Session # PC3
October 16, 2014
The Primary Care Behavioral Health Model (PCBH)
of Service Delivery: Clinical Skills, Effective
Interventions and Clinical Pathways
Christopher L. Hunter, PhD ABPP
Suzanne Bailey, PsyD
Patricia J. Robinson, PhD
Jeffrey T. Reiter, PhD, ABPP
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:
Learning Objectives:
● List the primary content areas for core competency development
● Describe 4 evidence-based primary care BH interventions for adults and children.
● Discuss at least 1 evidence-based clinical pathway that would work in most health
systems.
Practice Tools:
1. Know how to use the 5As paradigm to efficiently & effectively deliver evidencebased care.
2. Will have evidence-based assessment & intervention strategies for effective
adult, child & adolescent primary care behavioral health service delivery.
3. Understand what clinical pathway processes they can implement & how to
effectively implement them to improve the population impact of service delivery.
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Core Competencies
Patricia J. Robinson, PhD
Jeffrey T. Reiter, PhD, ABPP
Primary Care Behavioral Health Model
Behavioral Health Consultant
Core Competency Skills*
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I. Clinical Practice Skills
II. Practice Management Skills
III. Consultation Skills
IV. Documentation Skills
V. Team Performance Skills
VI. Administrative Skills
*Robinson & Reiter, 2014. Behavioral Consultation and Primary Care, 2nd Edition
Primary Care Behavioral Health Model
Behavioral Health Consultant Work
Sample Clinic: What To Expect
● Variety of methods for getting pt to the BHC
○ Before PCP
○ PCP and BHC in room together
○ After PCP
● Variety of problems and ages
○ Clinical (MH, SA, Beh Med, all ages)
○ Case management/Care coordination
● Variety in the goals of visits
○ PCP-Prep
○ Treatment augmentation
○ Medication and treatment planning.
Primary Care Behavioral Health Model
2014 Annual Conference
Sample Clinic
Complexity and Diversity
● 9:00 PCP wants meds rec
○ 52 y/o homeless, ? ADHD vs bipolar
● 9:30 Question re disability expiring
○ 64 y/o Russian-speaker, depression
● 10:00 PCP says “I don’t know her problem”
○ 62 y/o, psychiatrist d/c’d, on 3 meds from 3 Drs
● 10:30 Open→WH w/ PCP in exam room
○ 12 y/o autism, ADHD, recently showing tics, hall’s
Primary Care Behavioral Health Model
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Sample Clinic
Complexity and Diversity
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● 11:00 N/S→WH in exam room, PCP- prep
○ 6 y/o ADHD, insomnia, enuresis
● 11:30 Planned f/u from 1 week earlier
○ 20 y/o Spanish-speaker, depressed w/ SI
● 1:00 Team mtg (15-min talk on pain, 5-min on tobacco cessation)
● 2:00 Cx→same-day appt for NRT refill
Primary Care Behavioral Health Model
Sample Clinic
Complexity and Diversity
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● 2:30 Open→WH for CSA
○ 60 y/o severe etoh, chronic arm pain
● 3:00 Planned f/u after 2 weeks
○ 47 y/o homeless, MDD w/ psychosis, acute SI due to meds
● 3:30 Planned f/u after 1 month
○ 45 y/o homeless, MDD, trying to get disability
● 4:00 Cx→WH for PCP prep on new pt
○ 16 y/o expelled from school, needs risk assessmt
● 4:30 Open→Same-day f/u after 4 mos
○ 20 y/o seeking disability for PTSD, dep
Primary Care Behavioral Health Model
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The 5A’s An Operational Heuristic
Christopher L. Hunter, PhD, ABPP
Primary Care Behavioral Health Model
5A’s-Assess, Advise, Agree, Assist, Arrange
Operational Heuristic
Diagram adapted from: Glasgow, R. E & Nutting, P. A. (2004).
