The GPE Success Story: The Positive Public Health Impact of the Graduate Psychology Education Program

Transcription

1 The GPE Success Story: The Positive Public Health Impact of the Graduate Psychology Education Program Alex Ross, ScD, Health Resources and Services Administration Bruce Rybarczyk, PhD, ABPP, Virginia Commonwealth University Joseph Evans, PhD, University of Nebraska Medical Center Moderator: Karen Studwell, JD, American Psychological Association

2 Training Health Service Psychologists for Practice in Integrated Care Settings American Psychological Association Leadership Conference September 15, 2014 Alexander F. Ross, Sc.D. Senior Behavioral Health Advisor Division of Nursing and Public Health Bureau of Health Workforce Health Resources and Services Administration U.S. Department of Health and Human Services

3 Goal For This Presentation Highlight the role of training psychologists for practice in the re-designed primary care and broader healthcare system.

4 Current policy issues involved in integration of behavioral health into the PCMH Available Workforce Approximately 11.1 million adults aged 18 or older (4.9 percent of adults) reported an unmet need for mental health care in 2010, including 5.2 million adults aged 18 or older who reported an unmet need for mental health care and did not receive mental health services. Upwards of 11 million of the newly enrolled individuals may have a need for behavioral health services based on the prevalence of behavioral health disorders in the general population. According to the Bureau of Labor Statistics, the projected growth in behavioral health employment opportunities nationally between is: o Psychologists: 22% in job opportunities (+37,000 positions over 2010).

5 Supporting the role of psychologists in integrated care NHSC - Behavioral health care providers comprise nearly one in three clinicians in the NHSC (2,800/8,900 as of September 2013). 622 of the more than 2,800 behavioral health providers in the Corps are Clinical Psychologists. o More than 1,300 behavioral health providers approximately 15 percent of total NHSC field strength of 8,900 clinicians served at rural sites in the past year. Health Centers - Licensed clinical psychologists are key members of primary care teams in health centers where the medical home model is taking shape. o There are almost 500 psychologists working in health centers/over 500,000 patient visits a year.

6 Training Psychologists to Practice on Integrated Teams A number of forces are moving the field in the direction of integrated practice: The role of interprofessional education in building a more collaborative workforce. Primary Care providing more behavioral health Managed Care carve-ins. Financing integrated care Medicare, Medicaid (Health Homes), CMMI. How do these forces relate to the future training of psychologists through HRSA-funded programs?

7 HRSA s Behavioral Health Training and Education Programs Graduate Psychology Education Program (GPE) Prepare doctoral psychology students to work in organizations who serve the vulnerable and underserved populations, on integrating behavioral health, primary care, and public health competencies, and on interprofessional practice. Mental and Behavioral Health Education and Training Program (MBHET) Purpose is to increase the number of master level social workers and Ph.D. psychologists who pursue clinical work with high need and high demand populations namely rural, vulnerable, and/or underserved groups. Behavioral Health Workforce Education and Training (BHWET) for Professionals (new) To help fill the gap in available mental health service providers; two new grant programs funded through a joint initiative with SAMSHA and HRSA to train social workers, counselors, psychologists, and other mental health professionals/paraprofessionals.

8 Graduate Psychology Education Program Two tracks: 1) didactic focusing on schools/programs and curricula design, 2) experiential focusing on the practice based experience. Recent increase in funding allowed awards to increase from 16 to 40. Schools/programs must consult with and utilize the expertise at the pre-degree internship sites in their own curriculum development and instructional design. Pre-degree internships must demonstrate how trainees are applying new paradigms and concepts through practice in their internship experiences. Hearing from two great examples here today.

9 Mental and Behavioral Health Education and Training Program Special emphasis on serving veterans, military, and their families. 24 schools and programs received grant awards in FY 2012 funded out of the Prevention and Public Health Fund up front for 3 years. These grants will train 335 social workers and 98 Ph.D. psychologists over three years.

