Behavioral Health Lab: Building a Strong Foundation for the Patient-

Centered Medical HomeJohanna Klaus, PhD, Director, Behavioral Health Lab

Sara Kornfield, PhD, Post-doctoral fellowErin Ingram, BA, MIRECC Research Coordinator

Dave Oslin, MD, MIRECC Director, ACOS MH

Collaborative Family Healthcare Association 13th Annual ConferenceOctober 27-29, 2011 Philadelphia, Pennsylvania U.S.A.

Session #E1October 28, 201111:15AM

Faculty Disclosure

We have not had any relevant financial relationships during the past 12 months.

Need/Practice Gap & Supporting Resources

Primary care mental health (PCMH) integration has blossomed at facilities throughout the VA, and is consistent with the adoption of the Patient Centered Medical Home. However, the implementation of evidence based protocols for the collaborative treatment of depression, anxiety, and alcohol misuse and the consistent use of assessment to evaluate treatment and program effectiveness (i.e. measurement based care) has been slower in adoption.

Systematic use of informatics tools to support evidence-based and measurement-based care can help address this gap.

Objectives• Describe how the Behavioral Health Lab is consistent with the

principles of the Patient-Centered Medical Home including improved access, care coordination, team-based care, and partnering with the patient.

• List the Behavioral Health Lab services and target populations and how the program can be adapted for changing or individual clinic needs.

• Describe the importance of measurement-based care with collaborative care programs for triage, patient education and symptom monitoring, and program quality improvement.

• Identify the use and features of the BHL software system that can assist in implementation of a PCMH approach, including screening of behavioral health problems and ongoing tracking of care.

Expected Outcome

Consider the benefit of a flexible informatics platform to help implement evidence based protocols in primary care to inform both patient treatment outcomes and program effectiveness.

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Patient Centered Medical HomeReplaces episodic care based on illness and patient

complaints with coordinated care and a long term healing relationship    

The Primary Care Team • Takes collective responsibility for patient care

• Responsible for providing all the patient’s health care needs

• Arranges for appropriate care with other specialties as needed 

Enhanced Access Enhanced communication between

• Patients• Providers• Staff

Continuous Improvement in our work

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The spectrum of mental health problems

Mild-to-Moderate Severe

Large Numbers“Sub-optimal” functioning

•Depression•Anxiety•Alcohol misuse

Brief InterventionsPrimary Care Providers

Smaller NumbersMajor Impairment•Severe depression, anxiety•Personality disorders•Schizophrenia or

bipolar disorder

Complex interventionsSpecialty Care Providers

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Philadelphia VA Integrated Care program – Behavioral Health Lab

A platform for the delivery of collaborative care in primary care

A public health focus on non-complex patients A partnership with PC A bridge to specialty care Patient centered care – incorporating convenience and

preference A program that stresses self- management and

collaborative decision making Measurement-based care Ever evolving…

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Clinical ProcessPatient Identification

Screening / Clinical Assessment / Casefinding

Initial Assessment

ConsultationOr

Referral Mgt

Treatment Recommendations

Brief Treatment &

Care Management

No treatment &

Refusal of care

Patient Education

and Promote Self-Care

Watchful waiting&

Brief Interventions

Specialty Care Evidence based protocols

Prevention / Health Promotion

BHL software – provides the platform

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Behavioral Health Laboratory: components

A clinical management program focused on:

Identification: screening, pharmacy based, direct to consumer, etc

Seek out patients Assessment and triage to appropriate level of care

Care Management / Brief treatment/ Health Promotion and Prevention

Using Specialty Care and facilitating engagement

Tracking: software program

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Behavioral Health Laboratory: components

A clinical management program focused on:

Identification: screening, pharmacy based, direct to consumer, etc

Assessment and triage to appropriate level of care

Care Management / Brief treatment/ Health Promotion and Prevention

Using Specialty Care and facilitating engagement

Tracking: software program

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Initial Triage

All patients entering the program complete standard initial assessment

Completed via phone or in person (patient preference)

Includes array of behavioral health symptoms and substance use and overall functioning

Helps determine next step in treatment Completion rate of 80% BHL Software output: clinical report, patient

letter

Initial Triage Assessment• Demographics• Current MH care • Financial status• Social support• Blessed Orientation-Memory-Concentration (>55 yrs or head injury)• Mini International Neuropsychiatric Interview (psychosis, mania, GAD, panic)• Depression assessment: PHQ-9• PTSD Checklist (PCL-c)• Anxiety assessment: GAD-7 (optional)• Brief Pain Inventory Interference scale • Current Psychotropic/Pain medications• 5-item Paykel scale for suicidal ideation• Alcohol use (7 day follow-back)• Illicit substance use• Depression history• Work Limitations questionnaire (optional)• SF-12 (optional)

Communicating with PC team

Characteristics of Veterans who completed the BHL pre-assessment

Demographics and Background N = 3348

Age (M, SD) (N=4163) 52.6 (16.1)

Race non-Hispanic White 1617 (49%)

Employed 946 (28%)

Married/PartneredSeparatedDivorced

1462 (44%)298 (9%)

728 (22%)

Finances “Can’t make ends meet” “Just enough to get along”

1016 (31%)1672 (50%)

Served in Iraq/Afghanistan post 9/11 815 (25%)

SF-12 Physical component score Mental component score

41.0 (12.9)38.6 (13.6)

Mental Health and Substance Use Diagnoses N, %

PTSD PCL-c (M, SD); N=2066

1368 (43%)51.8 (17.5)

Major DepressionOther depression PHQ-9 (M, SD)

1422 (43%)433 (13%)12.4 (7.0)

Panic Disorder, current 190 (6%)

Generalized Anxiety Disorder 1206 (38%)

Mania 183 (6%)

Psychosis 91 (3%)

At-risk Alcohol Use/AbuseAlcohol Dependence

467 (15%)

361 (11%)

Used street drugs, ever Marijuana use, past 3 months

1895 (57%)

394 (12%)

Clinically significant MH or SA symptoms 1603 (50%)

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Behavioral Health Laboratory: components

A clinical management program focused on:

Identification: screening, pharmacy based, direct to consumer, etc

Assessment and triage to appropriate level of care

Care Management / Brief treatment/ Health Promotion and Prevention

Using Specialty Care and facilitating engagement

Tracking: software program

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Behavioral Health Lab Interventions

Evidence based (or we are working on it) and stepped care approach

Longitudinal but brief treatments (can be by telephone – patient choice)

Promote patient self-management Collaborate with PCP Pharmacological support Measurement based

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Evidence Base for primary care delivered interventions

Robust Evidence Base Depression Care

management Alcohol Brief

Interventions (alcohol misuse)

Referral management

Growing Evidence Base Alcohol care

management (alcohol dependence)

Watchful waiting Anxiety care

management Pain care management

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Measurement Based: BHL Software

Built in interview for tracking follow-up contacts for care management/brief treatment

6 optional domains:• Depression: PHQ-9• Anxiety: GAD-7• PTSD: PCL-c• Pain: BPI for pain interference• Alcohol: 7-day time line follow-back• Referral Management: to track engagement in

specialty care

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BHL Software support: patient level feedback

Tracking structured assessments:

•Ability to provide feedback to both the provider and the patient •Progress reports generated by BHL software

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BHL Clinician: the Glue

Primary Care Clinician

Mental Health Supervisor

BHL clinician Patient

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Behavioral Health Laboratory: components

A clinical management program focused on:

Identification: screening, pharmacy based, direct to consumer, etc

Assessment and triage to appropriate level of care

Care Management / Brief treatment/ Health Promotion and Prevention

Using Specialty Care and facilitating engagement

Tracking: software program

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Referral Management

Problem: low attendance rates for MH/SA treatment (30-40%)

Goal: increase referral adherence in symptomatic patients with complex behavioral health care needs

Possible psychosisDrug addictionManiaSevere/complicated depression or anxiety

Uses a motivational interviewing style to provide clinical support and promote problem-solving skills

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Appropriate Use of Specialty Care:Referral Management Module

Attended 1st

Appointment

Motivational Session 70%

Control Group 32%

Zanjani et al, 2008

p < .001

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Behavioral Health Laboratory: components

A clinical management program focused on:

Identification: screening, pharmacy based, direct to consumer, etc

Assessment and triage to appropriate level of care

Care Management / Brief treatment/ Health Promotion and Prevention

Using Specialty Care and facilitating engagement

Tracking: software program

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BHL Software Platform• Provides structured assessments across providers

and settings• Programmable decision logic that is exportable across

sites and testable• Allows capacity to define and follow a cohort of

subjects with prompts for additional clinical actions (panel management for follow ups)

• Allows integration across mental health conditions (not just one disorder)

• Creates patient material, including treatment progress• Provides program level outcome data• Allows rapid research engagement

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Patient Tracking: Panel Management

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Patient Tracking: Patient History Page

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Patient Tracking– Measurement based care

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Patient Level Reports Progress Note Creation for all interviews:

• Treatment plan• Results of all assessments

Patient letters and Progress reports• Patient education • Visual for treatment

progress

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Program Level Outcome Data

OUTCOME DATA: Available at the program, clinic, Primary Care Provider and staff level

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BHL as a platform: ex. Developing a Treatment for PTSD

• Of >17,000 BHL assessments 5,651 (33.2%) positive for PTSD; PCL-c mean = 49.8 (18.2)

• PTSD positive veterans: more symptomatic– 66% with depression vs 29% of PTSD negative

– More likely to have psychosis, mania, illicit drug use, problem drinking, other anxiety disorders

But 17% of Veterans at Philadelphia referred to specialty care because they endorsed symptoms consistent with PTSD had PCL scores < 60.

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PTSD Brief Treatment

For lower level PTSD symptoms 6-8 sessions of about 30 minutes 1-4 sessions focus on psychoeducation,

behavioral activation, and mindfulness Extra sessions for anger management, sleep,

alcohol misuse as needed Current pilot; outcomes soon

• Effective treatment? • Secondary triage?• Warm-up for evidence based treatment?

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Increase identification of patients needing behavioral health services (Oslin et al, 2006)

Increase engagement in specialty care (Zanjani et al, 2008)

Improve outcomes for depression and alcohol misuse (Oslin et al, 2003)

Platform for new treatments and research Allows for efficient staffing and collaboration with PC

The triage and tracking mechanisms allow for seamless referral and the ability to reduce waiting times, prioritize care, and provide administrative support for monitoring.

Behavioral Health Lab: In Summary

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Patient-Centered Medical Home and the Behavioral Health Lab

Key Principles Behavioral Health Lab

Patient-driven

Team-based

Efficient

Comprehensive

Continuous

Communication

Coordinated

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More information?

Session Evaluation

Please complete and return theevaluation form to the classroom monitor

before leaving this session.

Thank you!