Diabetes. In Handbook of Primary Care Psychology. Ed., Hass, L. J. (pp. 299-311)
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Assess
Risk Factors, Behaviors, Symptoms,
Attitudes, Preferences
Advise
Arrange
Specify plans for
follow-up
(visits, phone calls,
mail reminders)
Specific, personalized,
options for tx, how sx
can be decreased,
functioning, quality of
life/health improved
Personal Action Plan
1. List goals in behavioral terms
2. List strategies to change health behaviors
3. Specify follow-up plan
4. Share plan with practice team
Assist
Provide information, teach
skills, problem solve
barriers to reach goals
Agree
Collaboratively select goals
based on patient interest and
motivation to change
Primary Care Behavioral Health Model
*
5A’s-Assess, Advise, Agree, Assist, Arrange
Operational Heuristic
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The 5A’s format is “strongly” recommended for
assessment and intervention across a range
of problems in primary care.
Whitlock, Orleans, Pender & Allen (2002). Evaluating
primary care behavioral counseling interventions: An
evidence-based approach. American Journal of Preventive
Medicine, 22, 267-284.
Goldstein, Whitlock, & DePue (2004). Multiple
behavioral risk factor interventions in primary care:
Summary of research evidence. American Journal of
Preventive Medicine, 27(Suppl 2), 61-79.
Primary Care Behavioral Health Model
5A’s-Assess, Advise, Agree, Assist, Arrange
Operational Heuristic
1.
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Introduction of behavioral health consultation service (1-2 minutes)
2. Identifying/Clarifying consultation problem (10-60 seconds)
Assess
3. Conducting functional analysis of the problem (12-15 minutes)
4. Summarizing your understanding of the problem (1-2 minutes)
5. Listing out possible change plan options (selling it) (1-2 minutes)
Advise
Agree
6. Starting a behavioral change plan (5-10 minutes)
Assist
Arrange
Primary Care Behavioral Health Model
5A’s-Assess, Advise, Agree, Assist, Arrange
Operational Heuristic
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Assess Phase
Introduction
● Purpose: the appointment
○ Tell Them Your Profession
○ Consultant Role
○ Structure of Appointment
○ Who will have what access to information gathered
Primary Care Behavioral Health Model
5A’s-Assess, Advise, Agree, Assist, Arrange
Operational Heuristic
Assess Phase
Functional Assessment
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Referral Question Clarification
○ Problem (Duration, Intensity, Frequency)
○ What Makes Problem Better or Worse
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What is the Functional Impairment
Work, Performance or Relationships
Family Relations
Social Activities
Recreational Activities
Exercise
Primary Care Behavioral Health Model
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5A’s-Assess, Advise, Agree, Assist, Arrange
Operational Heuristic
Assess Phase
Functional Assessment (continued)
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Changes In:
○ Sleep
○ Energy
○ Concentration, Appetite
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Risk Assessment
○ Suicidal Ideation
○ Homicidal Ideation
○ Thoughts of Death
Primary Care Behavioral Health Model
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5A’s-Assess, Advise, Agree, Assist, Arrange
Operational Heuristic
Assess Phase
Functional Assessment (continued)
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Caffeine Consumption
TOB Consumption
ETOH Consumption
OTC Medication or Supplements
What does a Typical Work Day Look Like
What does a Typical Week-End Look Like
Patient Ideas on Behavioral Goals
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BHC asks patient what one or two things they have control of that if they
changed would improve functioning or decrease symptoms
Primary Care Behavioral Health Model
5A’s-Assess, Advise, Agree, Assist, Arrange
Operational Heuristic
Assess Phase
Problem Summary (1-2 minutes)
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Clarifies the patient’s presenting problem
Builds empathy
Primary Care Behavioral Health Model
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5A’s-Assess, Advise, Agree, Assist, Arrange
Operational Heuristic
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Advise Phase
● Give clear, specific & personalized change advice
● Changes the pt might make & how those changes might be beneficial
Primary Care Behavioral Health Model
5A’s-Assess, Advise, Agree, Assist, Arrange
Operational Heuristic
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Agree Phase
Collaboratively Select Goals
● Find common ground & define behavior change & goals
● Shared decision making = Greater sense of personal control
Choices based on realistic expectations
Change matches patient values
Primary Care Behavioral Health Model
5A’s-Assess, Advise, Agree, Assist, Arrange
Operational Heuristic
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Assist Phase
● Develop and implement a specific tailored action plan
○ Plan should:
1. Help identify, address and overcome barriers
2. Develop self-management skills
3. Develop confidence to successfully change
Primary Care Behavioral Health Model
5A’s-Assess, Advise, Agree, Assist, Arrange
Operational Heuristic
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Arrange Phase
● Review goals
● Provide additional interventions
● Follow-up plan
○ Create easy return access
○ If pt is to f/u with community provider, bridge the gap...prevents pts
falling through the cracks!
