPs
Why do this study?
• Impact of ACA
– Only 40% of US physicians are PCPs
• Of younger PCPs, 30% plan to leave PC within 5 years
• Of older PCPs, 27% plan to retire AND 25% to leave PC within 5
years
• Psychological flexibility related to work-stress
• Focus on integration
– Ranges of integration; what works best?
– Lessons have been learned over the years…
(Gray, Stockley & Zuckerman, 2012; Health et al., 2013; Levey, Miller & deGruy III, 2012;
SAMHSA, 2014; Robinson, Gould & Strosahl, 2011; Robinson & Strosahl, 2010)
Overview of Study
• Phase 1 (Online survey to medical providers)
– Primary Care Provider Stress Checklist (PCP-SC)
– Primary Care Provider Acceptance and Action
Questionnaire (PCP-AAQ)
– AAQ-II
– Primary Care Provider Satisfaction Form (O’Donahue)
• Phase 2
– 4 BHC’s paired with a total of 7 medical providers
(MD, DO, NP)
Provider Demographics
• 57 providers (50 completed entire survey)
– Majority (N = 37) MDs
– Majority early in their careers
•
•
•
•
0 – 5 years = 22
6 – 10 = 11
11 – 15 = 10
16+ = 13
Phase 1 Results
• Increases in flexibility, stress levels decrease
• PCP-SC (p < .01; r = -.52) with PCP-AAQ
• Increase in flexibility, stress levels decrease
• PCP-SC (p < .01; r = .60) with AAQ - II
• Providers’ satisfaction with BH increases, their stress
decreases *
• PCP-SC (p < .01; r = -.40) with BH satisfaction survey
• PCP-AAQ accounted for 27% of the variance (p < .000)
•
Control for degree type (i.e., MD, DO, NP), the variance is 30%
Specific BH satisfaction results
• 100% satisfied with BH
– 34 = Strongly Agree (68%); 16 – Somewhat Agree (32%)
• 100% recommend having BH services
– 47 = Strongly Agree (94%); 3 = Somewhat Agree (6%)
• 100% believe referral process easier
– 48 = Strongly Agree (96%); 2 = Somewhat Agree (4%)
• 84% agree patients more compliant
– 17 = Strongly Agree (34%); 25 = Somewhat Agree (50%)
• 100% agree having BH makes job easier
– 45 = Strongly Agree (90%); 5 = Somewhat Agree (10%)
• Write in responses***
Implications
• Supports #3 Trident approach
• Psychological flexibility & stress
– How to improve flexibility?
• Within every day practice?
• Formal training?
• Need psychometrics on measures
• BH satisfaction implications
Phase 2 of study
• Pairing BHC w/ PCPs for one week
– Incorporate some of the BH survey feedback
• Strive to see every patient
• Before, during, after
• Goals:
– Expand scope of BH services
– Decrease stigma of BH
– Increase collaboration and teamwork
– …evaluate new strategy to integrated care
Phase 2 Results
• Saw more patients!!!
– Total of 211 patients (M = 52.75, SD = 5.25)
• 2.61 patients per hour (SD = .51)
• 65% first time visits*
– Patient breakdown
•
•
•
•
•
•
<18 y/o = 39
18-64 = 159
65+ = 14
English speaking: 144
Spanish speaking: 46
Other: 21
Top BH Diagnoses for the Week
Top BH diagnoses prior to intervention
week
Top BH diagnoses during intervention week
1. Depression
1 Counseling NOS
2. Anxiety
2. Stress
3. Counseling NOS
3. Depression
4. Parenting related
4. Diabetes Mellitus
5. Stress
5. Anxiety
6t. Chronic Pain
6. Hypertension
6t. Sleep
7. Obesity
8. Obesity
8. Tobacco
9t. Mood NOS
9. Parenting related
9t. Alcohol
10. Chronic Pain
Qualitative Results
• Medical assistants themes
1.
2.
3.
4.
Improve workflow
Destigmatizing behavioral health services
Promoting behavioral health services
Improve efficiency
• PCP themes
1. Streamline workflow
2. New utilization of BH
3. Improve efficiency
Our experiences
Implications
• Evolution of the PCBH model at HealthPoint
– Closed model schedule
– Bothell clinic
•
•
•
•
Nurse schedule model
4 x 4 hour shifts of only warm handoffs/in-clinic patients
One full day a week of scheduled visits, still w/ warm handoff slots built in
Observations: Good and bad
• Training model?
– For PCPs, MAs and BHs
• Hitting the “mark” of level 5 and 6
• Addressing many issues of integration
Limitations
• HealthPoint FREE BHC services
– Easier to do co-visits with multiple providers
– Brief visits (15 minutes or less) are possible
– No concerns about cost (patient refusal low)
• Only 1 or 2 providers per clinic
– Fair?
• Do not have the “people power”
Rationale using “Trident Approach”
• PHASE 1
– Assess aspects of PCP stress (#3, Assist/Support PCPs)
– Program evaluation
• Phase 2
– Fulfill consulting role for increased PCP satisfaction (#3)
– Provide direct clinical interventions (#1, Clinical
Interventions)
• Provide appropriate better/more informed patient care (#1)
• Increased patient satisfaction, wait time (#3)
– Promotion of whole person care (#2, Train/Educate
providers for caring for “whole person”)
• BOTTOM LINE – IMPROVE INTEGRATION to become
STANDARD CARE
Questions?
Session Evaluation
Please complete and return the
evaluation form to the classroom monitor
before leaving this session.
Thank you!