Behavioral Medicine: The Future of
Behavioral Health Integration
Sheila North, LMFT,
Executive Director
Chris Farentinos, MD, MPH, CADC II,
Chief Operating Officer
Behavioral Medicine
• Behavioral Medicine (BM) is an
interdisciplinary field of medicine concerned
with the development and integration of
behavioral and biomedical science knowledge
and technics relevant to health and illness, and
the application of this knowledge and technics
to prevention, diagnosis, treatment and
rehabilitation. (Yale Conference on Behavioral Medicine Schwartz
and Weiss, 1978)
Behavioral Medicine
• BM has expanded its area of practice to
interventions with providers of medical services
• Provider behavior influences patient outcomes
• Quality of relationship and communication
between clinician and patient
• Other areas: Clinicians attitudes; bias toward
illness as opposed to wellness
Society of Behavioral Medicine (SBM)
• “Better health through behavioral change”
• 34th annual meeting in San Francisco in March
2013
Society of Behavioral Medicine 2013
• Adherence – theoretical and practical methods
for adherence
• Behavioral treatments for chronic diseases –
improved self-efficacy and self-regulatory skills
• Bio-behavioral mechanisms
(psychoneuroimmunology, psychophysiology
such as cardiovascular reactivity)
• Health communication
Jon Kabat-Zinn
• Professor of Medicine and Director of the Stress Reduction
Clinic and the Center for Mindfulness in Medicine, Health Care,
and Society at the University of Massachusetts Medical School
• Kabat-Zinn is student of Zen Buddhism.
• He integrates Buddhist teachings Western science.
• A mindfulness based stress reduction program created by Kabat-Zinn
is offered at medical centers, hospitals, and HMOs.
Health Literacy Conference (Legacy)
March 2013, Portland OR
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Health care reform and health literacy
Health disparities
“Plain language”
“Teach back”: two-way communication
Community health workers and health literacy
Health communication in cultural competence
Balancing Budget
• Cut people from care
• Cut provider rates
• Cut services
• “We either improve or we cut”
(Don Berwick, former Director for CMMI)
Triple Aim
(Quadruple Aim)
Better Health
Better Care - Improve Patient Experience
Reduce Costs
Equity
11
Inverting the Cost Pyramid
Current Configuration
Desired Configuration
Acute Care
Acute Care
Specialty Care
Prevention and
Primary Care
Specialty Care
Prevention and Primary Care
Focus
Medical Care
10%
Human
Biology 30%
Environmental
5%
Lifestyle &
Behavior 40%
Social
Determinants
15%
Cost of Behavioral Health
25% of CareOregon’s patients account for 83% of
CareOregon’s adult medical costs. This group’s most
common health problems (CareOregon data, 2011):
1) 35% Asthma
2) 30% Drug and Alcohol Problems
3) 24% Diabetes
4) 17% Complex Mental Illness
5) 14% Chronic lung disease and Congestive Heart
Failure
Cost of Substance Use Disorders
Individuals with SUD incur between two (Parthasrathy et
al., 2001) and three (McAdam-Marx et al., 2010; Thomas
et al., 2005) times the total medical expenses of people
who do not have SUD.
Payment Reform
•Fee for service
•Pay per volume
•Pay for value
•Pay for performance
(OHA) Oregon Metrics and Scoring Committee – CCO Performance
Michael Bailit October 10, 2012
1.
2.
3.
4.
5.
6.
7.
8.
CAHPs Composite (7Qs)
Rate of PCPCH enrollment
ED Utilization (HEDIS)
Initiation and Engagement of AOD
Follow-up after hospitalization for mental illness
Composite measure: mental health and physical
health/assessment for children in DHS custody
Screening for clinical
Depression and follow-up plan
(OHA) Oregon Metrics and Scoring Committee – CCO Performance
Michael Bailit October 10, 2012 (Continued)
9.
10.
11.
12.
13.
14.
15.
16.
17.
Prenatal care
Developmental screening by 36 months (hybrid)
Colorectal Cancer
Screening (hybrid)
Alcohol and Drug misuse, screening, brief intervention and
referral for treatment (SBIRT)
Optimal Diabetes Care (D3)
Controlling Hypertension
Adolescent Well-Care Visit
EHR Composite measure
Behavioral Medicine:
Rediscovering the Neck
Practitioners
EBP Guidelines
Patients
Targeted Behavior Change
Skilled Communication
Relationship
Patient Satisfaction
What is Treat to Target?
• The concept gained traction in diabetes and
rheumatology care, but it is now achieving wider
applications in all health care
• Treating to achieve a measurable and agreeable
target (practitioner and patient), and changing
the care plan when the interventions are not
achieving the target
• Common sense (but common sense is not that
common)
Treat to Target
• Some examples:
 Hemoglobin
A1C in Diabetes
 Disease activity markers in Rheumatology
 Days of use in Substance Use Disorders
 Symptom Reduction in Mental Health : ACORN
Motivational Interviewing and Patient Centered Care
• Big demand on training new and current medical
and BH practitioners workforce in Motivational
Interviewing skills
• Addresses Motivation and Behavioral Change
• Hand and glove with Treat to Target
• Hand and glove with patient activation, patient
self-regulation and self-efficacy enhancement
• Hand and glove with patient satisfaction
MI efficacy on treatment adherence
• In a majority of controlled studies (12 of 21) MI was found to
produce significant adherence effects (Miller and Rollnick,
Motivational Interviewing, second edition page 306, 2002)
• Nicotine cessation: MI has shown to impact outcomes of nicotine
cessation efforts when coupled with NRT
• Example of adherence studies:
 MI and effectiveness in facilitating transition of clients from
one level of care to the another (Swanson, Pantalon and Cohen
1999)
 Six studies found effects on measures of attendance, treatment
commitment, readiness for change, and task completion, and
medication compliance
What are the active ingredients?
• Practitioner empathy – MI teaches active listening
and empathic responses
• MI trained practitioners do less of non empathic
interactions such as directing the conversation, not
listening, not collaborating, and confronting
• Practitioners who are better in MI have patients
who respond with more “change talk” and change
talk predicts behavioral change
Patient Centered Care Clip 5 min
• http://www.youtube.com/watch?v=dmrJJPCuTE
Challenges and Opportunities
• Find a partner in the audience.
• Take a few minutes to jot down what do you
think the transformation towards behavioral
medicine will look like?
• What are the challenges?
• What are the opportunities?
Models for Integration
What is “Primary Care Integration”?
• Collaboration between SUD and MH service
providers and primary care providers (e.g., FQHC’s,
CHC’s)
•MINIMAL
Collaboration
manyCLOSE
forms along
a
BASIC can take
BASIC
CLOSE
At a *Distance
On-Site
continuum
Partly Integrated
Coordinated
Co-located
Fully Integrated
Integrated
*Source: Collins C, Hewson D, Munger R, Wade T. Evolving Models of Behavioral
Health Integration in Primary Care. New York: Millbank Memorial Fund; 2010.
Minimal Coordination
The Primary Care
System
• BH and PC providers
– work in separate facilities,
– have separate systems, and
– communicate sporadically.
SUD
Care
System
MH
Care
System
Basic AT A DISTANCE
The Primary Care
System
Two-way
communication
• BH And PC providers