Primary Care Behavioral Health Model
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Primary Care Interventions With Adults
Suzanne Bailey, PsyD
Primary Care Behavioral Health Model
Primary Care Interventions with Adults
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Overview
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Essential Components of Interventions
Intervention Framework
Population-based Interventions in Primary Care
○ Substance Use
○ Depression
Primary Care Behavioral Health Model
Interventions with Adults:
Essential Components
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● Brief Encounters
● Emphasis on Self-Management
● Focus on Functional Outcomes
● Flexible Follow-up
● Liaison with Specialty Services
Primary Care Behavioral Health Model
Essential Components:
Brief Encounters
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● Brief redefined
○ 15-30 minute visits
○ Limited number of contacts
○ Episodes of care within context of longitudinal PC
relationship
● Multiple change agents
● Patient is the primary agent of change
● Capture teachable moments
Primary Care Behavioral Health Model
Essential Components:
Emphasis on Self-Management
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● The patient is your guide
● Support with strategies
● Monitor level of engagement and motivation for change
● Provide behavioral rehearsal & resources
Primary Care Behavioral Health Model
Essential Components:
Focus on Functional Outcomes
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● Target improved functioning
● Symptom reduction is not the only target
● Follow the referral question
● Outcomes are measurable
Primary Care Behavioral Health Model
Essential Components:
Flexible Follow-up
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● Intervention unified and congruent with overall primary care plan
● Intervention plan is dynamic and evolves based on ongoing
assessment of symptoms, functioning, engagement, & motivation
● Flexible scheduling and follow-up strategies
● Conjoint and coordinated appointments
Primary Care Behavioral Health Model
Essential Components:
Liaison with Specialty Services
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● Primary care is first line
● Triage
● Psychoeducation about treatment options
● Build motivation and engagement
● Facilitate access and coordinate care
● Reabsorption
Primary Care Behavioral Health Model
Interventions with Adults:
Framework
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● Framework
● Define a Target
● Conduct Brief Intervention
● Assess Response to Intervention
● Develop Follow-up Plan
● Coordinate Care
Primary Care Behavioral Health Model
Framework:
An Initial BHC Visit
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Robinson & Reiter, 2014. Behavioral Consultation and Primary Care: A Guide to Integrating Services. See Chapter 9.
Primary Care Behavioral Health Model
Define a Target
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● Follow PCP referral
● Assess symptoms, functioning, and health behaviors
● Defined target focuses brief interventions
Primary Care Behavioral Health Model
Strategic Reframe
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● Distill core elements into a workable problem
○ Restate, reflect, refocus
● Be mindful of context, but stay focused on target
● Mirror and model the process
● Prioritize
Primary Care Behavioral Health Model
Target
Conceptualization
Context
Features of Effective Brief Interventions
● Solution focused
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● Targets specific behavior
change
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● Active and empathic
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therapeutic style
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● Support increase in quality
and meaning in life
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Incorporate patient values and
beliefs
Measurable outcomes
Enhance self-efficacy
Patient responsible for change
Primary Care Behavioral Health Model
Effective Brief Interventions
● Relaxation Skills
● Cognitive Therapy
Strategies
● ACT Strategies
● Motivational Interviewing
● Mindfulness Strategies
● Behavioral Structure and
Hygiene
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Goal Setting
Problem Solving Skills
Behavioral Activation
Stimulus Control
Communication Skills
Exercise
Solution Focused Strategies
Primary Care Behavioral Health Model
Factors to Consider
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Patient preference
Symptom severity
Readiness to change
Level of engagement
Psychosocial stressors
Co-morbid conditions
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Cultural beliefs
Resources
Health status
Health beliefs
Health literacy
Primary Care Behavioral Health Model
Assess Response to Intervention
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● Monitor level of motivation and confidence
● Monitor symptoms and functioning
● Active problem-solving
● Discuss obstacles
● Review and reinforce progress
Primary Care Behavioral Health Model
Follow-up Plan Options
Close
(1-2 weeks)
• Severity &
acuity of
problem
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Intermediate
(1 month)
• Clinical needs
of patient
• Overall primary
care plan
With PC Visits,
PRN, or None
• Level of
motivation and
engagement
• Clinical needs
of patient
Primary Care Behavioral Health Model
Care Coordination Options
Face-to-Face
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Phone
• Visit type &
timing
• Clinical needs
of patient
• Severity &
acuity of
problem
• Overall
primary care
plan
EHR
• Overall
primary care
plan
• Clinical needs
of patient
Primary Care Behavioral Health Model
Application: Population-Based Interventions 2014 Annual Conference
● Substance Use
● Depression
Primary Care Behavioral Health Model
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Substance Use:
Motivational Interviewing
Primary Care Behavioral Health Model
Target: Substance Use
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Enhance motivation to change
Use values to develop discrepancy
Provide psychoeducation
Identify strategies to avoid or cope with triggers
Build coping skills
Identify positive social supports and activities
Provide self-help resources (AA/NA)
Collaboratively develop a relapse prevention plan
Coordinate referral to more intensive treatment
Build motivation for engagement more intensive treatment
Primary Care Behavioral Health Model
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Depression:
Behavioral Activation
Primary Care Behavioral Health Model
Target: Behavioral Activation
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● Increase patient engagement in activities that
provide enjoyment and sense of accomplishment
● Behave first, feel later
○ “Outside-In”
● Act according to plan or goal, not feeling
Primary Care Behavioral Health Model
Behavioral Activation in Primary Care
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● Step 1. Rationale.
○ Explain that when we feel down, we sometimes stop doing many
activities that we used to like to do
● Step 2. Select activities that increase and sense of mastery
○ Ask the patient about activities they used to enjoy and any activities
they already do but would like to do more often
○ Ask if there is something that they need to do they’ve been avoiding
● Step 3. Review, Reinforce, Reset
○ In follow up visits, the BHC reviews progress on goals, reinforces
progress, problem-solves barriers to progress, and resets goals as
needed.
Primary Care Behavioral Health Model
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Primary Care Interventions With
Children and Adolescents
Patricia J. Robinson, PhD
Primary Care Behavioral Health Model
*
2014 Annual Conference
Primary Care Behavioral Health Model
Pediatric PCBH Services: SUPPORT Study
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1. Significant increase identification of psychiatric, health-related,
or phase of life problems among children
2. Significant increase in pediatrician documentation of behavioral
issues addressed
3. Significant increase in appointment show rate among SUPPORT
participants compared to non-participants
4. Parent/child satisfaction with SUPPORT services
5. Significant increase in child functioning as measured by
Child Behavior Checklist
Pediatric Quality of Life
School Grades & Attendance
Primary Care Behavioral Health Model
Aims & Objectives
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6. Significant decrease in hospitalization/breathing problems among
children with asthma/respiratory disorders.