10 Behavioral Health Workforce Education and Training for Professionals (new) In support of the White House s Now is the Time initiative, aims to expand the mental health and substance abuse workforce targeting children, adolescents, and transitionalage youth at risk for developing or who have developed a recognized behavioral health disorder. The program has a special emphasis on developing curriculum that address the needs of individuals ages 16 to 25 at high risk for mental illness and include stipends to train more mental health professionals serving young people in our schools and communities. Applications are going through the review process and awards will be made shortly.

11 Measuring the performance of Behavioral Health Interprofessional Training Programs GPE - semi-annual reporting: program characteristics, demographic and program completion data related to student trainees who receive stipends, characteristics of the settings where internships and trainings take place, activities related to curriculum development and enhancement, and characteristics of faculty development programs. MBHET overall number of enrolled students, create more field placement and internship slots for students working with high need and high demand populations, the number of graduates who entered practice in area of high need and low behavioral health resources; place more students in these field placements and internships. BHWET - guidance will be provided in the Notice of Award in September.

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13 Partnership to Promote Integration SAMHSA/HRSA Center for Integrated Health Solutions (CIHS) Technical Assistance and Training Center on Primary and Behavioral Health Integration A strong emphasis on building a well trained integrated care workforce CIHS Framework Tables Determine where you (as a psychologist) fit with integrated care models Business Models The case for integration of behavioral health and guidance on how to evaluate this business case for a primary care provider organization.

14 Core Competencies 1. Interpersonal Communication 2. Collaboration & Teamwork 5. Intervention 6. Cultural Competence & Adaptation 3. Screening & Assessment 4. Care Planning & Care Coordination 7. Systems Oriented Practice 8. Practice-Based Learning & QA 9. Informatics

15 The Role of Psychologists in Integrated Care and Education/Training Conclusion HRSA-funded training and education programs increased investments in training the future psychology workforce to work in integrated care settings and improve care for underserved populations. Themes these programs share in common: Recruit new students interested in pursuing a clinical concentration with identified special populations; Develop and implement interprofessional training; Add to existing, expand and/or foster the development of new pre-degree internship slots for PhD/PsyD psychology students or field placements for MSW students; Provide stipend support for students for the required field placement or predegree internship requirements; (and) The role of psychologists as a vital part of the integrated care team is very encouraging.

16 Contact Information Julia Sheen-Aaron Branch Chief, Public Health and Behavioral Health Bureau of Health Workforce Health Resources and Services Administration The Behavioral Health Training and Education Programs Team Miryam Gerdine Gloria Ortiz Sylvia Joice Seh Welch Alexander F. Ross Senior Behavioral Health Advisor Division of Nursing and Public Health

17 A Training Program in Primary Care Psychology: Meeting Future Workforce Needs & Promoting Mental Health Access for the Underserved Bruce Rybarczyk, PhD Professor Associate Director of Clinical Training Clinical Psychology Program Virginia Commonwealth University

18 Primary care medicine is the de facto first line of mental health service in our country.

19 Jeffrey L. Goodie, Ph.D.

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21 VCU Primary Care Psychology Twofold Mission Mission Part I: to equip future psychologists to meet the workforce demands of a changing healthcare system -- predicated on expansion of PCMH and integrated behavioral services. Mission Part II: to address unmet mental health and behavioral health needs by providing brief, interdisciplinary-focused services in Richmond safety net primary care clinics.

