DBT Skills Group: A Primary Care Success Story at a FQHC

Joan Fleishman, PsyD, Behavioral Health Clinical and Research Director, Department of Family MedicineOregon Health & Science University

Myong O, MSW, LCSW, Lead Behavioral Health Consultant, Family Medicine at RichmondOregon Health & Science University

Nate Goins, MA, PsyD CandidateGeorge Fox University

Collaborative Family Healthcare Association 17th Annual ConferenceOctober 15-17, 2015 Portland, Oregon U.S.A.

Session D1b in Period 1October 16, 2015

Faculty Disclosure

The presenters of this session• have NOT had any relevant financial

relationships during the past 12 months.

Learning Objectives

At the conclusion of this session, the participant will be able to:

• Identify the role and utility of DBT skills for complex care patients in a FQHC primary care.

• Name key features of group visits that contribute to their success with complex population in primary care.

• Describe how these groups can help meet healthcare system goals to meet the triple aim objectives.

Learning Assessment

• A learning assessment is required for CE credit.

• A question and answer period will be conducted at the end of this presentation.

Family Medicine at Richmond• Urban Community Health Center• Federally Qualified Health Center• Academic health center• OHSU Family Medicine Primary Care Providers --Faculty (Lots!) --resident (12)• 12,500 patients• Integrated Behavioral Health

– Embedded BHCs• Primary Care Behavioral Health Model

– REaCH Team– PMHNP– Consulting Psychiatrist

Our Patients

• Trauma/Chronic Stress/Mental Health– 4 or more ACES– + PC-PTSD screen– Social Determinants of Health– Substance use– Axis II disorders

• Somatic complaints/Physiological distress – Chronic pain– Chest pain– GI complaints– Headaches

Group Visits in Primary Care

• Chronic care model– DM, chronic pain, opiate dependence, hypertension,

asthma, OB, obesity• Mental health conditions– Mood disorders, OCD

• Example: Living Well with Chronic Conditions– Improvements in bio, psycho, & social functioning– Fewer days in hospital, outpatient visits, &

hospitalizations– Cost to savings ratio of approx 1:10

History of Groups in the Clinic

– Informal pilot: First group run by 2 social workers• Pt recruitment by BHCs • Complex trauma• 1 Social worker – Trained in DBT• No documentation in EHR

– Added second group• Providers became interested• Curriculum development

– Added third group• Women’s only

– Started running out of space

Dialectical Behavior Therapy• Marsha Linehan early 1990s

– Support oriented, cognitive-based, collaborative

• Traditional model– Weekly Individual and group sessions– 24 hr phone coaching– Medication management

• Richmond’s skills based groups– “DBT lite”– Weekly for 2 hrs for 6 weeks

• Why this model? – Primary care setting

• Skills based vs process oriented work

– Working towards the Triple Aim

Group Structure and Curriculum

• Modified from Coffee Creek Correctional Facility (with permission)– Grade 4 reading level

• Incorporated additional components based on BHC’s knowledge, patient interests– Mindfulness exercises every meeting– Body-mind techniques, such as yoga– Use of multimedia

• TED Talks• ACT Videos

– Psychoeducation• neurobiology/physiology of trauma• impact of mindfulness

Group Structure and Curriculum

• 4 six-week modules, 2 week break in between– Core Mindfulness• Wise Mind, Right vs Effective

– Distress Tolerance• Distraction, Radical Acceptance

– Emotion Regulation• Describing emotions• vulnerability to emotion

– Interpersonal Effectiveness• Boundaries, Validation

Women’s and Men’s Groups

• All women welcome• All men welcome

Increased the number of groups

Started new groups…

So what does the community think about these groups?

Providers?Patients?

Video clip

What has made these groups successful?

• For Patients– Lack social support– We address what they actually need• Address impact of trauma• Coping skills

• For providers– Support for complex patients

• For clinic/community– No cost access to DBT groups

What has made these groups successful?

– High levels of patient need & interest• Patients often familiar with “DBT”

– No charge to pts for groups– Embedded BH– BHCs don’t bill

– Provides space where patients labelled “Most difficult” are served• Protective factor for high-utilization patients• Offers relief to providers

– Leadership has been fully supportive– Large space available to hold group

What makes it difficult…

– Limited availability of space• Acupuncture, yoga, meetings, etc.

– No revenue generated– Variation in medical provider understanding• “Difficult” patients referred

– Group leader factors• No formal training offered at clinic• Time investment

What do you think?

• What groups are taking place in your setting?• What are the supports and barriers for groups

in your setting?• We are available for questions, now or later• We are available for consultation via e-mail:

Myong Oom@ohsu.edu

Bibliography / Reference

1. Amaro, H., Dai, J., Arévalo, S., Acevedo, A., Matsumoto, A., Nieves, R., & Prado, G. (2007). Effects of integrated trauma treatment on outcomes in a racially/ethnically diverse sample of women in urban community-based substance abuse treatment. Journal of Urban Health, 84(4), 508-522. 2. Samet, J.H., Friedmann, P., Saitz, R. (2001) .Benefits of Linking Primary Medical Care and Substance Abuse Services: Patient, Provider and Societal Perspectives. Archives of Internal Medicine, 161(1):85-91. 3. Sharp, D. M., Power, K. G., & Swanson, V. (2004). A comparison of the efficacy and acceptability of group versus individual cognitive behaviour therapy in the treatment of panic disorder and agoraphobia in primary care. Clinical Psychology & Psychotherapy, 11(2), 73-82. 4. Jaber, R., Braksmajer, A., & Trilling, J. (2006).Group Visits for Chronic Illness Care: Models, Benefits and Challenges. Family Practice Management, 13(1), 37-40. 5. Wagner, A. W., Rizvi, S. L., & Harned, M. S. (2007). Applications of dialectical behavior therapy to the treatment of complex trauma?related problems: When one case formulation does not fit all. Journal of Traumatic Stress, 20(4), 391-400.

Session Evaluation

Please complete and return theevaluation form to the classroom

monitor before leaving this session.

Thank you!