7. Significant decrease in weight & body mass index among obese
children.
8. Significant decrease in Hemoglobin A and Fasting Blood Sugar
(FBS) among children with diabetes.
9. Significant decrease in office visits and school absence among
children with multiple somatic complaints.
Primary Care Behavioral Health Model
Provider Satisfaction
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● One month after implementation of
Overall Clinical Skills Mean Satisfaction by Region
SUPPORT, Pediatricians and
office staff were very satisfied with
Sample
the overall clinical skills of the
Region
Size
Mean
SUPPORT therapist.
Ft. Worth (Cook Children’s)
52
1.48
● Also, 74.5% strongly agreed that
Dallas (Parkland)
40
1.22
integration of the BH provider
San Antonio
50
1.32
enhanced the practice’s efficiency.
Lubbock
7
1.00
El Paso
34
1.38
Valley
18
1.06
Mean Range: 1 (very satisfied) to 5 (very
dissatisfied)
Primary Care Behavioral Health Model
Clinical Improvements for Multiple Problems 2014 Annual Conference
Children 18 months to 5 years
Significantly fewer problems on the
Child Behavior Checklist at 3-month F-U
Primary Care Behavioral Health Model
Clinical Improvements for Multiple Problems 2014 Annual Conference
Children 6 – 18 years
Significantly fewer problems on the
Child Behavior Checklist at 3-month follow-up
Primary Care Behavioral Health Model
Components of an Initial BHC Visit
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Robinson & Reiter, 2014. Behavioral Consultation and Primary Care: A Guide to Integrating Services. See Chapter 9.
Primary Care Behavioral Health Model
·
Interview & Intervention Skills
Life Context Questions for
Children and Teens (see pdf)
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Functional Analysis Questions
(see pdf)
Primary Care Behavioral Health Model
A Great Intervention for Adolescents & Adults
Bulls Eye Plan: Prevention & Intervention
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Values Clarification
Values Connection
Approach (not avoidance)
Perspective taking (observer
stance)
● Supports on-going planning
● Involves SMART goals
See Robinson, Gould, & Strosahl, 2010. ● Encourages PCMH team support of
Real Behavior Change in Primary Care:
committed health promoting
Improving Outcomes and Increasing
actions over time
Satisfaction
Primary Care Behavioral Health Model
RX Pad for PCBH Team: Preventive and
On-Going Management of Chronic Pain
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Your Clinic
Your Phone Number
Love
Work
Play
Plan: _________________________________________________
______________________________________________________
______________________________________________________
Primary Care Behavioral Health Model
FACT Worksheet
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Overview of worksheet
Role Play set up
During role play, use Worksheet as if you were the BHC
After role play, work with partner: Conceptualize
powerful interventions
Is patient clear about values? connected to values?
Engaged in life? Accepting of challenges? Able to defuse?
Can shift from participant to observer perspective?
Primary Care Behavioral Health Model
Components of A Follow-Up BHC Visit
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Primary Care Behavioral Health Model
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Clinical Pathways
Christopher L. Hunter, PhD ABPP
Patricia J. Robinson, PhD
Jeffrey T. Reiter, PhD, ABPP
Primary Care Behavioral Health Model
*
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Clinical Pathways: The Military Health System
Christopher L. Hunter, PhD ABPP
Primary Care Behavioral Health Model
Military Health System
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What Is A Clinical Pathway?
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Method of pt screening/assessment/intervention for a well-defined
group of people
States the goals and key elements of care
Based on Evidence Based Medicine guidelines, best practice and
patient expectations by facilitating the communication, coordinating
roles and sequences of multidisciplinary care team activities.