22 Barriers to workforce development in PC psychology Training world slow to respond to changes in health care Absence of faculty with knowledge Absence of sites/partners for training (reimbursement issues) Clinical Health Psychology training, a natural fit, has been focused on specialty and inpatient medical services

23 Paradigm shift Population based care Faster pace (think on feet) Be interruptible & flexible on session length Knowledge of basic disease management Targeted and brief interventions More psycho-educational; less psychotherapy No true termination of BHC services

24 Unique training aspects Variety, complexity, severity Learning to think on your feet and be flexible Inter-professional training, collaboration and communication Vertical team and co-treatment opportunities: watch one, do one, teach one" Real-time same day supervision in place of weekly hour-long meetings Clinical research opportunities Efficiency of time in clinical hours

25 How to be effective Be accessible Be a generalist Be a teacher: help PCPs build skills, knowledge Be in the chaos Be a team player

26 Mission Part 1 Outcomes Since 2008, over 55 students from all class levels of the VCU Clinical and Counseling Psychology PhD programs have participated; > 20 fully or partially funded. ~75% of students who have advanced to internship selected a site where they continue primary care training. 6 students have advanced to post-doctoral fellowships that include primary care and 4 licensed graduates since the program inception are now in primary care staff positions 7 licensed clinical faculty members or affiliate faculty members have received funding to provide training and on-site supervision. Since 2010, 10 tri-annual team-based learning workshops to foster interdisciplinary collaboration with >90 trainees per session from psychology, medicine, and pharmacy.

27 Table 2: Psychology Trainee Satisfaction Ratings Mean answers for N= 30 graduate student trainees (January, 2013) (0 = Strongly Disagree, 1 = Moderately Disagree, 2 = Neutral, 3 = Moderately Agree, 4 = Strongly Agree) MEAN Score "My training experience in Primary Care Psychology..." Substantially enhanced my interdisciplinary communication skills Led me to view primary care as a top choice for a career path if a job opportunity was available Led/will lead me to look for an internship that includes a similar rotation Greatly enhanced my confidence in working with challenging situations Provided excellent training in administering brief interventions Enhanced my belief that integrating psychologists into primary care will be important for reducing health care costs.

28 Anonymous Internal Medicine Resident Survey (N=34) EFFECTIVENESS Strongly Disagree Somewhat Disagree Somewhat Agree Strongly Agree Having psychology clinicians present has enhanced the care received by patients at Primary Care. 3% (1) 0% (0) 23% (8) 74% (25) TRAINING EXPERIENCE The presence of psychology clinicians has significantly enhanced the training at the Primary Care residency program. 3% (1) 6% (2) 60% (20) 30% (10) CAREER PLANNING IMPACT I am more likely to continue working in underserved care if I can work with a program similar to the Primary Care Psychology Program. 19% (6) 13% (4) 50% (16) 18% (6) EFFICIENCY I am able to see a greater proportion of my patients within the 20 minute appointment times as a result of the Primary Care Psychology Program. 23% (7) 32% (10) 39% (13) 7% (2)

29 Mission Part 2 Outcomes Since 2008, provided over 8,000 sessions of free care to underserved patients. Most patients have significant difficulty accessing mental health services and many have never seen a mental health clinician. Services provided at 4 different urban clinics in Richmond: adult and pediatric primary care at the VCU Medical Center, the Daily Planet Clinic for the Homelessness, and the Fan Free Clinic. Dissemination: 4 publications, 3 master s theses, and 3 dissertations addressing the efficacy of integrated primary care.

30 Services We Provide Mental Health Depression Anxiety Panic Disorder Somatization Adjustment Suicide Risk Assessment Brief Cognitive Evaluations Interventions are brief, problemfocused, and generally based on cognitive-behavioral principles Behavioral Health Motivational interviewing Pain management Behavioral Treatment of Insomnia Smoking Cessation Medication adherence Diabetes management Diet/Weight loss Coping with chronic disease

31 Underserved = Complex, Multi-layered Does not feel like getting out of bed most days.

32 SRRS-R Sadock, E., Auerbach, S.M., Rybarczyk, B. Aggarwal, A., & Lanoye, A. (in press). The Relationship of life stressors, mood disorder and health care utilization among primary care patients referred for integrated behavioral health services. Journal of Nervous and Mental Disorders.

