Session #E1
October 28, 2011
11:15AM
Behavioral Health Lab: Building a
Strong Foundation for the PatientCentered Medical Home
Johanna Klaus, PhD, Director, Behavioral Health Lab
Sara Kornfield, PhD, Post-doctoral fellow
Erin Ingram, BA, MIRECC Research Coordinator
Dave Oslin, MD, MIRECC Director, ACOS MH
Collaborative Family Healthcare Association 13th Annual Conference
October 27-29, 2011 Philadelphia, Pennsylvania U.S.A.
Faculty Disclosure
We have not had any relevant financial relationships
during the past 12 months.
Need/Practice Gap & Supporting Resources
Primary care mental health (PCMH) integration has blossomed at
facilities throughout the VA, and is consistent with the
adoption of the Patient Centered Medical Home. However,
the implementation of evidence based protocols for the
collaborative treatment of depression, anxiety, and alcohol
misuse and the consistent use of assessment to evaluate
treatment and program effectiveness (i.e. measurement
based care) has been slower in adoption.
Systematic use of informatics tools to support evidence-based
and measurement-based care can help address this gap.
Objectives
• Describe how the Behavioral Health Lab is consistent with the
principles of the Patient-Centered Medical Home including
improved access, care coordination, team-based care, and
partnering with the patient.
• List the Behavioral Health Lab services and target populations
and how the program can be adapted for changing or
individual clinic needs.
• Describe the importance of measurement-based care with
collaborative care programs for triage, patient education and
symptom monitoring, and program quality improvement.
• Identify the use and features of the BHL software system that
can assist in implementation of a PCMH approach, including
screening of behavioral health problems and ongoing tracking
of care.
Expected Outcome
Consider the benefit of a flexible informatics platform to help
implement evidence based protocols in primary care to
inform both patient treatment outcomes and program
effectiveness.
Patient Centered Medical Home
Replaces episodic care based on illness and patient
complaints with coordinated care and a long term
healing relationship
 The Primary Care Team
• Takes collective responsibility for patient care
• Responsible for providing all the patient’s health care needs
• Arranges for appropriate care with other specialties as needed
 Enhanced Access
 Enhanced communication between
• Patients
• Providers
• Staff
 Continuous Improvement in our work
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The spectrum of mental health problems
Mild-to-Moderate
Large Numbers
“Sub-optimal” functioning
•Depression
•Anxiety
•Alcohol misuse
Brief Interventions
Primary Care Providers
Severe
Smaller Numbers
Major Impairment
•Severe depression, anxiety
•Personality disorders
•Schizophrenia or
bipolar disorder
Complex interventions
Specialty Care Providers
Philadelphia VA Integrated Care
program – Behavioral Health Lab
 A platform for the delivery of collaborative care in
primary care
 A public health focus on non-complex patients
 A partnership with PC
 A bridge to specialty care
 Patient centered care – incorporating convenience and
preference
 A program that stresses self- management and
collaborative decision making
 Measurement-based care
 Ever evolving…
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Clinical Process
Patient Identification
Screening / Clinical Assessment / Casefinding
Patient
Education
and Promote
Self-Care
Initial
Assessment
Treatment
Recommendations
Specialty Care
Evidence based
protocols
Prevention / Health
Promotion
Consultation
Or
Referral Mgt
Brief Treatment
&
Care
Management
Watchful waiting
&
Brief Interventions
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BHL software
– provides the
platform
No treatment
&
Refusal of care
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Behavioral Health Laboratory:
components
A clinical management program focused on:
 Identification: screening, pharmacy based, direct to consumer, etc
 Seek out patients
 Assessment and triage to appropriate level of care
 Care Management / Brief treatment/ Health Promotion
and Prevention
 Using Specialty Care and facilitating engagement
 Tracking: software program
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Behavioral Health Laboratory:
components
A clinical management program focused on:
 Identification:
screening, pharmacy based, direct to consumer, etc
 Assessment and triage to appropriate level of care
