Session #B2b
Friday, October 17, 2014
Mapping New Territory: Implementing the
Primary Care Behavioral Health (PCBH)
Model in Homeless Shelter Clinics
Stacy Ogbeide, PsyD, MS
David S Buck, MD, MPH
Jeff Reiter, PhD, ABPP
Collaborative Family Healthcare Association 16th Annual Conference
October 16-18, 2014
Washington, DC U.S.A.
Faculty Disclosure
• I/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): Gain knowledge regarding the unique needs of homeless
clinics and strategies for tailoring the PCBH model to this
population with co-morbid health conditions;
• 2): Gain an understanding of the clinical and systems
challenges to implementing the PCBH model in a homeless
clinic; and
• 3): Understand the basic descriptive data for a new PCBH
service in a homeless clinic, including preliminary clinical
outcomes, descriptive patient data, most common conditions
treated, and others.
References
•
•
•
•
•
1. Mauer, B. J., & Druss, B. G. (2010). Mind and body reunited: Improving care at the
behavioral and primary healthcare interface. Journal of Behavioral Health Services &
Research, 37(4), 529-542.
2. Miller, B. F., Brown-Levey, S. M., Payne-Murphy, J. C., & Kwan, B. M. (2014). Outlining the
scope of behavioral health practice in integrated primary care: Dispelling the myth of the
one-trick mental health pony. Families, Systems, & Health. Advance online publication.
http://dx.doi.org/10.1037/fsh0000070
3. Robinson, P. J., & Strosahl, K. D. (2009). Behavioral health consultation and primary care:
Lesson learned. Journal of Clinical Psychology in Medical Settings, 16, 58-71. doi:
10.1007/s10880-009-9145-z
4. Vogel, M. E., Malcore, S. A., Illes, R. C., & Kirkpatrick, H. A. (2014). Integrated primary care:
Why you should care and how to get started. Journal of Mental Health Counseling, 36(2),
130-144.
5. Weinstein, L. C., LaNoue, M., Collins, E., Henwood, B., & Drake, R. E., (2013). Health care
integration for formerly homeless people with serious mental illness. Journal of Dual
Diagnosis, 9(1), 72-77. doi: 10.1080/15504263.2012.750089
Learning Assessment
• A question and answer period will be
conducted at the end of this presentation.
Introduction
• The mission of Healthcare for the Homeless –
Houston (HHH):
– to promote health, hope, and dignity for
Houston's homeless through accessible and
comprehensive care.
• Eligibility: homelessness
– Services sliding scale
• Services are offered 7 days a week
Introduction
• Services offered:
– Primary Care and
Behavioral Healthcare
– Case Management
– Dental Services (fullservice)
– Jail Inreach Project
– Project Access
– The HOMES Clinic
– Women’s Clinic
– Volunteer-run podiatry
services
– Medical Street
Outreach
– Bi-annual Vision Fairs
Utilization Data
Data Type
2008
2009
2010
2011
2012
2013
# Unduplicated Patients
8,674
8,810
10,170 9,634
# Patient Visits
14,240
19,268 21,995 19,619 21,400 21,765
# Units of Service
56,700
71,471 71,010 80,055 81,169 90,466
10,202 9,343
8
Gender
39%
61%
Male
Female
9
Race/Ethnicity
5%
2%
59%
33%
Black
Asian/Pacific Islander
White
1%
Hispanic
Other Multiracial / Unreported or Unknown
10
Age Distribution
20%
18%
16%
14%
12%
10%
8%
6%
4%
2%
0%
Age
<15
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
11
60+
Introduction
• Most common diagnoses in 2013:
–
–
–
–
–
–
–
–
Severe Mental Illness
Hypertension
Addiction
Obesity
Diabetes
Asthma
Heart Disease
Hepatitis C
Introduction
• In 2013:
– 4,879 PC patients for medical services, 4,285 (88%) have behavioral
health issues
• 722 behavioral health patient visits out of 8,834 medical
visits or 8%
– Specialty behavioral health providers (psychiatry, LCSW, LPC)
Introduction
• Individuals with severe mental illness (SMI)2, 5:
– Higher rates of mortality
– Higher prevalence of chronic disease compared to the general
population
• Weinstein, LaNoue, Collins, Henwood, and Drake (2014)5:
– Individuals with experiences of homelessness and SMI also have
serious medical/chronic illnesses
– Integrated behavioral health care programs can improve access to care
and offer regular health screenings
Introduction
• Miller, Brown-Levey, Payne-Murphy, & Kwan (2014)2: Behavioral Health
Consultants (BHCs) can address needs of persons with SMI by:
– Behavioral interventions for physical health diagnoses
– Monitoring medications and side effects
– Lower no-show rates in PC compared to specialty mental health
Development and Infrastructure
• Previous Primary Care and Behavioral Health Practice
Structure
– Historically a collocated model of care with behavioral health
services on site (on the same floor as the medical clinic)3, 4.