33 Snapshot of Data from Recent Studies by Students

34 17 PHQ-9 Scores over time referral day last session 6-12 months f/u MCV N= 147 subset (n=48) Hays Clinic Control (N = 139)

35 15 GAD 7 scores over time Referral Day Last Session 6-8 month F/U MCV N = 147 subsample (N = 48) Hays Control (N = 139)

36 The Impact of a Primary Care Psychology Training Program on Medical Utilization in a Community Sample Autumn Lanoye Thesis Defense July 25, 2014

37 Results: ER Use Not Followed by Inpatient ns * *** p <.10 * p <.05 ** p <.01 *** p <.001

38 Integrated Behavioral Health in Pediatric Primary Care Joseph H. Evans, PhD Professor Munroe-Meyer Institute University of Nebraska Medical Center

39 UNMC Munroe-Meyer Institute

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41 Addressing Pediatric Behavior Issues Parents most often bring their children with behavior problems to primary care physicians first (Wildman, Stancin, Golden, & Yerkey, 2007). Up to 25% of all Pediatric visits are for specific behavioral health concerns (Lavigne, Gibbons, Arend, et al, 1999; Williams, Klinepeter, Palmes et al, 2004, Cooper, et al, 2006). During 50% to 80% of child health care visits, parents or physicians raise concerns of behavioral or psychosocial issues (Sharp, Pantell, Murphy, & Lewis, 1992).

42 What Parents/Docs Expect!!!!

43 What Parents/Docs Sometimes Get!!!

44 Behavioral Problems Presenting in Pediatric Primary Care Non-compliance Excessive Tantrums Elimination Disorders Enuresis Encopresis ADHD Inattentive Hyperactive/Impulsive Combined Sleep Disorders Learning Disabilities School Behavior Problems & Refusal Developmental Delays Depression Anxiety Relationship Problems

45 LB 556 Screenings ( through )

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47 Addressing Pediatric Behavior Issues Problem: Shortage of Trained Peds BH Specialists - Significant MH professions shortages exist in 2/3 of U.S., particularly in rural areas (HRSA, 2009) - Appointments for Child Psychiatry or Psychology or LMHP can take weeks or even months - Patient follow-through with BH referrals = 46% for children and 25% for adults (Briggs-Gowan, 2000; Strosahl, 2006) - Physicians not well-trained nor comfortable with Behavioral Health problems

48 One Solution: Integrated Behavioral Health in Primary Care Defined as Provision of BH care within a primary health care setting Integration of behavioral and physical health care services Preventive and first line interventions for common behavioral/mental health problems presenting in primary care practices

49 MMI Pediatric Psychology Integrated BH Internship Data Last 11 Years (2004 to 2016) - Funding from HRSA BHPr: Graduate Psychology Education (GPE) grants Last 3 Years (2012 to 2015) HRSA Mental & Behavioral Health Education and Training (MBHET) grant Other Funding: LEND and Americorps NICPP MMI Interns = %+ enter Primary Care

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51 Why Pediatric Integrated Care? Primary Care Pediatricians are de facto first line mental health providers!!! 60% of all care mental health visits occur in Primary Care settings (Magill & Garrett, 1988) 25% pediatric PC visits include behavioral health concerns (Cooper, Valleley, Polaha, Begeny, Evans, 2006) Pediatricians ranked behavior as most common problem (over otitis) (Arndorfer, Allen, & Aljazireh, 1999) Pediatricians receive one month of Developmental and Behavioral Peds formal training during their residencies!!!

