Adult Mental Health Module
An Organized Approach to Mental
Health Issues in Realistic Time
Learning Session 1
2015
www.pspbc.ca
www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources
Support Team Advisor Roles
Psychiatrists and Mental Health Clinicians
 Learn/understand module
 Share resources
 Comment/advise
 Tell colleagues/Root for the PCPs
www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources
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Support Team Advisor Roles
Office Assistants:
 Understand module
 Take course on Mental Health First Aid
 Organize office scheduling, materials

 Flag patient issues
›
www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources
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Support Team Advisor Roles

Nurses

Absorb these tools through your own lens.

.

Think about your own scope of practice
Present your ideas during the action period
planning and strategize with your doc how you
will implement today’s training
www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources
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Adult Mental Health Module Team
 GP Champ, OA, nurse
 Psychiatrist
 Mental Health Clinicians
 PSP Coordinators
 Data Analyst
 PSP Tech Group
 Bounce Back Coaches
5
Request your Permission
 Anyone NOT wishing their name and EMR
information shared with our PSP Technology
Partners
 please let ___ know.
6
Faculty/Presenter Disclosures
 Faculty’s Name
 Relationship with Commercial Interest
 Faculty’s Name
 Relationship with Commercial Interest
7
Housekeeping
www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources
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Welcome
1.
2.
3.
4.
Roles
Survey feedback
Funding, CME credits
What are we trying to accomplish
Context, aims, goals, module pathway, CBT, QI,
Results
5. Physician, patient advocate testimonial
6. Break
7. Algorithm scavenger hunt
8. Tools intro, tips, PL, RL, PLAP
Separate: MOAs billing and scheduling
9. BB
10. Billing
11. Action planning, Evaluations
9
Where You are Now Where You
Would Like to Be
Thank you for your responses to the following questions.
1. What are your challenges or frustrations supporting patients with
mental health concerns?
2. How do you currently support these patients & how is this working?
3. What are you hoping to get out of the PSP Mental Health module?
4. Are you familiar with the PHQ 9 screening tool
5. Are you paper based or do you have an EMR?
6. Are you with a group practice or alone?
www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources
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Results of pre-course assessment survey N=36
What are your challenges and frustrations?
www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources
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How do you currently support MH patients?
www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources
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What do you hope to get from PSP training?
www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources
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Familiarity with the PHQ9 screening tool?
www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources
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Paper or EMR?
www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources
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What did we learn about you?
 Want to provide the best care for your patients with MH
problems
 Concerned about time efficiency in your practices
 Doing a lot of MH care already
 Some don’t feel confident in MH care they provide and some feel
emotionally drained by it
 Would like clearer and more timely access to mental health
specialists for your patients
 Here to learn skills and tools to help with diagnosis and in-office
management as well as learn about helpful resources
www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources
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Funding for Modules
Learning Sessions
3 x ½ day (max)
GP
Session x 3
MOA
12 hrs
$ 1, 235.64
$ 240
Action Periods
1
►Planning
& initial implementation in practice
►Report on experiences and successes at LS2
►Billable at or after LS2
$ 823.76
2
►Refine
$ 610.72
implementation, embed and sustain the change
►Report on experiences and successes at LS3
►Billable at or after LS3
Potential Total: $ 2,910.12
Participant Funding GPs: Mental Health Module
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Mainpro Credits for Primary Care Physicians
 10.5 Mainpro M-1 credits based on
 Attendance hours at all learning sessions (LSs)
 Fewer if not all sessions attended
 IN ADDITION