 Care Management / Brief treatment/ Health Promotion
and Prevention
 Using Specialty Care and facilitating engagement
 Tracking: software program
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Initial Triage
 All patients entering the program complete
standard initial assessment
 Completed via phone or in person (patient preference)
 Includes array of behavioral health symptoms
and substance use and overall functioning
 Helps determine next step in treatment
 Completion rate of 80%
 BHL Software output: clinical report, patient
letter
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Initial Triage Assessment
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Demographics
Current MH care
Financial status
Social support
Blessed Orientation-Memory-Concentration (>55 yrs or head injury)
Mini International Neuropsychiatric Interview (psychosis, mania,
GAD, panic)
Depression assessment: PHQ-9
PTSD Checklist (PCL-c)
Anxiety assessment: GAD-7 (optional)
Brief Pain Inventory Interference scale
Current Psychotropic/Pain medications
5-item Paykel scale for suicidal ideation
Alcohol use (7 day follow-back)
Illicit substance use
Depression history
Work Limitations questionnaire (optional)
SF-12 (optional)
Communicating with PC team
Characteristics of Veterans who completed
the BHL pre-assessment
Demographics and Background
N = 3348
Age (M, SD) (N=4163)
52.6 (16.1)
Race
non-Hispanic White
1617 (49%)
Employed
946 (28%)
Married/Partnered
Separated
Divorced
1462 (44%)
298 (9%)
728 (22%)
Finances
“Can’t make ends meet”
“Just enough to get along”
1016 (31%)
1672 (50%)
Served in Iraq/Afghanistan post 9/11
815 (25%)
SF-12
Physical component score
Mental component score
41.0 (12.9)
38.6 (13.6)
Mental Health and Substance Use Diagnoses
N, %
PTSD
PCL-c (M, SD); N=2066
1368 (43%)
51.8 (17.5)
Major Depression
Other depression
PHQ-9 (M, SD)
1422 (43%)
433 (13%)
12.4 (7.0)
Panic Disorder, current
Generalized Anxiety Disorder
190 (6%)
1206 (38%)
Mania
183 (6%)
Psychosis
91 (3%)
At-risk Alcohol Use/Abuse
Alcohol Dependence
467 (15%)
361 (11%)
Used street drugs, ever
Marijuana use, past 3 months
1895 (57%)
394 (12%)
Clinically significant MH or SA symptoms
1603 (50%)
Behavioral Health Laboratory:
components
A clinical management program focused on:
 Identification:
screening, pharmacy based, direct to consumer, etc
 Assessment and triage to appropriate level of care
 Care Management / Brief treatment/ Health
Promotion and Prevention
 Using Specialty Care and facilitating engagement
 Tracking: software program
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Behavioral Health Lab Interventions
 Evidence based (or we are working on it) and
stepped care approach
 Longitudinal but brief treatments (can be by
telephone – patient choice)
 Promote patient self-management
 Collaborate with PCP
 Pharmacological support
 Measurement based
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Evidence Base for primary care
delivered interventions
Robust Evidence Base
 Depression Care
management
 Alcohol Brief
Interventions (alcohol
misuse)
 Referral management




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Growing Evidence Base
Alcohol care
management (alcohol
dependence)
Watchful waiting
Anxiety care
management
Pain care management
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Measurement Based: BHL Software
 Built in interview for tracking follow-up
contacts for care management/brief treatment
 6 optional domains:
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•
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Depression: PHQ-9
Anxiety: GAD-7
PTSD: PCL-c
Pain: BPI for pain interference
Alcohol: 7-day time line follow-back
Referral Management: to track engagement in
specialty care
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BHL Software support: patient level
feedback
Tracking structured
assessments:
•Ability to provide
feedback to both the
provider and the patient
•Progress reports
generated by BHL
software
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BHL Clinician: the Glue
Primary Care
Clinician
BHL clinician
Patient
Mental Health
Supervisor
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Behavioral Health Laboratory:
components
A clinical management program focused on:
 Identification:
screening, pharmacy based, direct to consumer, etc
 Assessment and triage to appropriate level of care
 Care Management / Brief treatment/ Health Promotion
and Prevention
 Using Specialty Care and facilitating engagement
 Tracking: software program
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Referral Management
 Problem: low attendance rates for MH/SA treatment
(30-40%)
 Goal: increase referral adherence in symptomatic
patients with complex behavioral health care needs
Possible psychosis
Drug addiction
Mania
Severe/complicated depression or anxiety
 Uses a motivational interviewing style to provide
clinical support and promote problem-solving skills
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Appropriate Use of Specialty Care:
Referral Management Module
Attended 1st
Appointment
Motivational Session
70%
Control Group
32%
p < .001
Zanjani et al, 2008
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Behavioral Health Laboratory:
components
A clinical management program focused on:
 Identification:
screening, pharmacy based, direct to consumer, etc
 Assessment and triage to appropriate level of care
 Care Management / Brief treatment/ Health Promotion
and Prevention
 Using Specialty Care and facilitating engagement
 Tracking: software program
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BHL Software Platform
• Provides structured assessments across providers
and settings
• Programmable decision logic that is exportable
across sites and testable
• Allows capacity to define and follow a cohort of
subjects with prompts for additional clinical actions
(panel management for follow ups)
• Allows integration across mental health conditions
(not just one disorder)
• Creates patient material, including treatment progress
• Provides program level outcome data
• Allows rapid research engagement
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Patient Tracking: Panel Management
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Patient Tracking: Patient History Page
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Patient Tracking– Measurement based care
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Patient Level Reports
 Progress Note Creation for all interviews:
• Treatment plan
• Results of all assessments
 Patient letters and Progress reports
• Patient education
• Visual for treatment
progress
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Program Level Outcome Data
OUTCOME DATA:
Available at the program, clinic,
Primary Care Provider and staff
level
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BHL as a platform: ex. Developing a
Treatment for PTSD
• Of >17,000 BHL assessments  5,651 (33.2%)
positive for PTSD; PCL-c mean = 49.8 (18.2)
• PTSD positive veterans: more symptomatic
– 66% with depression vs 29% of PTSD negative
– More likely to have psychosis, mania, illicit drug use,
problem drinking, other anxiety disorders
 But 17% of Veterans at Philadelphia referred to
specialty care because they endorsed symptoms
consistent with PTSD had PCL scores < 60.
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PTSD Brief Treatment
 For lower level PTSD symptoms
 6-8 sessions of about 30 minutes
 1-4 sessions focus on psychoeducation,
behavioral activation, and mindfulness
 Extra sessions for anger management, sleep,
alcohol misuse as needed
 Current pilot; outcomes soon
• Effective treatment?
• Secondary triage?
• Warm-up for evidence based treatment?
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Behavioral Health Lab: In Summary
 Increase identification of patients needing behavioral
health services (Oslin et al, 2006)
 Increase engagement in specialty care (Zanjani et al,
2008)
 Improve outcomes for depression and alcohol misuse
(Oslin et al, 2003)
 Platform for new treatments and research
 Allows for efficient staffing and collaboration with PC
 The triage and tracking mechanisms allow for seamless
referral and the ability to reduce waiting times, prioritize
care, and provide administrative support for monitoring.
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Patient-Centered Medical Home and
the Behavioral Health Lab
Key Principles
Behavioral Health Lab
Patient-driven
√
Team-based
√
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√
√
√
√
Efficient
Comprehensive
Continuous
Communication
Coordinated
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More information?
 Johanna Klaus:
 Erin Ingram:
 Sara Kornfield:
 David Oslin:
Johanna.Klaus@va.gov
215-823-5899
Erin.Ingram@va.gov
Sara.Kornfield@va.gov
Dave.Oslin@va.gov
http://www.mirecc.va.gov/visn4/BHL/bhlindex.asp
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Session Evaluation
Please complete and return the
evaluation form to the classroom monitor
before leaving this session.
Thank you!