Engage in regular collaboration and
communication about shared patients
leading to improved coordination
SUD
Care
System
Two-way
communication
Two way
communication
MH
Care
System
At a Distance Example
• De Paul Treatment Centers counselor attends
interdisciplinary team meetings at Legacy Pain
Management Center (pharmacist, physicians, nurse,
social worker).
• Patients with chronic pain and SUD are referred to De
Paul’s chronic pain tx. program (DBT and CBT).
• Information exchanged bi-directionally throughout
treatment.
• De Paul expert provided patient centered care training
for practitioners at Legacy
Basic On Site (co-location of services)
The Primary Care
System
SUD
SBI
Care
Counseling
System
Counseling
• BH and PC providers


Still have separate systems, or share some
systems (EMR access, scheduling)
Allows for face to face between providers
MH
Care
System
MH Services
Co-location Example
• Legacy Good Sam clinic care team: Outreach caseworker from
CareOregon, social worker, nurse case manager, pharmacist,
SUD counselor from De Paul.
• Behavioral health clinicians are co-located at the primary care
clinic. Behavioral health and primary care providers share
patients and coordinate care.
• Specialty mental health or SUD referrals happen but most BH
treatment happen in primary care.
• The patients experience MH and SUD counseling as part of PC
Integrated
The Primary Care System
SUD
Care
System
MH
Care
System
• BH and PC providers



share the same facility, patient experiences BH tx as part of PC
have systems in common (e.g., financing, EMR, management)
regular face-to-face communication, treatment plan and treat to target
plans are shared and coordinated
CCO’s Leadership and Management New Core
Competencies
CCO’s need leaders and managers who are skilled in:
• Leadership
• Innovation and change management,
• How health care and behavioral health operates,
• How to incorporate evidence based prevention and innovation
to reduce preventable disease (obesity, tobacco, eating,
exercise, depression, risky drinking and drug use)
•And can embrace payment reform.
Several New Team Members
Care Manager/ BH
Consultant
•Behavioral activation
•Health literacy
•Health education
•Case management
•Coaching
•Follow up
SUD counselor
•Recovery management
•EB guidelines for referrals to
specialty
•Case management
•Health literacy
Consulting MH Expert
•Caseload consultation for PCP and CM
•Diagnostic consultation in difficult cases
•EB guidelines for referrals to specialty
Peer mentor
•Recovery
•Wellness
Community Health Worker
•Promote health
•Trusted community members
•Address social determinants
•Remove barriers to health
•Advocacy and education
•Health literacy
What about the Physicians???
Physicians
• Have big demands on their time
• Vary on “health care transformation readiness”
• Are glad to have a BH experts on care team to do a warm
hand off
• Seldom have expertise or skills to deal with MH and SUD
• Depend to a large extent on their communication skills to
be successful
• Training on “Patient Centered Care”
What about the BH providers?
BH Providers
• Have big demands on their time
• Vary on “health care transformation readiness”
• Would be glad to collaborate with doctors on patient care
but feel unskilled in the medical field
• Training on basic concepts of chronic disease
management (such as diabetes, hypertension, asthma etc.)
• Are skilled on improving client self-efficacy and self
regulatory skills using Motivational Interviewing and
Brief Therapy
Behavioral Health Field Transformation
• Less long-term – “fern and lamp” – 50 min session
therapies
• Shorter inpatient and outpatient lengths of stay
• More short term, brief intervention, Treat to Target
treatment – increase on the “back door”
• More treatment at non-traditional settings; e.g., primary
care, mobile van, housing site, community based, school
and home
• More access to primary care at BH facilities
Medicine will look more like BH and BH will
look more like medicine = Behavioral Medicine
Contacts
• sheilan@depaultreatmentcenters.org
• chrisf@depaultreatmentcenters.org
De Paul Treatment Centers
www.depaultreatmentcenters.org
503-535-1151 (Downtown- Adult)
503-535-1181 (NE- Youth)
503-693-3104 (Hillsboro- Outpatient)