Goal is to improve quality of care, reduce risks, increase pt satisfaction
and increase the efficiency in the use of resources
Primary Care Behavioral Health Model
Military Health System
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Developed by behavioral health and physician PCMH leads
Designed to increase use of BHCs as part of standard care
Designed to improve pt outcome & pt & PCP satisfaction with care
9 Pathways developed
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Alcohol Misuse
Anxiety
Depression
Diabetes
Obesity
Chronic Pain
PTSD
Sleep Problems
Tobacco Use
Primary Care Behavioral Health Model
2014 Annual Conference
Clinical Pathways: Neurodevelopmental Screening
Patricia J. Robinson, PhD
Primary Care Behavioral Health Model
Neurodevelopmental Screening Pathway
2014 Annual Conference
● Target: Children 18-24 months
● Methods: Exam Room Poster, Well-Child Visits
● Objectives:
○ Increase early screening
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Increase child and family access to BHC services
Address behavioral concerns at primary care level as possible
Improve relationships with community partners
Provide earlier referrals to community resources
Improve parent satisfaction
See PDFs:
M-CHAT EXAM ROOM POSTER
N-D Dev Pathway Statement
Template for charting ASQ
Primary Care Behavioral Health Model
2014 Annual Conference
Clinical Pathways: Chronic Pain
Jeffrey T. Reiter, PhD, ABPP
Primary Care Behavioral Health Model
Overview: Chronic Pain and Opioids
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● Participants: Patients considered for long-term opioid
treatment
● Goals:
○ improve functioning
○ decrease opioid abuse
● Core Pathway Components:
○ Initial risk assessment stratifies care protocol
○ Process for regular CSA, planned UDS
○ Group/class substitutes for PCP visit
Primary Care Behavioral Health Model
Assessing Risk of Medication Abuse
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● Commonly used paper-and-pencil screens
○ SOAPP, ORT
○ Aberrant behavior checklist
● Urine drug screen (UDS) at 1st visit—matches hx?
● Substance use hx
● Review old records
○ Problems w/ past Drs? Inconsistent history?
Primary Care Behavioral Health Model
Controlled Substance Agreements (CSA)
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● Purposes of a CSA
○ Decrease: abuse/diversion, self-dosing, urgent pt calls, conflicts
w/ staff, early RF
○ Increase: discussion about meds issues, PCP satisfaction
● Components of a helpful agreement
○ Education, conditions for RF, functional goals
● Important to use routinely (not after a problem is suspected)
Primary Care Behavioral Health Model
Group Workflow
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Weekly class, different time each week
PCPs notified in advance of patients attending
Check-in begins 30 mins prior to group
Lab tech obtains UDS
BHC conducts group for 45 mins
Pts return to lobby
BHC checks UDS results, confers with PCP as needed
Pts retrieved for brief PCP visit for refill only
Primary Care Behavioral Health
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QUESTIONS?
Primary Care Behavioral Health Model
Bibliography / Reference
2014 Annual Conference
1. Hunter, C. l., Goodie, J. l., Oordt, M. S. & Dobmeyer, A. C. (2009). Behavioral Health in
primary care: A practitioners handbook. Washington, DC: American Psychological
Association
1. Nash, J. M., Khatri, P., Cubic, B. A., Baird, & Macaran, A. (2013). Essential competencies
for psychologists in patient centered medical homes. Professional Psychology: Research and
Practice, Vol 44(5), 331-342.
1. Robinson, P. J., & Reiter, J. D. (2014). Behavioral Consultation in Primary Care: A Guide
to Integrating Services. NY: Springer.
1. Robinson, P. J., Gould, D. A., & Strosahl, K. (2011). Real Behavior Change in Primary
Care: Improving Outcomes and Increasing Job Satisfaction. Oakland: New Harbinger.
1. Strosahl, K. D., Robinson, P. J., & Gustavsson, T. (2012). Brief Interventions for Radical
Change. Oakland: New Harbinger.
Learning Assessment
• A learning assessment is required for CE credit.
• A question and answer period will be conducted at the end of this
presentation.
Session Evaluation
2014 Annual Conference
Please complete and return the
evaluation form to the classroom monitor
before leaving this session.
Thank you!