Integrating Behavioral Health Care
into the
Navy Medical Home Port
(Patient Centered Medical Home)
Patricia C. Hasen, CDR, NC, USN
Rocio Porras, LT, NC, USN
Family Medicine Department
Naval Hospital Camp Pendleton
AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort
1
Disclosure / Disclaimer
LT Rocio Porras and CDR Patricia Hasen
have nothing to disclose.
The views and opinions expressed during
this presentation do not necessarily reflect
those of Naval Hospital Camp Pendleton,
the Department of the Navy or the
Department of Defense.
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AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort
Objectives
1. Define Behavioral Health and Health.
2. Verbalize the rationale for integrating Behavioral Health (BH) in the
Patient Centered Medical Home (PCMH)
3. Discuss how integration of BH is in alignment and consistent with
principles of the PCMH, the Quadruple Aim and the MHS.
4. Discuss the benefits of integrating BH in the PCMH.
5. Compare and contrast the three models of BH integration in the
PCMH Describe how to build BH in your clinic.
6. Verbalize required elements for successful integration of behavioral
health in an outpatient clinic setting.
7. Verbalize principles for leading and managing change
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AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort
Define Behavioral Health
and Health
BEHAVIORAL HEALTH
• “is integral to overall
health as mind and body
are inseparable. As a
general concept,
behavioral health is the
reciprocal relationship
between human behavior
and the well-being of the
body, mind, and spirit,
whether considered
individually or as an
integrated whole.” (PCPCC, 2012)
HEALTH
• “Health is a state of
complete physical,
mental and social wellbeing and not merely
the absence of disease
or infirmity.”(WHO,
1946)
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AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort
“…she was a little startled by
seeing the Cheshire Cat sitting
on a bough of a tree a few
yards off...”
‘Would you tell me, please,
which way I ought to go from
here?’
‘That depends a good deal on where you want
to get to,’ said the Cat.
‘I don’t much care where ’ said Alice.
‘Then it doesn’t matter which way you go,’ said
the Cat.
‘ so long as I get somewhere,’ Alice added as an
explanation.
‘Oh, you’re sure to do that,’ said the Cat, ’if you
Cat pictures (screencaps) from Disney's Alice I
only walk long enough.’ Cheshire
in Wonderland. Image Source Page: http://www.alice-inwonderland.net/pictures/cheshire-cat-pictures.html
(Carroll, 1865)
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AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort
Strain of Past
Decade of War
U.S. Marine Corps photo by Cpl. Reece Lodder. Taken 19 April
2012. http://www.flickr.com/photos/40927340@N03/6963905442/
U.S. Marine Corps photo by Cpl. Alfred V. Lopez. Taken 22 April 2012.
http://www.flickr.com/photos/40927340@N03/6963905682/
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AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort
A Military Readiness
Concern
U.S. Marine Corps photo by Cpl. Vanessa American Horse. Taken 2 April
2012. http://www.flickr.com/photos/40927340@N03/7044870495/
U.S. Marine Corps photo by Sgt. Mark Fayloga. Taken 19 Feb 2012.
http://www.flickr.com/photos/40927340@N03/6776118198/
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AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort
Whom We Serve
Over 9.6 Million Beneficiaries
Program Enrollment
• Beneficiaries by Category
•
– Active duty: 1.7 million
– Active duty family: 2.4 million
– Retirees: 1 million
•
– Retiree family: 1.8 million
•
– Medicare-eligible: 2.1 million
5.4 million TRICARE Prime
o 3.7 mil in direct care system
o 1.7 mil in contractor networks
2.1 mil TRICARE Standard/Extra
Others use TRICARE Reserve
Select, TRICARE For Life
Source: TMA, 2011.
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AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort
Rationale for Integrating
Population Health
•30.5% US adult population meets criteria for one or more mental
health problems (estimated for a 1-year period) and only 32% of these
receive treatment (Kessler, et. al., 2005).