10.5 Mainpro C bonus credits based on
Completion of all 3 LSs plus an Action Period and post
reflective survey (we will contact DocBC 3 months after LS3
and AP1 completion to request them to send your Reflective
Questionnaire)
Details are found on all PSP Sessional Forms in bottom right box
19
MOC for Psychiatrists
“This event is an Accredited Group Learning Activity eligible for up
to 10.5 (3.5 per session) Section 1 credits as defined by the
Maintenance of Certification Program of the Royal College of
Physicians and Surgeons of Canada.
This program has been reviewed and approved by the UBC Division
of Continuing Professional Development.”
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M 1 Credits for Residents
Residents can claim a maximum of 30 M-1 credits
during their residency.
Residents are eligible to receive M1 credits for
attending learning sessions (up to and within their
maximum allowance of 30 M1 credits).
To obtain M1 credits please contact:
cthomas@doctorsofbc.ca
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CME and Compensation: Who to
Contact?
PSP Modules
• Mainpro C and M1 credits
Physician Forums
• Mainpro M1 credits
• Fax all Learning Session and
Action Period Invoices to
Doctors of BC
(604.638.2939)
• MUST sign in so we can
send your name to VIHA
Physician Compensation for
both reimbursement and
CME tracking
• Contact:
• Contact:
Who sees MH patients in Canada?
Pan Canadian Survey 2011
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Hypothesis
 Family docs need:
 time efficient skills to increase their comfort and
confidence in treating their mental health patients
 fee codes that fit this mental health work
www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources
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Developed Training tools
 CBIS manual – cognitive behavioral
interpersonal skills manual.
This formed the core of the BC provincial
practice support program adult mental
health module
Weinerman R et al, Improving Mental Healthcare by Primary Care physicians In British Columbia. Healthcare
Quarterly, 2011. 14:1, 36-38
MacCarthy,D;Weinerman,R:Kallstrom,L;Kadlec,H;Hollander,M;Patten,S;Mental Health Practice and Attitudes
Can be Changed. The Permanente Journal, 2013, Summe; 17(3);14-17.
www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources
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Key Components of the Adult Mental Health (AMH)
Module
1. Screening scales: ie PHQ9
2. CBIS Screening Assessment tools: ie Diagnostic Assessment
Interview (DAI)
3. Three Supported Self-Management Cognitive Behavioural
Therapy (CBT) skills options
 CBIS Manual
 Bounce Back
 Antidepressant Skills Workbook
www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources
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Results n=525 physicians
100
90
80
70
60
50
40
30
20
10
0
Training improved
pt care
Enhanced skills
Improved MD
confidence
Improved MD job
satisfaction
Further Results
100
90
80
70
60
50
40
30
20
10
0
Help pts return to
work
Help pts stay at
work
Increased pts sense Reduced reliance
of partnership
on meds alone
Hope/Aim/Goals
 Provide PCPs with effective tools
to screen, diagnose, engage, partner with, manage their
MH patients
 Improve PCPs’ comfort, confidence and satisfaction
 Improve patient experience and outcomes
 Reduced healthcare provider stigma
www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources
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Depression used as Lens (Anxiety too)
High prevalence
in isolation/comorbid and comorbid with chronic disease
Lifetime prevalence of
Ranked by frequency **
 Major Depressive Episode: 12.2%
 Major depressive disorder
 Past-year episodes: 4.8%
 Specific Phobia
 Past-month episodes: 1.3% *

* Descriptive Epidemiology of Major Depression in
Canada. Patten, SB; Wang, JL; Williams, JVA et al.
Canadian Journal of Psychiatry; Feb 2006; 51, 2; 84.
 Social phobia
 PTSD
 GAD
 Separation anxiety

** Twelve-month and lifetime prevalence and lifetime
morbid risk of anxiety and mood disorders in the US.
Kessler, RC, Petukhova, M, Sampson, NA, Zalavsky,
AM, Wittchen, H-U. Int J Methods Psychiatr Res. 2012
Sep:21(3) 169-184
 Panic
 Bipolar
 Agoraphobia
 OCD
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Focus of this module
Patients that present with:
1.fatigue, depression, anxiety,
panic, insomnia,
psychosomatic symptoms
2. chronic pain, headache,
chronic illness,
3. depressed demeanor, worrier
a thick chart
and trigger you to generate a
mental health screening.
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Bike ride Improvement Ramp
 Plan: Ride my bike to work
Attempt #3
Attempt # 2
•
•
•
•
Attempt # 1
Get up
Get ready
Get bike
Go
•
•
•
•
•
•
•
•
I was late
I was sweaty
Bike was
rusty
I was stiff
Fix bike
Stretch
Leave early
Take clothes/shower at
work
•
•
•
•
Rain/wind
Forgot soap
Still late
Too many
hills
•
•
•
•
•
Done!!
Check google for bike
time
Got poncho/glasses
Brought shampoo
Find straighter route
Leave earlier
• On time!!
• Felt good!!
• I Can do
this!
Always go back to why is this important!
 Get exercise
 Save on gas & wear/tear on car
 Contribute to carbon footprint
 Promote exercise/wellness in
community
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 Lessen traffic flow by one car………
Module Pathway
•Ongoing Support
•CME
•Post Module Reflective
Questionnaire (mid-March)
•Survey-barriers, desires
•Orientation to Algorithm,
•Review use of MH Log Sheet
•Location of tools on algorithm
• Confirm use of EMR
•Confirm patient population
•Locate tools on algorithm
•Begin trying out tools
•Review use of MH Log Sheet
•Confirm MOA role
•Billing questions/tech assistance
Pre-visit
•Review Log Sheet progress
•Use of DAI
•Use of other resources
•Discuss optimal office flow
(include MOA)
AP1
AP2
Month 0
Sustain
Month 7-8
•Overview of aims, CBIS, ASW
Bounceback and
practice finding the tools
(Scavenger Hunt)
•Log sheet/AP requirements
•Billing and EMR
optimization
•Develop an action plan
•Share experiences
(good & bad) w peers
• Use of tools
•DAI role play
•Log sheet/AP requirements
•Update action plan
•Share experiences
•Community Resource Cafe
•Troubleshoot issues
for sustainability &
improvement
•Sustainability Plan
Cognitive Behavioural Therapy (CBT):
Setting the Stage
www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources
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What is a Cognitive Behavioral Approach?

