Integrated Care: The Behavioral Health Primary Care Model. M. Hunter Hansen, PsyD, MP

Transcription

1 Integrated Care: The Behavioral Health Primary Care Model M. Hunter Hansen, PsyD, MP

2 Objectives Brief Review of the History of Mental Health Care The State of Mental Healthcare The Role of Primary Care Medicine in Mental Health Care Brief History if Integration Attempts A New Model: Behavioral Health Consultant Model/ Integrated Care Barriers for Psychologists Opportunities for Psychologists

3 The State of Mental Healthcare 50% of people with a mental disorder get no mental heath care at all! ( Bijl et. al., 2003), but 80% will see PCP in a year. 80% of this no treatment group will go to primary care for other health reasons Primary care is the de facto mental health system in the U.S. Norquist, G.S. Regier, D.A. (1996 Most get care from PCP, ¼ get adequate care (Kessler, 2011). No care worsen outcomes (e.g. 20% completed suicide rate untreated bipolar disorder ( McLaren, P. 2006) Primary care prescribes 75% of all psychotropic medications, with little specialty training in mental health. Results in poorer outcomes vs specialty care Lopsided growth in mental healthcare professionals Psychiatrists are not replacing themselves & estimated 45,000 needed now Use of prescription medication is increasing, use of psychotherapy is decreasing.

4 Limitations of Special Care Models Guarantees continued separation of healthcare and MH care (even in same facility) Many PC pts reluctant to seek specialty MH care Time-intensive: requires large expenditure of resources Verbally-oriented vs. Action-oriented

5 Primary Care Psychology- A Rapid Growth Area Behavioral Consultation and Primary Care: A Guide to Integrating Services Robinson & Reiter Integrated Behavioral Health in Primary Care: Step-by-Step Guidance for Assessment and Intervention Hunter, Goodie, Oordt & Dobmeyer

6 What Behavioral Functions Are Relevant In Primary Care? Screening for MH problems Psychosocial Assess Psychiatric Assess Improving Adherence to Medical Procedures Behavioral weight loss Smoking cessation Chronic illness Response to trauma Pharm. Management & followup Crisis management Pain Management Prep for med/surg procedures

7 Behavior Health Consultation PSYCHOLOGIST An integrative model of mental and physical healthcare Transtheoretical model of change (Prochaska and DiClemente s Stages of Change Model) and Motivational Interviewing. Gentlemen, we can rebuild him. We have the technology. We have the capability to build the world's first bionic psychologist. Better than he was before. Better, stronger, faster."

8 What is a BHC? A behavioral health provider, usually at the LCSW or PhD/PsyD level, who assists the PCP & the patient make behavior changes in important health and psychosocial areas. The BHC is not a therapist, though benefits usually associated with therapy are expected.

9 What is a BHC? The BHC model is based on the following premises: a. small behavior changes can have significant impact b. population-based care is the best use of the skills of the BHC c. focused, time-limited intervention fits the primary care medicine model and the needs of stressed, disadvantaged persons. The BHC model relies on evidence-based treatment tailored to the typical medical visit.

10 Specialty MH Care vs. BHC Model Primary BHC Visits timed around provider visits Long term follow up rare, hi risk only Informal by provider assessment/goals Low intensity, between session interval longer Relationship not primary focus Specialty MH Visit structure not related to medical visits Long term follow up encouraged Formal: intake & tx planning Higher intensity, more concentrated care Relationship built to last over time

11 Specialty MH Care vs. BHC Model Tx Methods Primary BHC Limited face to face contact Uses pt education as primary model Consultant as technical resource to pt Home-based practice to promote change May involve PCP in visits Specialty MH Face to face primary vehicle Education model ancillary Therapist directs change efforts for pt Home practice linked back to tx PCP rarely involved in visits

12 Challenges with the BHC Model General: Not working in a psychological model/context No office, less control over schedule Faster pace, see pts a day Much hire rates of abuse reports, disability claims, legal problems, involuntary hospitalizations Broad knowlege/skill base required (e.g. medications, neuropsych). LCHC Ethical dilemmas related to multiple roles

13 Specialty MH Care vs. BHC Model Dimension Primary BHC Specialty MH # Sessions 1-3 (typical) Variable, by condition Session Length mins. 50 min. hr.

14 Qualities of An Ideal BH Provider Likes Fast Pace (Adrenaline Junkie) Think Skin (working tights spaces, interdisciplinary jabbing, grumpy providers) A Heart for Serving the massive underserved community Competencies and Capacities Brief Assessment and Treatment Psychopharmacology Group Treatment Medical Conditions Motivational Interviewing

15 Where? Cold Calls Federally Qualified Health Centers Opportunities In Primary Care Veterans Administration Medical Centers Rural Health Centers The Military and Public Health System Centers How? Networking CCHF.org (Christian Community Health Fellowship) CFHN.net (Collaborative Family Healthcare Network) SBM.org (Society of Behavioral Medicine) State Primary Care Associations nhsc.hrsa.gov (National Health Service Corp) Me

16 Barriers To Integrated Care LCSW/LPC dominated field so far primarily due to salary costs Need for psychiatric prescribers

17 References Bijl et. al. (2003) The Prevalence Of Treated And Untreated Mental Disorders In Five Countries Health Affairs, 22, no Norquist, G.S. Regier, D.A. (1996). The Epidemiology Of Psychiatric Disorders And The De Facto Mental Health Care System. Annual Review of Medicine, 47, Kessler, R. (2011). Psychiatric Epidemiology. The Carlat Psychiatry Report, 9, 3, 4-5 McLaren, P. (2006) Bipolar Disorder. Pulse, Vol. 66 Issue 17, p48-49, 2p.