• 12-27% of US pediatric population meet behavioral health problem
criteria (Simonian, 2006; Sakolsky & Birmaher, 2008)
• 11-17% of OEF/OIF combat veterans met BH screening criteria
(Hoge, et. al., 2004)
• 80% of BH problems in US youths are not identified or treated
(Teen Screen, 2011)
• MH problems are 2-3 times more common in patients with chronic
health problems (Katon, 2007; Dowrick, et al., 2005)
• Half of all life-time BH disorders start by age 14 (TeenScreen, 2011)
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AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort
Rationale for Integrating
Readiness
•52% of all BH treatment occurs in Primary Care (Kessler, et al., 2005)
•48% of all psychotropic drug visits occur in PC (Pincus, et al., 1998)
•80% with BH disorder visit Primary Care at least once a year (Narrow,
et al., 1993)
•11-17% of OIF/OEF combat veterans met BH screening criteria; only
38-45% indicated an interest in receiving help; only 23-40% reported
received professional help in the past (Hoge, et al., 2004)
• 32% (average) of Military Health System beneficiaries report
difficulties accessing BH care (HCSDB, 2008; TMA, 2009)
• 64% (average) of MHS beneficiaries report difficulties accessing
urgent BH care (HCSDB, 2008; TMA, 2009)
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AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort
Rationale for Integrating
Per Capita Costs
•
•
•
•
•
•
Mental health conditions 3rd costliest medical condition (AHRQ,
2009)
33.2% of adults being treated for BH concerns receive minimally
adqequate care (Wang, et al., 2005)
30-50% of referrals from PC to outpatient BH clinic don’t make 1st
appt (Fisher & Ransom, 1997; Hoge, et al., 2006)
84% of the time, the 14 most common physical complaints have no
identifiable organic etiology (Kroenke & Mangelsdorf, 1989)
40% of premature deaths in the US are from behavioral factors
(Kindig & McGinnis, 2007)
Lower costs – medical use decreased 15.7% for those receiving
BH treatment and increased 12.3% for controls who did not receive
BH treatment (Chiles, Lambert & Hatch, 1999)
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AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort
Rationale for Integrating
Source: MHS 2012 Stakeholder’s Report
http://mhs.osd.mil/About_MHS/StakeholdersR
eport.aspx
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AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort
Determinants of Health
Source: MHS 2012 Stakeholder’s Report
http://mhs.osd.mil/About_MHS/StakeholdersR
eport.aspx
The actual causes of
illness and death in the
United States often
relate to personal
behaviors that the health
care system fails to
address. To achieve our
transformation from
healthcare to health, we
will have to learn better
ways to help people
adopt a healthier
lifestyle. In the near
term, we will focus on
ways to reduce obesity
and reduce tobacco use.
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AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort
Rationale for Integrating
Experience of Care
•Better access to BH services
•Stigma-free BH access
•Better health outcomes
•Improved satisfaction
•Ongoing education to Medical Home teams and residents
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AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort
Rationale for Integrating
Current military environment
–
–
–
–
–
–
–
Stigma
Family Readiness affects Military Readiness
Strain of past decade of war
Lack of BH capacity in MTF for Family members
Lack of community capacity for Family members
Lack of providers who accept TRICARE
Cultural gap between military and civilian providers
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AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort
Summary of Rationale for
Integrating
• BH problems are common
• Complex inter-relationship between physical and psycho-social
symptoms
• PC is largest platform for health care delivery in the US
• PC is the defacto BH treatment platform
• BH problems often go unrecognized in PC
• When recognized, treatment is often suboptimal
• BH problems compromise the quality and outcomes of treatment for
physical health conditions
• The leading preventable cause of premature death is behavior
• Appropriate BH treatment can alleviate impediments to well-being
• BH treatment can assist in building resiliency and maintaining
military readiness
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AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort
Benefits of Integration
When BH is integrated in the PCMH:
•Less stigma - patients prefer to be seen at PCMH rather than specialty
clinic
•Better coordination - shorter wait times and better communication
•Reduce morbidity with early recognition and treatment
•Serve all patients - opportunity for prevention
•Integration of physical and emotional care
•Integrate screening and brief psychosocial update into visit - improved
screening, recognition, identification, early intervention, treatment,
monitoring
•Conduct an assessment alone or collaboratively
•Overcome barriers to seeking mental health care
•Skills to build resilience, promote healthy lifestyles
•Improves Military Readiness
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AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort
Illustration in PC Morning Clinic
56 yo diabetic with poor control
19 yo smoker for P.E.
33 yo with multiple somatic complaints
7 yo for earache
67 yo w/insomnia
70 yo w/sinusitis
52 yo hypertensive patient for f/u
45 yo w/tinnitus
38 yo w/acute asthma
29 yo w/chest pain & SOB
Source: Blount, http://www.massleague.org/Calendar/LeagueEvents/BehavioralHealthConference/BlountIntegratedPrimaryCareStories.pdf
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AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort
Example with Highlighted
Mental Health Needs
•
•
•
•
•
•
•
•
•
•
56 yo diabetic with poor control
19 yo smoker for P.E.