– Behavioral health team: 5 case managers (4 full, 1 half), 2 half-time
master’s level mental health providers, and 1 half-time psychiatrist.
• There are also 6 community health workers
Development and Infrastructure
• Program Development
– Initial leadership support
– Continuous education of medical, mental health, case
management, and administrative staff.
– Outside PCBH consultant (Dr. Reiter) role
– Weekly meeting took place with part of leadership team (e.g.,
medical director, PCBH consultant) to discuss implementation
progress and well as barriers to implementation.
– The medical director and BHC provided onsite clinical oversight
and management of the BHC service.
Development and Infrastructure
612
600
538
455
450
PCP Visits
300
150
BHC Consults
128
119
100
0
June
July
August
Development and Infrastructure
Top 5 Reasons for Consultation - June 2014
Depression
Anxiety
Psychosis
Relapse Prevention
Other
Development and Infrastructure
Top 5 Reasons for Consultation - July 2014
Depression
Anxiety
Relapse Prevention
Wellness Intervention
Other
Development and Infrastructure
Top 5 Reasons for Consultation - August 2014
Depression
Anxiety
Relapse Prevention
Stress
Other
Development and Infrastructure
• Example interventions:
– Sx/mood management
• Patient Education
• Building Awareness/Options for bx change (L.E.A.P.)
• Problem Solving
• Goal Setting
– Behavioral Activation
– Relapse Prevention Skills
– Behavioral Medicine (e.g., self-mgmt for diabetes, sleep
hygiene)
Development and Infrastructure
• System Integration and Operation Issues
– Clinical service delivery altered(e.g., cold consult, joint consult,
warm-hand off).
– EHR already in place - allowed for BHC to create a same-day
encounter with a patient as well as create a note that can be
viewed by the entire treatment team, as well as a note that can
have additional signers (e.g., PCC and BHC, BHC and case manager).
– Medical assistants: continued role as ancillary staff to the PCCs, but
also provided additional assistance for the BHC such
– BHC access to schedule
Development and Infrastructure
• Financial Sustainability
– Sustainability: BHC’s ability to increase clinical revenue through
Medicaid and Medicare over time
• Difficult to sustain
– Grant funding: Medicaid 1115 Waiver: Texas Healthcare
Transformation and Quality Improvement Program
– Increase # of PCP patients
– Work in progress…
Level of PCBH Integration
• Level 4 collaborative care model1:
• Close collaboration in a partly integrated system.
• BHC is embedded in the medical clinic.
• PCC and BHC share the same scheduling system and EHR, thus
allowing all providers real-time access to each other’s appointments,
notes, and labs/tests.
• BHC participates in medical staff, behavioral health, and case manager
meetings.
• The interdisciplinary team manages patients’ primary medical and
behavioral health problems in a comprehensive, integrated fashion.
• BHC is changing the culture of the medical clinic by educating staff and
patients about behavioral health consultation services.
Implementation Challenges
• 4 months thus far!
• An ongoing challenge: addressing operational
differences between behavioral health
consultation vs. traditional mental health
services.
Implementation Challenges: The
Implementation Dip
Michael Fullan, The Six Secrets of Change
Implementation Challenges
• Clinic space and patient flow:
– The Search Clinic
• 4 exam rooms
– Cathedral Clinic
• 3 exam rooms
– Small or no nurses station:
• BHC is working out of an exam room (rather than being housed at the nurses
station).
– Patient flow:
• Because there are only 1-2 medical providers at a clinic at any given time, each
provider typically works out of one exam room (compared to 2-3 rooms at a time).
Implementation Challenges
• Clinic space and patient flow:
– The current volume does not allow for a high amount of BHC contacts at
this time.
– At the end of 2015, new building with 10 exam rooms
– The new space may allow for an improved patient flow and an increase in
the amount of patient contacts per day.
Future Directions
• Overall, the medical clinic has been receptive to an integrated PCBH
practice model.
• Long term and ongoing goals include:
• measuring patient function (at least once per year)
• continuing with PCBH program outcome measurement (e.g.,
patient/provider satisfaction, fidelity to PCBH model)
• develop the business case for sustainability.
• Create a system in which patients recognize they have a “health team”
that cares for behavioral medical care needs.
Questions? Comments? Feedback?
Session Evaluation
Please complete and return the
evaluation form to the classroom monitor
before leaving this session.
Thank you!