Level 1 Evidence based. CBT prevention endures beyond tx cessation. If both CBT and
meds stopped after successful acute treatment, patients who received CBT have lower
rates of relapse **

Behavior/Activation oriented

Helps patients learn to change thought patterns/behaviors that negatively affect mood

Gives patients a sense of power and control

Retrains the brain!

You are the coach not the therapist
**CANMAT Clinical Guidleines for the management of major depressive disorder in adults: Kennedy SH, Lam RW, Prikh
SV, Patten SB, Ravindran AV
www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources
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How does CBT and CBT skills work?
Use this to introduce CBT skills
Situation
Situation
www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources
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How does CBT and CBT skills work?
Use this to introduce CBT skills
Problem Solving
Behavioural Activation
ACTIONS
SITUATIONS
• Loss
• Conflict
• Isolation
 Withdrawal
 Reduced activity
 Poor self-care
PHYSIOLOGY
 Altered sleep
 Low energy
 Δ brain chemistry
3
7
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Realistic Thinking
THOUGHTS
• Harsh selfcriticism
• Over-pessimistic
• Catastrophic
about future
EMOTIONS
 Sadness
 Despair
 Numbness
37
The benefits of using CBT skills?
Helps on its own
Mild or moderate depression, mild and moderate anxiety disorders such as GAD, social
anxiety, panic, stress, anger, self esteem, some personality disorders
As an adjunct with medications in primary care or collaborating with secondary care
Severe depression, anxiety disorders, obsessive compulsive disorder, bulimia, posttraumatic stress disorder, personality disorders, stable bipolar disorder and stable psychosis
Engages, empowers patients to work towards their recovery
Provides patients with coping skills & a sense of control
A non-pharmaceutical option/adjunct for treatment that is enduring and prevents relapse
www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources
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An alternate approach….consider
saying to your patient….
“Before just jumping into pharmaceuticals you can start with other
things like re-training your brain, I have some strategies involving
some homework to help you, what do you think about trying this?”
Dr. Howard Bright, Chilliwack
www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources
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Results n=525 physicians
100
90
80
70
60
50
40
30
20
10
0
Training improved
pt care
Enhanced skills
Improved MD
confidence
Improved MD job
satisfaction
New Hypothesis
 Giving practitioners and patients more coping tools reduced
healthcare provider stigma against AIDS **
 Family docs feel unequipped to deal with mental health issues ***
Novel hypothesis
Providing tools for practitioners, patients to use will reduce
healthcare provider stigma against mental health issues
** Brown, L. Trujillo, L., Macintyre, K.; (2001)Interventions to Reducde HIV/AID Stigma: What have we
learned?, Horizons Program/Tulane School of Public Health and Tropical Medicine, New Orleans,
Louisiana,
*** Clatney, L., MacDonald, H., & Shah, S.M. (2008). Mental health care in the primary care setting:
Family physicians’ perspectives. Canadian Family Physician, 54,
www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources
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OMS-HC Total average scores:
Both groups
42
*Wilcoxen rank sum test was used to measure between group change from pre-test to followup, p<.001
**Wilcoxen sign rank test was used to measure within group change. Intervention group pretest to post-test change, p=.002; post-test to follow-up change, p=.017. Control group, not
significant.
43
43
Dr. Fiza video
 Why this module will change everything!
44
Perspective
www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources
Break
46
Let’s Do it!
www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources
Today: Start with Algorithm and 4
Basic tools
PHQ9/
GAD7
Bounce
Back
Coaching/
DVD
AntiDepressant
Skills
Workbook
CBIS
Manual
Updated Algorithm Available
Scroll to this:
‘Google’ this:
www.gpsc
bc.ca
Click PSP
•
•
•
•
•
Scroll down
Click Adult Mental Health
Select
Algorithm for Mental Health (pdf)
Right click select "Save target" to
download to your desktop
Algorithm Scavenger Hunt
(locating the tools quickly)
MH Tools Scavenger Hunt
 Form groups of 2-3,
each with at least one
laptop with downloaded
MH Algorithm
OR Google
www.gpscbc.ca click
PSP, scroll down click
Adult Mental Health
Module, select
Algorithm, right click
save target
51
Format
 Each Pair:
 Will review 2
Case Studies (Anxiety, Depression)
 Must complete each task to receive next task
 One person to bring completed task to Coordinator
 Each Group Member:
 Will receive an Action Period log to fill in (keep at your table
until the end of the Scavenger Hunt)
 Bonus Tasks = Prizes 
Coordinators will be circulating to provide assistance
52
Algorithm Scavenger Hunt
Discussion and “Treasures”
MOA Tasks to discuss
 Reschedule MH patients in
blocks
 Organize relevant resources
– forms, booklets, other
materials
 Provide patient follow-up calls
 Identify how Action Period logs
will be completed and faxed
 Complete the CMHA Mental
Health First Aid course
 Contact the Practice Support
Team for support
 Ensure Algorithm is loaded on
each computer
54
Today: Start with 4 Basic tools
PHQ9/
GAD7
Bounce
Back
Coaching/
DVD
AntiDepressant
Skills
Workbook
CBIS
Manual
PHQ-2 & PHQ-9
www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources
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Need one or both
questions endorsed as
“2” or “3”
(“More than half the days”
or “Nearly every day”)
57
PHQ-9 Scoring
Major Depressive Disorder: Need
5 or more questions endorsed as
“More than half the days” or
“Nearly every day” (i.e. in shaded
areas)
8
1
9
18
58
PHQ-9 Scoring
Is functional impairment endorsed as
“Somewhat difficult” or greater?
8
1
9
18

www.gpscbc.ca/psp-learning/
adult-mental-health/tools-resources
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DSM 5 Confirming Diagnosis of Major
Depressive Episode
Criteria A: reflected in
PHQ9 nine questions
 1 symptom is either
depressed mood or
loss of interest or
pleasure
(PHQ9
1st
2 questions)
 5/more symptoms
present in same 2 week
Criteria B:
 Reflected in PHQ9
function question
Criteria C:
 episode is not due to a
substance or other
medical condition
period/change of function
60
Bereavement
 May resemble a major depressive episode
 Use your clinical judgment depending on your
knowledge of the individual and their cultural
norms
61
Manual Overview
Assessment
 DAI
 Problem List
 Action Plan
 Resource List
 SAQ
 Anxiety Dx
Flow
Skills
 Activation
 Cognition
 Relaxation
 Lifestyle
 Anxiety
62
63
Flexibility of Use - Key Strategy
 Tools – use according to your needs
 Be selective
 Use all, some, now, later
 Be strategic
www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources
64
Shift in How we Work
 Shift to shared patient
responsibility
 Chronic problems
 No quick fix
 All tools to engage
 Build partnership
65
General
 Breathe, relax
 No right or wrong
 PDSA
 Can’t hurt
 Negotiate,
demonstrate and soft
sell
 Validate, encourage
and praise
66
Skills
• Activation - first
• Cognition – prepare
• Relaxation/Anxiety –
demonstrate
• Lifestyle – always good
• Anxiety disorders -
Organizing Tips
 Handouts available
 One at a time
 Small goals
 Chart homework
given
 Regular follow-up
 Practice
68
Problem List
69
Resource List (Reslience)
 About the patient
 Shift to strength
 Challenging
 Help
 Internal and external
 Wellspring
70
Problem List Action Plan
 All known
 Patterns, not solutions
 Chaos organized
 Being heard
 Validated
 Prepares for action
71
Small Group Activity – Problem List Action Plan
10 min
Ask patient:
What action do you think would be helpful for this problem….
? Activation
? Relaxation
? Thought changing
? lifestyle changes
? medications
? referrals to other resources
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Summary
•
•
•
•
Just do it!
Jump in!
Use favorites!
Own it!
Supported Self Management Cognitive
Behavioral Skill Building Mood
Improvement Program
www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources
75
Accessibility Alternatives
 Brief ‘Little Booklet’
format with less text

Cantonese versions +
Coaching also available
76
Additional Information
 To learn more about Bounce Back in
general:
 Visit our Website: www.bouncebackbc.ca
Bounce Back toll-free #s:
Phone: 1-866-639-0522
Facsimile: 1-877-688-3270
www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources
77
Advocate Perspective
Importance of
 being heard
 being asked the questions
 Short term more time, long term less time/gain
 Stigma experience
 Other experience
www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources
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Discussion
www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources
79
Funding for Modules
Learning Sessions
3 x ½ day (max)
GP
Session x 3
MOA
12 hrs
$ 1, 235.64
$ 240
Action Periods
1
►Planning
& initial implementation in practice
►Report on experiences and successes at LS2
►Billable at or after LS2
$ 823.76
2
►Refine
$ 610.72
implementation, embed and sustain the change
►Report on experiences and successes at LS3
►Billable at or after LS3
Potential Total: $ 2,910.12
Participant Funding GPs: Mental Health Module
80
MSP Compensation
CBIS tools
• DAI
2 counseling visits 00120 x 2
1 counseling visit finish with MH planning fee 00120, 14043
• Problem List Action Plan
Counseling visit 00120
• Skills
Office Visit 00100
Tel Fup
14079
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Impact of using the tools:
Dr. Egan’s Renewed Practice
Visit 1
PHQ9/GAD & PL/RL
Bill 0010 or if >20 minutes, bill 00120 worth 1.5 of a 00100 up to 4 times a year
Visit 2
Review PL/RL & create Action Plan, choose
Skill sheet
Bill 0010 or if >20 minutes, bill 00120 worth 1.5 of a 00100 up to 4 times a year
Visit 3
Review and add ASW (pt may choose
Bounce Back too)
Bill 0010 or if >20 minutes, bill 00120 worth 1.5 of a 00100 up to 4 times a year
Visit 4
May need more in depth Diagnostic
Assessment Interview
82
More about Visit 4
 Visit 4 May need more in depth Diagnostic Assessment
Interview
Bill 14043 MH planning fee, and after this is billed, this generates 4 more
counseling visits giving access to 8 prolonged visits in one calendar year in
addition to the planning visit 14043 worth $100 once a year. Plan must include a
screening assessment and a planning document to keep on chart. If you take 2
sessions to do this bill 00120 for first and 14043 for second giving you the time to
discuss with patient easily.
83
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Action Period Planning
Plan Your Pathway
•Ongoing Support
•CME
•Post Module Reflective
Questionnaire (mid-March)
•Survey-barriers, desires
•Orientation to Algorithm,
•Review use of MH Log Sheet
•Location of tools on algorithm
• Confirm use of EMR
•Confirm patient population
•Locate tools on algorithm
•Begin trying out tools
•Review use of MH Log Sheet
•Confirm MOA role
•Billing questions/tech assistance
Pre-visit
•Review Log Sheet progress
•Use of DAI
•Use of other resources
•Discuss optimal office flow
(include MOA)
AP1
AP2
Month 0
Sustain
Month 7-8
•Overview of aims, CBIS, ASW
Bounceback and
practice finding the tools
(Scavenger Hunt)
•Log sheet/AP requirements
•Billing and EMR
optimization
•Develop an action plan
•Share experiences
(good & bad) w peers
• Use of tools
•DAI role play
•Log sheet/AP requirements
•Update action plan
•Share experiences
•Community Resource Cafe
•Troubleshoot issues
for sustainability &
improvement
•Sustainability Plan
PSP Mental Health Log
Successful
planning
for
achieving
Action
Period
activities
To complete Action Period 1
Replace this box:
With your practice ideas
• Scheduling options
• Create/Review patient registry
• Select specific patient
criteria…complex care, migraine,
others?
• Organize relevant resources –
forms, booklets, other materials
• Follow up with patients (MOA can
follow up with patients on
homework and goals agreed to in
action plans)
• Identify changes to work processes
and office re-design
• Record overall progress on log
sheets
Paperwork
• Learning
Session
Evaluation
• KEEP Invoices
to FAX to
Doctors of BC
(FAX # at
lower R side)
What is your proof that this stuff works???
My communications
with Mental Health
and Addictions will
improve
My MOA will have
an enhanced role
and a workflow in
place
Some of my
patients may not
need to see
psychiatry
My income
will increase
My patients will
progress and respond
to my approach
My
appointments
will be faster
My
appointments
will be proactive
How will you know that what you are
doing is an improvement???
90
Thanks for Attending
Lunch Info
www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources
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