33 yo w/ multiple somatic complaints
7 yo for earache
67 yo w/insomnia
70 yo w/sinusitis
52 yo hypertensive patient for f/u
45 yo w/tinnitus
38 yo w/acute asthma
29 yo w/chest pain & SOB
• Old Dx BPD
• Depression
•
Alcohol abuse
•
Panic disorder
Source: Blount, http://www.massleague.org/Calendar/LeagueEvents/BehavioralHealthConference/BlountIntegratedPrimaryCareStories.pdf
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AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort
Example with Highlighted
Psychosocial Distress
• 56 yo diabetic with poor control
• 19 yo smoker for P.E.
• 33 yo with multiple somatic
complaints
• 7 yo for earache
• 67 yo w/insomnia
• 70 yo w/sinusitis
• 52 yo hypertensive patient for f/u
• 45 yo w/tinnitus
• 38 yo w/acute asthma
• 29 yo w/chest pain & SOB
• Anxious (Old Dx BPD )
• (Depression)
• Bedwetting
• (Alcohol abuse)
• Family violence
•
Hypochondriasis
• (Panic disorder)
Source: Blount, http://www.massleague.org/Calendar/LeagueEvents/BehavioralHealthConference/BlountIntegratedPrimaryCareStories.pdf
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AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort
Example with Highlighted
Behavioral Health Needs
• 56 yo diabetic with poor control
• 19 yo smoker for P.E.
• 33 yo with multiple somatic
complaints
• 7 yo for earache
• 67 yo w/insomnia
• 70 yo w/sinusitis
• 52 yo hypertensive patient for f/u
• 45 yo w/tinnitus
• 38 yo w/acute asthma
• 29 yo w/chest pain & SOB
• Smoking/weight loss (Anxious;
Old Dx BPD )
• Smoking cessation
• (Depression)
•
•
•
•
•
•
•
(Bedwetting )
(Alcohol abuse)
(Family violence )
Cardiac risk factors
(Hypochondriasis)
Medication compliance
(Panic disorder)
Source: Blount, http://www.massleague.org/Calendar/LeagueEvents/BehavioralHealthConference/BlountIntegratedPrimaryCareStories.pdf
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AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort
Integration is Consistent with
Joint Principles of the PCMH
– Personal Physician
– Physician-directed Medical Practice
– Whole Person Orientation
– Care is Coordinated and/or Integrated
– Quality and Safety
– Enhanced Access
– Payment Reform
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AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort
Integration is Consistent
with the Quadruple Aim
•
•
•
•
Readiness
– Pre- and Post-deployment
– Family Health
– Behavioral Health
– Professional Competency/Currency
– Delivering the Right Care at the Right Time
Population Health
– Healthy service members, families, and retirees
– Quality health care outcomes
– Prevalence of BH conditions in PC
A Positive Patient & Staff Experience
– Patient and Family centered Care, Access, Satisfaction
Cost
– Responsibly Managed
– Focused on value
– Cost of unmet needs; decreased costs when address
BH needs
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AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort
Integration is Consistent
with the MHS Mission
• Provide optimal health
services in support of our
nation’s military mission—
anytime, anywhere.
• DoD Mission To provide
the military forces needed
to deter war and to
protect the security of our
country.
Source: MHS.
http://www.health.mil/About_MHS/Organizations/MHS_Offices_and_Programs/
OfficeOfStrategyManagement.aspx
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AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort
3 Models of Integration
1. Care Management Model
2. Primary Care Behavioral Health Model
3. Blended Model
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AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort
Care Management Model
• Population-based model of care typically focused on a
discrete clinical problem (e.g., depression).
• It incorporates specific pathways to systematically
address how BH problems are managed in PC.
• PC providers & care managers share information via
direct communication, shared medical record, treatment
plan, and standard of care.
