Integrating Mental Health into Primary
Care: The BHL Model
VISN4-Healthcare Network
Department of Veterans Affairs
Where is Mental Health / Depression
Care Delivered
 Depression: FY 2002: 64% of all outpatient
depression visits for elderly occur in primary
care (only 25% by psychiatrists) (Harmon et al
2006)
 Nearly half of all antidepressants, sedatives,
and hypnotics were prescribed by a primary
care provider (20% of all antipsychotics)
(cdc.gov/nchs/data/series/sr_13/sr13_157.pdf)
2
UPENN / VISN 4 MIRECC
Alcohol Use Disorders
18
16
14
12
10
8
6
4
2
0
Alcohol Abuse/
Dependence
Alcohol
Dependence
Seeking
Treatment
Grant BF et al. Arch Gen Psychiatry. 2004;61:807-816.
SAMHSA, Office of Applied Studies. Substance Dependence, Abuse and Treatment Tables; 2003
IMS - MAT March 2006
3
UPENN / VISN 4 MIRECC
How is Care Provided?
 Key Facts:
• Depressive disorders are common
(10-15% prevalence)
• Less than 50% of patients have treatment initiated
• Less than 50% are adequately treated
• Rates of follow-up to new treatments (HEDIS) ~20%
4
UPENN / VISN 4 MIRECC
The Patient’s Perspective
Integrated
Care
Referral
Care
Odds Ratio
Depression
75 %
52 %
2.86 [2.26,3.61]
Anxiety
71 %
56 %
1.93 [0.69, 5.40]
At-risk Drinking
61 %
34 %
3.09 [2.07, 4.63]
Overall
71 %
48 %
2.84 [2.35, 3.43]
Engagement = at least one contact with the mental health specialist.
5
UPENN / VISN 4 MIRECC
The BHL Program
6
UPENN / VISN 4 MIRECC
So What’s the BHL Program?
 A clinical program providing prevention and treatment services
designed around the following principals:
• An emphasis on use of structure assessments and
algorithms
• An emphasis on the use of care management modules
• Patient centered care – incorporating convenience and
preference
• A focus on both patients and providers as the stakeholders
• A population based approach to care
• A focus on self- management and collaborative decision
making
• A focus on open access
7
UPENN / VISN 4 MIRECC
What are the (potential) parts?

Specialty Care (usually PhDs and MDs)
•
•

Care Management (BHSs usually RNs, SW)
•
•

Depression, Alcohol,(abuse and dependence), Anxiety , Pain, Smoking
Cessation, Referral Management (optimizing specialty care)
PTSD, Bipolar, Dementia
Prevention and Health promotion (mix RNs, SW, PhDs, counselors,
etc)
•
•
•
•
•
•
8
Consultative
Brief therapies
Watchful Waiting for subsyndromal symptoms
Problem solving therapy
Caregiver and family support
MOVE for weight
Education
Adherence
UPENN / VISN 4 MIRECC
Step 1
1. Identification and triage
9
•
•
•
•
•
Primary care screening
Primary care assessment
Self-referral
Outreach
Prescribing
•
Driving principal – we take anyone you are
concerned about.
UPENN / VISN 4 MIRECC
Initial Assessment Module
Philadelphia BHL data from 1/2008 to 1/2010
• 5626 referred
• 79% had a complete assessment
–
–
–
–
–
PTSD (85%)
Depression (81%)
MH and SA problems (79%)
Alcohol problems (76%)
Drug problems (71%)
• Only 7% refuse!
10
UPENN / VISN 4 MIRECC
Impressions from Initial Assessment
 Enormous range of psychopathology
 Greatly appreciated by patients
 Phone vs face to face – access or provider
comfort
 Greatly appreciated by primary care providers
 A great tool for research recruitment
11
UPENN / VISN 4 MIRECC
Step 2 – Treatment Options
Patient Identification
Screening / Clinical Assessment / Case-finding
Patient
Education
and Promote
Self-Care
Initial
Assessment
Initial triage /
treatment plan
Specialty Care Care Management
12
Prevention / Health
Promotion
No treatment
&
Refusal of care
UPENN / VISN 4 MIRECC
Optimizing Specialty Care
Referral Management
• Different methods of case finding lead to
different rates of complex patients.
 30-50% of patients may have psychosis, PTSD, Illicit drug use,
Severe depression, bipolar disorder, suicidal ideation
 Limited evidence for treating these patients in primary care
• Problem: Low rates of MH/SA treatment
engagement (30 – 40%)
13
UPENN / VISN 4 MIRECC
Zanjani F, Oslin D (2005). Telephone Based Referral-Care Management. Grant Supported by Philadelphia Veteran’s Affairs: Mental Illness Research Education and Clinical Center (MIRECC)
Referral Management
 Brief workbook based intervention designed
to enhance engagement in specialty MH/SA
services
 Focus
• Enhancing motivation
• Addressing practical issues
• Preparing the patient
14
UPENN / VISN 4 MIRECC
Referral Management Module
Attended 1st
Appointment
Motivational Session
70%
Control Group
32%
p = .006
15
UPENN / VISN 4 MIRECC
Zanjani F, Oslin D (2005). Telephone Based Referral-Care Management. Grant Supported by Philadelphia Veteran’s Affairs: Mental Illness Research Education and Clinical Center (MIRECC)
Care Management Modules
 Care Management is algorithm driven care
delivered by a Behavioral Health Specialist as
an adjunct to primary care.
•
•
•
•
•
•
16
Depression
Panic Disorder
Generalized Anxiety disorder
Alcohol Dependence
Pain
?PTSD
UPENN / VISN 4 MIRECC
Disease Management
Percent of Patients Achieving
Remission
50.0
% Remitted
40.0
30.0
Control
Intervention
20.0
10.0
0.0
4
8
Months Months
17
12
Months
18
24
Months Months
UPENN / VISN 4 MIRECC
Change in Depressive Symptomatology
over the Course of Monitoring (n=140)
11
Mean PHQ Score
10
9
8
7
6
5
4
Baseline
2 Weeks
6 Weeks
9 Weeks
Assessment
18
UPENN / VISN 4 MIRECC
First 12 weeks
 Issues addressed early
• 26% report non-adherence to treatment
• 12% report significant side effects
 22% managed (dose change or med change)
 53% symptom remission
19
UPENN / VISN 4 MIRECC
Alcohol Care Management
 Two components
• Non dependent
 Brief alcohol intervention - Time-limited (20
minutes in 1-3 brief sessions) and targets
alcohol misuse
• Dependent
Pharmacotherapy
Referral management
20
UPENN / VISN 4 MIRECC
Alcohol Care Management
 BHS meets with patient for 16 sessions over 6
months
 Collaborates with PCP to:
•
•
•
•
•
21
Increase motivation to abstain
Be supportive and optimistic
Naltrexone
Encourage AA attendance
Provide education (health risks and detrimental
outcomes)
UPENN / VISN 4 MIRECC
What patients said
 “I’ll take the chance on getting the nurses
help”
 “I have no interest in going back to the ARU, I
am not that sick”
 “I could use a med to help with my cravings”
22
UPENN / VISN 4 MIRECC
Preliminary Outcomes
 ACM
• 90% (55/61) had at least 1 face to face visit
• mean #visits = 10.2 (range 0-28)
23
UPENN / VISN 4 MIRECC
Prevention Services
 Sub syndromal anxiety and affective
disorders
• Most common treatment is an SSRI but no
evidence of efficacy
• Psychotherapy is time consuming and not without
risks
• Limited research on problem solving therapy and
other brief focused interventions
24
UPENN / VISN 4 MIRECC
Close Monitoring
 8 Weeks of prospective monitoring by
telephone using the PHQ-9
 Patient choice for treatment engagement is
also allowed
 Those with persistent symptoms or who
choose are enrolled in depression disease
management
25
UPENN / VISN 4 MIRECC
Study Results
 223 Subjects randomly assigned to WW (130)
or usual care (93)
 In the WW arm
• 81 (62%) no further treatment required
• Improved MH outcomes
• Improved Physical functioning
26
UPENN / VISN 4 MIRECC
What are the keys to success?
 A plan – including training, supervision, etc
 BHL software to promote measurement
based care and to provide decision support
and tracking
 Great staff
27
UPENN / VISN 4 MIRECC
Panel management
28
UPENN / VISN 4 MIRECC
Patient History
29
UPENN / VISN 4 MIRECC
Summary of Interview
30
UPENN / VISN 4 MIRECC
Patient and chart documents
31
UPENN / VISN 4 MIRECC
Implementation Factors

Facility
•
•
32
Small clinics may be collocated and collaborative just by size
Location – more rural clinics manage more BH in primary care

Leadership – very important to resource management

Access to Specialty care – factors into how complex cases are managed

Staff – highly variable on all sides

Scope – the more limited typically the less useful or hard to use

Method of case finding – screening, clinical exam, self referral leads to very different
case mixes and thus different program needs

Marketing and program description – what you are known for.

Resources and reimbursement
UPENN / VISN 4 MIRECC
Conclusions
 Depression and anxiety care management Works!
•
•
•
•
By telephone or face to face
Reduced mortality
Reduced symptoms
But not for complex patients
 Close monitoring Works!
• For subsyndromal depressive symptoms waiting and targeting
care management is effective
 Referral management Works!
• For complex patients with affective illnesses, substance abuse
or more other complex presentations.
 A Brief alcohol intervention Works!
• For patients without alcohol dependence
 Alcohol Care Management Very Promising!
• For patients with alcohol dependence
33
UPENN / VISN 4 MIRECC
Thank You
David Oslin, MD
Johanna Klaus, PhD
Elena Volfson, MD
Steve Sayers, PhD
Shahrzad Mavandadi, PhD
Health Specialists
Lisa Dragani, BSN, RN
Suzanne DiFilippo, RN
Trisha Stump, BSN, RN
Shani Simmons-Wilson, BSN, RN
Janet Sherry Cocozza, MA, RN, APN.C
Coordinator
Erin Ingram, BA
34
Health Technicians –
Megan Aiello, BS
Lauren Witte, BA
Victoria Farrow, BS
Kelly Stracke, BA
Natacha Jacques, MS
Chris Cardillo, BS
Henry Quattrone, BS
Lindsey Reid, BA
Brian Cox, BS
a host of others
Funders: NIH, VA, BCBS
UPENN / VISN 4 MIRECC
35
UPENN / VISN 4 MIRECC