52 BH Treatment in Pediatric Primary Care 80-85% BH Tx in PC 10-15% Referral & Community Tx 5% Specialty Care

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54 UNMC Training in Integrated Behavioral Health in Primary Care Mission Attract, Recruit, Train, Place and Retain Behavioral Health Providers in Primary Care Practices (Pediatric and Family Medicine) Provide Learning Through Service & Modeling Opportunities - Provision of Behavioral Health in underserved areas Training for Physicians in Community Settings Research and Program Evaluation DISSEMINATION and Replication

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56 MMI Integrated Pediatric Behavioral Health Training Program Medical psychology training focuses on Bodily Systems and Diseases: Cardiology Pulmonology Endocrinology Oncology Gastroenterology Orthopedics, etc Psychiatry (OCD, Dementia, Schizophrenia Depression, etc) Primary Care psychology training focuses on Prevention & Wellness: In Pediatrics, Scheduled check-ups Anticipatory guidance Screening Acute Care protocols Management of Common Health issues Wellness Activities Knowing When & to Whom to Refer

57 UNMC/MMI Integrated BH Faculty, Interns, & Post-Docs-2014

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59 South Dakota 4 1 STATEWIDE IMPACT 297 Sioux Dawes Sheridan Cherry Keyapaha Boyd Iowa Holt Knox Cedar Brown Rock Dixon Dakota Box Butte Antelope Pierce Wayne Thurston Grant Hooker Thomas Blaine Loup Garfield Wheeler 88 Madison Stanton Cuming Scottsbluff Morrill Garden Burt Boone Arthur McPherson Logan Custer Valley Greeley Platte Colfax Dodge Banner Washington Nance Cheyenne Saunders Kimball Keith Lincoln Sherman 113 Howard Polk Butler Douglas Merrick Deuel Sarpy Dawson Buffalo Hall Hamilton York Seward Lancaster Perkins Cass Otoe Counties Served by Pediatric Chase Hayes Frontier Gosper Adams Clay 219 Phelps 272 Fillmore Saline Kearney Behavioral Health Gage 64 Nemaha 142 Johnson Clinics Serving Pediatric Dundy Hitchcock Red Willow Furnas Harlan Franklin Webster Nuckolls Thayer Jefferson Behavioral Health Pawnee Richardson Kansas 1 cc Nebraska Cities Served by Munroe-Meyer Pediatric Behavioral Health 1. Abie (Butler) 35. Bloomfield (Knox) 69. Crawford (Dawes) 103. Farnam (Dawson) 137. Hemingford (Box Butte) 2. Ainsworth (Brown) 36. Blue Hill (Webster) 70. Creston (Platte) 104. Filley (Gage) 138. Henderson (York) 3. Albion (Boone) 37. Boelus (Howard) 71. Crete (Saline) 105. Firth (Lancaster) 139. Hershey (Lincoln) 4. Alda (Hall) 38. Brainard (Butler) 72. Crookston (Cherry) 106. Fort Calhoun (Washington) 140. Hildreth (Franklin) 5. Allen (Dixon) 39. Bridgeport (Morrill) 73. Curtis (Frontier) 107. Franklin (Franklin) 141. Holdrege (Phelps) 6. Alliance (Box Butte) 40. Broken Bow (Custer) 74. Dannebrog (Howard) 108. Fremont (Dodge) 142. Holstein (Adams) 7. Alma (Harlan) 41. Burwell (Garfield) 75. Davenport (Thayer) 109. Friend (Saline) 143. Hooper (Dodge) 8. Amelia (Holt) 42. Cairo (Hall) 76. David City (Butler) 110. Fullerton (Nance) 144. Hordville (Hamilton) 9. Amherst (Buffalo) 43. Callaway (Custer) 77. Denton (Lancaster) 111. Furwell (Howard) 145. Hoskins (Wayne) 10. Anselmo (Custer) 44. Cambridge (Furnas) 78. Deshler (Thayer) 112. Geneva (Fillmore) 146. Howells (Colfax) 11. Ansley (Custer) 45. Campbell (Franklin) 79. Deweese (Clay) 113. Genoa (Nance) 147. Humphrey (Platte) 12. Arapahoe (Furnas) 46. Carleton (Thayer) 80. Dewitt (Saline) 114. Gering (Scottsbluff) 148. Hyannis (Grant) 13. Arcadia (Valley) 47. Carroll (Wayne) 81. Dodge (Dodge) 115. Gibbon (Buffalo) 149. Imperial (Chase) 14. Arlington (Washington) 48. Cedar Bluffs (Saunders) 82. Doniphan (Hall) 116. Giltner (Hamilton) 150. Indianola (Red Willow) 15. Ashby (Grant) 49. Cedar Creek (Cass) 83. Dorchester (Saline) 117. Glenvil (Clay) 151. Inland (Clay) 16. Ashland (Saunders) 50. Central City (Merrick) 84. Dunbar (Otoe) 118. Gordon (Sheridan) 152. Johnson Lake (Gosper) 17. Auburn (Nemaha) 51. Ceresco (Saunders) 85. Duncan (Platte) 119. Gothenburg (Dawson) 153. Juanita (Adams) 18. Aurora (Hamilton) 52. Chadron (Dawes) 86. Eagle (Cass) 120. Grand Island (Hall) 154. Julian (Nemaha) 19. Avoca (Cass) 53. Chambers (Holt) 87. Edgar (Clay) 121. Grant (Perkins) 155. Kearney (Buffalo) 20. Axtell (Kearney) 54. Chapman (Merrick) 88. Elgin (Antelope) 122. Greeley (Greeley) 156. Kenesaw (Adams) 21. Ayr (Adams) 55. Chappell (Deuel) 89. Elkhorn (Douglas) 123. Greenwood (Cass) 157. Kilgore (Cherry) 22. Bassett (Rock) 56. Chester (Thayer) 90. Ellsworth (Sheridan) 124. Gresham (York) 158. LaVista (Sarpy) 23. Battle Creek (Madison) 57. Clarks (Merrick) 91. Elm Creek (Buffalo) 125. Gretna (Sarpy) 159. Lawrence (Nuckolls) 24. Beatrice (Gage) 58. Clarkson (Colfax) 92. Elmwood (Cass) 126. Guide Rock (Webster) 160. Leigh (Colfax) 25. Beaver City (Furnas) 59. Clatonia (Gage) 93. Elwood (Gosper) 127. Hallam (Lancaster) 161. Leshara (Saunders) 26. Beaver Crossing (Seward) 60. Clay Center (Clay) 94. Emerson (Dakota) 128. Hampton (Hamilton) 162. Lexington (Dawson) 27. Belgrade (Nance) 61. Clearwater (Antelope) 95. Emmet (Holt) 129. Harrison (Sioux) 163. Lincoln (Lancaster) 28. Bellevue (Sarpy) 62. Coleridge (Cedar) 96. Ericson (Wheeler) 130. Hartington (Cedar) 164. Lindsay (Platte) 29. Bellwod (Butler) 63. Columbus (Platte) 97. Eustis (Frontier) 131. Harvard (Clay) 165. Litchfield (Sherman) 30. Bennet (Lancaster) 64. Cook (Johnson) 98. Exeter (Fillmore) 132. Hastings (Adams) 166. Loomis (Phelps) 31. Bennington (Douglas) 65. Cordova (Seward) 99. Fairbury (Jefferson) 133. Hay Springs (Sheridan) 167. Louisville (Cass) 32. Bertrand (Phelps) 66. Cortland (Gage) 100. Fairfield (Clay) 134. Hazard (Sherman) 168. Loup City (Sherman) 33. Bladen (Webster) 67. Cotesfield (Howard) 101. Fairmont (Fillmore) 135. Heartwell (Kearney) 169. Lyons (Burt) 34. Blair (Washington) 68. Cozad (Dawson) 102. Falls City (Richardson) 136. Hebron (Thayer) 170. Macy (Thurston) I drive/psych/evans/cities BHC located in 2006.ppt 205. Oakdale (Antelope) 239. Richland (Platte) 240. Rising City (Butler) 206. Oakland (Burt) 241. Riverdale (Buffalo) 207. Octavia (Butler) 242. Riverton (Franklin) 208. Odell (Gage) 243. Rosalie (Thurston) 209. Ogallala (Keith) 244. Roscoe (Keith) 210. Omaha (Douglas) 245. Roseland (Adams) 211. Ord (Valley) 246. Rushville (Sheridan) 212. Orleans (Harlan) 247. Saint Libory (Howard) 213. Osceola (Polk) 171. Madison (Madison) 214. Osmond (Pierce) 248. Sargent (Custer) 172. Marquette (Hamilton) 215. Overton (Dawson) 249. Schuyler (Colfax) 173. Marsland (Dawes) 216. Oxford (Furnas) 250. Scotia (Greeley) 174. Martell (Lancaster) 217. Page (Holt) 251. Scottsbluff (Scottsbluff) 175. Martin (Hall) 218. Palisade (Hitchcock) 252. Scribner (Dodge) 176. Mason City (Custer) 219. Palmyra (Otoe) 253. Seward (Seward) 177. Max (Dundy) 220. Panama (Lancaster) 254. Shelby (Polk) 178. Maxwell (Lincoln) 221. Papillion (Sarpy) 255. Shelton (Buffalo) 179. Maywood (Frontier) 222. Peru (Nemaha) 256. Shickley (Fillmore) 180. McCool Junction (York) 223. Petersburg (Boone) 257. Shubert (Richardson) 181. McCook (Red Willow) 224. Phillips (Hamilton) 258. Sidney (Cheyenne) 182. Mead (Saunders) 225. Pickrell (Gage) 259. Silver Creek (Merrick) 183. Meadow Grove (Madison) 226. Pierce (Pierce) 260. Smithfield (Gosper) 184. Memphis (Saunders) 227. Platte Center (Platte) 261. Springfield (Sarpy) 185. Merna (Custer) 228. Plattsmouth (Cass) 262. St. Edward (Boone) 186. Milford (Seward) 229. Pleasanton (Buffalo) 263. St. Paul (Howard) 187. Miller (Buffalo) 230. Plymouth (Jefferson) 264. Stanton (Stanton) 188. Minatare (Scottsbluff) 231. Polk (Polk) 265. Stapleton (Logan) 189. Minden (Kearney) 232. Prague (Saunders) 266. Sterling (Johnson) 190. Monroe (Platte) 233. Prosser (Adams) 267. Stromsburg (Polk) 191. Mullen (Hooker) 234. Ralston (Douglas) 268. Sumner (Dawson) 192. Murdock (Cass) 235. Randolph (Cedar) 269. Superior (Nuckolls) 193. Murray (Cass) 236. Ravenna (Buffalo) 270. Surprise (Butler) 194. Naponee (Franklin) 237. Red Cloud (Webster) 271. Sutherland (Lincoln) 195. Nebraska City (Otoe) 238. Richfield (Sarpy) 272. Sutton (Clay) 196. Nehawka (Cass) 197. Neligh (Antelope) Cities Outside of Nebraska 4. Carter Lake 14. Harlan 24. Missouri 198. Nelson (Nuckolls) Served by MMI 5. Clarinda 15. Honey Creek Valley 199. Nenzel (Cherry) 200. Newman Grove (Madison) Pediatric Behavioral Health 6. Clarksville 16. Logan 25. Moorhead 26. Neola 7. Cornelia 17. Macedonia 201. Norfolk (Madison) 8. Council Bluffs 18. Magnolia 27. New Market 202. Norman (Kearney) IOWA 9. Crescent 19. Malvern 28. Oakland 203. North Bend (Dodge) 1. Ankeny 10. Defiance 20. McClelland 29. Pacific 204. North Platte (Lincoln) 2. Atlantic 11. Emerson 21. Merrill Junction Persia 3. Carson 12. Griswold 22. Minden Swanton (Saline) 274. Syracuse (Otoe) 275. Talmage (Otoe) 276. Taylor (Loup) 277. Tecumseh (Johnson) 278. Tekamah (Burt) 279. Tilden (Antelope) 280. Trumball (Clay) 281. Union (Cass) 282. Upland (Franklin) 283. Utica (Seward) 284. Valentine (Cherry) 285. Valley (Douglas) 286. Venango (Perkins) 287. Wahoo (Saunders) 288. Wallace (Lincoln) 289. Walthill (Thurston) 290. Walton (Lancaster) 291. Waverly (Lancaster) 292. Wayne (Wayne) 293. Weeping Water (Cass) 294. West Point (Cuming) 295. Western (Saline) 296. Weston (Saline) 297. White Clay (Sheridan) 298. Whitman (Grant) 299. Whitney (Dawes) 300. Wilber (Saline) 301. Wilcox (Kearney) 302. Winside (Wayne) 303. Wisner (Cuming) 304. Wood River (Hall) 305. York (York) 306. Yutan (Saunders) 32. Red Oak 42. Vail 33. Shelby 43. Walnut 34. Shenandoah 44. Waterloo 35. Sidney 45. Whiting 36. Sioux City 46. Whitten 37. Soldier 47. Wiota 38. Spaulding 48. Woodbine 39. Tennant 40. Treynor KANSAS 1. Almena SOUTH DAKOTA 1. Batesland 2. Martin 3. Pine Ridge 4. Porcupine

60 The Integrated Behavioral Health Model Components: Location, Location, Location: In the primary care practice Frequent contacts re: referrals with physicians and nurses Relationships with community schools, courts, agencies, other providers Provision of dx assessment info and clinical data for physicians (e.g., ADHD diagnostic protocols) Training in the Business of BH and primary care

61 Behavioral Health Clinics in Underserved Areas Columbus (20,000)Pediatrics Crawford (900) Medical Clinic Kearney (27,000) Physicians Clinic

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63 The MMI Integrated Behavioral Health Training Program Dissemination Locations: Current: Danville, Pennsylvania (Geisinger Health Systems see APA Monitor) Tampa, FL (University of South Florida Peds) Ann Arbor, Michigan (Univ of Michigan Peds) Planned: Johnson City, Tennessee (ETSU) Greenville, NC (Eastern Carolina University)

64 MMI Successes in Integrated Care RURAL Nebraska Clinics - 19 Integrated Sites with MMI Trained BH staff: 8 Owned 4 Contracted 7 Collaborating private practices URBAN Clinics (Omaha and Lincoln): 19 of 24 Pediatric Practices in Omaha are integrated (13 with MMI trained Psychologists) 4 of 7 Peds practices are integrated in Lincoln DISSEMINATION at 3 additional University/Community training sites in Florida, Pennsylvania and Michigan

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68 BH Referral Follow Through:Traditional Referral vs Integrated BH Resources 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% BH Appointment Follow Through Strosahl Adults Briggs-Gowan-kids 0 Overall IBH Clinics

69 Medication Cost Off-Set: Geisinger Clinics Pilot Project

70 Clinician Time Usage: University of Michigan Integrated BH Project

71 Reimbursements per Minute for Pediatric Primary Care Visits: MMI Integrated BH Clinics % Visit Type Reimbursement Rate when NO Behavioral Concern Raised M (SD) Reimbursement Rate when Behavioral Concern Raised M (SD) Average Difference in Reimbursements per Minute Acute 35% $16.68 (21.35) $5.89 (2.53) $10.79 Well-Child 28% $20.17(15.42) $9.34 (4.36) $10.83 Chronic 1% $7.37 (4.55) NA Psych Consult 36% $5.02 (6.01) NA Average $18.12 (18.56) $5.53 (15.57) $12.59 Not included due to no occurrences