• Typically, there is some form of systematic interface with
the outpatient mental health
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AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort
Primary Care Behavioral
Health Model
• Population-based model of focused on all enrolled patients (e.g.,
depression, anxiety, substance use, stress, obesity, diabetes,
insomnia, chronic pain)
• BHC is embedded with PC team serving as a team member in the
assessment, intervention & health care of the patient
• BHCs & PCMs share patient information, medical record &
coordinate health care plans
• Brings a team-based management approach to care
• BHC helps PC team improve BH assessment & intervention
• BHC sees patients in 15-30 minute appointments in PC clinic
• Same day as well as scheduled appointment availability
• BHC focuses on full range of BH & health behavior change
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AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort
Blended Model
• Focused on all enrolled patients
• Care Manager and Embedded BHP
oContinuity of Care
oStepped Care
oAccess to all enrollees to BHC in the
PCMH
oClinical Feasibility and Efficiency
oImplements DoD/VA guidelines
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AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort
Re-Engineering Healthcare
Integration Programs (REHIP)
From: REHIP https://www.pdhealth.mil/education/2011_Presentations/AFPCH%2011%20Re-Engineering%20Healthcare.pdf
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AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort
Blended Model
From: REHIP https://www.pdhealth.mil/education/2011_Presentations/AFPCH%2011%20Re-Engineering%20Healthcare.pdf
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AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort
Building BH into Your Clinic
•
•
•
•
Educate yourself – read your instructions, support documents
Educate your staff
Staffing ratios
Facilities – patients seen in the exam room; common check-in
areas; BH providers imbedded into the PCMH; can share office
spaces with other providers
• Administrative support
– Templates, business operations, position descriptions, 4th level
MEPRS, coding, POM, documentation
– Ancillary support staff support
– Handling referrals
– Referrals to MH
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AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort
Building BH into Your Clinic
• Training primary care providers and staff in prevention, recognition,
management, and referral of adult and pediatric patients with social
and emotional concerns is essential to fully integrating Behavioral
Health into Primary Care
• Required skills of the Behavioral Health providers
• Training program
– Phased training program through BUMED by qualified trainers
– Didactic and practicum
– Phase I – self guided, didactic
– Phase II – Didactic, In Vivo, Feedback (San Antonio, July 2012)
– Phase III – (6 mo following Phase II), Sustainment training, site
visits
• Monthly teleconferences with other BH personnel
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AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort
Principles for Leading &
Managing Change
• Leading and managing change
– Involve the stakeholders – that is the entire staff – in who, what,
where, when of integration, accessing BH, utilizing BH
– Communicate, communicate, communicate – early and often
– Delineate roles
– Set up business plan – templates, coding, referral management,
appointing, develop patient registry
– Care Coordination
– Celebrate victories
• Lessons learned
• Outcomes/Metrics/Dissemination
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AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort
8-Step Process for
Leading Change
1.
2.
3.
4.
5.
6.
7.
8.
Create urgency
Form a powerful coalition
Create a vision for change
Communicate the vision
Remove obstacles
Create short-term wins
Build on the change
Anchor the changes in corporate culture
Source: Kotter, J. (1996). Leading Change. Boston: Harvard Business School Press.
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AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort
References
AHRQ. (2009). Heart Conditions, Cancer, Trauma-related Disorders, Mental disorders, and Asthma Were
the Five Most Costly Conditions in 1996 and 2006. AHRQ News and Numbers, August 5, 2009.
Blount, A. (unk). What Does a Behavioral Health Clinician Add in a Primary Care Practice?: A Set of Stories.
Available at http://www.massleague.org/Calendar/LeagueEvents/BehavioralHealthConference/BlountIntegratedPrimaryCareStories.pdf
Carroll, L. (1865) Alice’s Adventures in Wonderland. London: Macmillan and Company. Available at
http://www.readcentral.com/chapters/Lewis-Carroll/Alices-Adventures-in-Wonderland/003
Chiles, J., Lambert, M., & Hatch, A. (1999). The impact of psychological interventions on medical cost offset:
A meta-analytic review. Clinical Psychology: Science and Practice, Vol., 6, pp. 204-220.
Croghan, T. W. and Brown, J. D. (2010) Integrating Mental Health Treatment Into the Patient Centered
Medical Home. (Prepared by Mathematica Policy Research under Contract No. HHSA290200900019I
TO2.) AHRQ Publication No. 10-0084-EF. Rockville, MD: Agency for Healthcare Research and Quality.
Available at
http://pcmh.ahrq.gov/portal/server.pt/gateway/PTARGS_0_12547_955657_0_0_18/Integrating%20Ment
al%20Health%20and%20Substance%20Use%20Treatment%20in%20the%20PCMH.pdf
Dowrick, C., Katona, C., Peveler, R., and Lloyed, H. (2005) Somatic Symptoms and Depression: Diagnostic
Confusion and Clinical Neglect. British Journal of General Practice, pp. 829-830. Available at
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1570790/pdf/bjpg55-829.pdf
Fisher, L., & Ransom, D. (1997). Developing a strategy for managing behavioral health care within the
context of primary care. Archives of Family Medicine, Vol. 6, Issue 4, pp. 324-333.
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AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort
References
HCSDB. (2008). MHS Beneficiaries’ Access to Behavioral Health Care Issue Brief, Health Care
Survey of DoD Beneficiaries (HCSDB), July 2008. Available at
http://www.tricare.mil/survey/hcsurvey/issue-briefs/issuebriefQ4FY08.pdf
Hoge, C., Auchterlonie, J., and Miliken, C. (2006). Mental health problems, use of mental health
services, and attrition from military service after returning from deployment to Iraq or Afghanistan.
Journal of American Medical Association, Vol. 295, Issue 9, pp. 1023-1032. Available at
http://jama.ama-assn.org/content/295/9/1023.full.pdf+html
Hoge, C., Castro, C., Messer, S., McGurk, D., Cotting, D. and Koffman, R. (2004). Combat duty in Iraq
and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine,
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Katon, W., Lin, E., and Kroenke, K. (2007) The Association of Depression and Anxiety with Medical
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Medicine. Vol 352, No 24, pp. 2515-23. Available at
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Kotter, J. (1996). Leading Change. Boston: Harvard Business School Press.
Kroenke, K. & Mangelsdorff, D. (1989). Common symptoms in ambulatory care: Incidence, evaluation,
therapy and outcome. American Journal of Medicine. Vol. 86, pp 262–266.
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AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort
References
Kindig, D. & McGinnis, J. (2007). Determinants of U.S. population health: Translating research into
future policies. Altarum Policy Roundtable Report. 28 Nov 2007; Washington, D.C. Available at
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Narrow, W. E., Regier, D. A., Rae, D. S., Manderscheid, R. W., Locke, B. Z. (1993) Use of Services by
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PC-PCC. (2012) Behavioral Health Defined. Available at http://www.pcpcc.net/behavioral-health.
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(1998) Prescribing Trends in Psychotropic Medications: Primary Care, Psychiatry, and Other
Medical Specialties. The Journal of the American Medical Association, Vol 279, Issue 7, pp. 526531. Available at http://jama.ama-assn.org/content/279/7/526.full.pdf+html
TMA. (2009). Health Care Survey of DoD Beneficiaries 2009 Annual Report. Sept 2009.Available at
http://www.tricare.mil/survey/hcsurvey/downloads/hcsdb-2009-20090910.pdf
TMA. (2011) The Evaluation of the TRICARE Program: Fiscal Year 2011 Report to Congress. Available
at http://www.tricare.mil/tma/StudiesEval.aspx
Sarkolsky, D., & Birmaher, B. (2008) Pediatric Anxiety Disorders: Management in Primary Care.
Current Opinion In Pediatrics, Vol 20, pp. 538-543.
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AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort
References
Simonian, S. J. (2006). Screening and Identification in Pediatric Primary Care. Behavior Modification.
Vol 30, pp. 114-131.
TeenScreen . (2011) TeenScreen Primary Care Fact Sheet: Research Supporting the Integration of
Mental Health Checkups Into Adolescent Health Care. National Center for Mental Health
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Wang , P., Berglund, P., Olfson , M., Pincus, H., Wells, K. and Kessler, R. (2005). Failure and Delay in
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http://archpsyc.ama-assn.org/cgi/reprint/62/6/603
Wang, P., Lane, M., Olfson, M., Pincus, H., Wells, K. and Kessler, R. ( 2005) Twelve-Month Use of
Mental Health Services in the United States: Results from the National Comorbidity Survey
Replication. Archives of General Psychiatry, Vol 62, pp. 629-640. Available at http://archpsyc.amaassn.org/cgi/reprint/62/6/629.pdf
WHO. (1946) Preamble to the Constitution of the World Health Organization as adopted by the
International Health Conference, New York, 19-22 June, 1946.
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AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort
Questions & Comments
CDR Patricia C. Hasen, NC, USN
patricia.hasen@med.navy.mil
dgflightnurse@hotmail.com
760-908-9568
LT Rocio Porras, NC, USN
rocio.porras@med.navy.mil
760-725-0952
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AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort