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PCBH
Foundations
Day 2: Getting
Your BHC Wings
Presented By: Patricia Robison, PhD
Mountainview Consulting Group
Oregon’s PCPCH Model is defined by six core attributes, each with specific standards and measures
• Access to Care – “Be there when we need you”
• Accountability – “Take responsibility for us to receive the best possible health care”
• Comprehensive Whole Person Care – “Provide/help us get the health care and information we need”
• Continuity– “Be our partner over time in caring for us”
• Coordination and Integration – “Help us navigate the system to get the care we need safely and timely
manner”
• Person and Family Centered Care – “Recognize we are the most important part of the care team, and we our
responsible for our overall health and wellness”
Read more: http://primarycarehome.oregon.gov
PCPCH Model of Care
PCBH Foundations Training
1. Tuesday: Getting Your BHC WingsConsultation, Team, and Clinical Competencies
2. Wednesday: Tool Kit and Initial Visit Clinical Competencies
3. Thursday: Communication, Follow-up Visit, Group and Other InterventionsClinical, Team, Consultation, Documentation Practice Management Competencies
4. Friday: Administrative Procedures, Pathways, Meds, More Interventions, GraduationAdministrative and Clinical Competencies
Daily Routines
Schedule
– 10:30 Break
– 12-1 Lunch
– 2:30 Break
– 4:00 End (Friday at 3:00)
Afternoon: 2+ Participant presentations (Patient Ed
protocols or case example)
3:45 Daily Review Q & A (Tues-Thurs)
Getting the Lay of the Land
• Introduction to Primary Care
– Primary Care Terms
– Your New Colleagues
• Start Up Checklist
• Competency Self-Assessment Review, Discussion, Goal Setting
• Consultation Competencies
• Team Competencies: Influencing PCCs and RNs
• Influencing Patients
A Primer on Primary Care
The Mission:
Provision of integrated, accessible health care
services by clinicians who are accountable for
addressing a large majority of personal health care
needs, developing a sustained partnership with
patients and practicing in the context of family and
community.
Institute of Medicine
Four Functions of PC
Providing:
1. Accessible
2. Comprehensive
3. Longitudinal
4. Coordinated
care in the context of families and communities.
Starfield
National Academy of Sciences
Triple Aim
Centers for Medicare and Medicaid (CMS) adopted
his moniker; lots of effort to measure these 3 goals
Affordable Care Act
• A series of health insurance reforms
signed into law March, 2010
• 15 billion for prevention and public
health
• Guidance for care of ill (Community
Care Transition Programs)
• Address health disparities (millions
of uninsured to soon be insured)
Accountable Care Organizations (ACOs)
• Provider-led, strong PC base, collectively
accountable for quality and total per capita costs
across the full continuum of care for a population
of patients
– Payments link to quality improvements that reduce
overall costs
– Performance is reliably measured
Coordinated Care Organization CCOs)
• Network of different types of health care
providers (medical, addictions, MH, dental)
• Agreeing to work together to better serve the
health care needs of people in their community
• Provide both preventive and chronic care
management services
OHA Transformation Center
• Will support CCOs, and the adoption of the coordinated care model throughout the health care system, through technical assistance and learning collaboratives that foster peer-to-peer sharing of best practices among CCOs and other health plans and payers
http://transformationcenter.org/
Primary Care Clinicians (PCCs)
• Independently make decisions about all aspects of patient care
• Leader of the team
• Includes physicians, nurse practitioners, physician assistants, naturopathic physicians
• Most trained minimally in BH interventions
• Trained in medical model: Match symptoms to diagnosis and provide EBT
RNs, CNAs, Others
• RNs: Coordinate a variety of patient care activities; provide triage; provide chronic disease management services; provide chronic care services to MH patients
• CNAs/MAs: Involved throughout patient visit
• Support staff: Front desk, Ward Clerks, Appointment Line, Billing Specialists, Interpreters
PCBH Impact: PCPs
• All PCPs reported
– Satisfaction with the PCBH program
– Improved job satisfaction
– Better able to address behavioral
problems
– Recommend the service for other sites
Your Digs
Location
Pros and Cons of options
Ways to work with limitations
Equipment
Start Up Checklist
• Week 1: Be Visible & Get the Lay of the Land
� Set-up voicemail, email, portal account, pager
and/or text plan
� Have your number added to roster
� Post list of staff and PCC contact numbers at your
work station
� Meet with BHC mentor & senior leadership
� Clarify billing plan
Start Up Checklist
• Week 1: Be Visible & Get the Lay of the Land
� Shadow every willing PCC for part of the day &
survey PCCs re: problems they most desire help with
� Obtain list of clinic meetings and determine which
to attend; attend huddles & clinical team meetings
� Form a PCBH steering committee
� Refine BHC program manual and move toward
ratification
� Visit or call important social service organization you
may use
Start Up Checklist
• Week 2: Begin Patient Care and Continue
Service Planning
� Meet with scheduling staff to discuss BHC
appointments; develop initial visit template
� Practice role introduction
� Learn EMR and / or dictation service
� Clarify CNA support to BHC
� Talk with interpreters about BHC services
� Prepare patient education handouts, outcome and
screening tools
Start Up Checklist
• Week 2: Begin Patient Care and Continue Service
Planning
� Review clinic risk management policies & procedures
� Shadow an experienced BHC
� Distribute handout to staff (intro self and service)
� Speak at a provider’s meeting
� Talk with referral manager and visit affiliated MH
service (if available)
� Walk through clinic hourly
� See patients!
Start Up Checklist
• Week 3 & Beyond: Expand and Be Guided by
Outcomes
� Preview schedules with PCCs (or by self) to identify
possible same-day patients
� Administer Referral Barriers Questionnaire and use
results to increase referrals
� Develop needed or requested materials
� Start classes or groups
Start Up Checklist
• Week 3 & Beyond: Expand and Be Guided by
Outcomes
� Start pathway development project
� Schedule standing time in provider / staff meetings
� Problem solve processes for evaluating program
� Spend another day with experienced BHC with plan
of observing class or pathway activity
BHC Competencies
• Review Self Assessments
• Q & A
• Clarification by modeling
• Set learning targets for week; 3 / domain
• Discuss with partner (will work together
again on Friday)
Consultation Competencies
• Differences between a psychotherapist and a
consultant, beginning with referral
• Role of consultant
• Expectation of referring PCC
Population-Based Care
1. A community perspective
2. A clinical epidemiology perspective (population-
based data)
3. Evidence-based practice
4. Emphasis on effective outcomes
5. Emphasis on primary prevention
From wellness to illness; optimal aging
Your Primary Customer Is . . .
1. Very busy
2. Stands to gain a great
deal from your
services
3. May not know this
How can you best
influence him / her?
Influencing PCCs
• Share evidence (1/2 page handouts)
• Shadowing (see Shadowing sheet)
• Scrub schedule
• Request of the day at huddles
• Exam room posters
• Routine orientation of new PCCs, RNs, CNAs
• Short presentations at meetings
Influencing PCCs
• The Evidence
– Improved job satisfaction
– Improved ability to serve patient with BH needs
– Improvement in ability to ser patients with substance
abuse needs
– Increase in rate of using behavioral intervention and
decrease in prescribing
PCCs: Use of a Relapse Prevention Plan
Are you facing difficult problems and
having trouble finding solutions?
� Reach out; talk to your PCM or Nurse today
� Coaching on problem solving is available in primary care
� You may be able to see the Behavioral Health Consultant (BHC) today
Practice
Find a Launch partner:
Pretend that you have 5 minutes to present evidence
about the PCBH model at a staff meeting. Select your
slides (okay to use some from yesterday, along with
some from today)
1. Make a 5-minute presentation to your partner (who
is a PCC at the meeting)
2. Switch roles
Dimension PCBH Spec. MH
1. Model of Care Population-based Client-based
2. PC Receivers PCP, then patient Client, then others
3. Key Goals PCP efficiency Intensive services
Small changeLess time for prevention
Prevent morbidity, high risk
Achieves med. cost offset
You Might Mention Some of These Points
Dimension PCBH Spec. MH
4. Therapy model Part of PC TeamSpecialized &
separate
5. Care manager PCP Therapist
6. Dominant modality
Consultation Specialty TX
7. Access to care Same day, every day Variable
8. Cost / episode Potentially lessHighly variable,
related to pt condition
You Might Mention Some of These Points
Practice
With your Launch partner:
Pretend that you have 3-5 minutes to talk about the
differences between the PCBH model and specialty MH
services at a staff meeting. Select the slides you will use.
1. Make a 3-5-minute presentation to your partner
(who is a PCC at the meeting)
2. Switch roles
Practice
• Review PCC and RN Competencies from Day 1
– What could you teach?
– What do you need help with?
• Discussion
• Small Group Practice
Influencing Patients
• The Evidence
– 90% said visit length “just about right”
– 76% were satisfied with ability to get appt
– 83% felt BHC understood their problems
– 89% said it was helpful to meet with BHC
– 65% said physical health improved
– 72% said mental health improved
Children: PSC Total Scores
*62% Hispanic, 40% Spanish-speaking
RURAL HC System
Adults with Chronic Disease: Duke Scores
*62% Hispanic, 40% Spanish-speaking
RURAL HC System
Adults with Major Depression:
Use of Coping Skills
CC
UC
Adults with Minor Depression:
Use of Coping Skills
CC
UC
EXAMPLE: STEP-UP PATHWAY
Evidence for PCBH Impact on Linkage
• BHC use of a “referral
management”module
increases engagement
twofold over typical
reminder mechanisms
such as automated
telephone remindfers
(Zanjani, 2008)
• Recent RCT: PCB with
module vs without
Influencing Patients
• Adapting ESTs for Primary Care
– See book chapter (USB)
• Framing the Problem for Change
– May see only 1 X; normalizing, de-pathologizing; strength context; framed as problem to solve; acceptance; bigger picture; will pass; trajectory questions, etc.
• Commonly Taught Skills
– See booklets, Living Life Well, Using Medications Successfully
Team Competencies
Is this true for you?
Understands and operates comfortably within primary care
culture
Shows awareness of team roles
When away from station, leaves information as to location and
time of return
Readily provides unscheduled services when needed
Is available for on-demand consultations
Wrap-Up
• Participant presentations
• Daily review
PCBH
Foundations
Day 3:
Tool Kit and
Initial Visit
Presented By: Patricia Robison, PhD
Mountainview Consulting Group
The PBCH Tool Kit
• The PCBH Manual (Tab 1)
– Vision and Mission
– Guidelines, Goals and Objectives
– Roles and Responsibilities of the PCBH team
– Training Program Overview
– Clinical Activities
• Brief Intervention Services, Pathways, Excluded Services
• Practice Support Tools
Primary Care
Behavioral Health
Toolkit
Provided as part of Primary Care Behavioral Health (PCBH) Introduction and Foundations
training provided by Mountainview Consulting Group through the Patient-Centered Primary
Care Institute
October 2013
A public-private partnership transforming primary care
www.pcpci.org
Mountainview
Consulting Group
The PBCH Tool Kit
• The PCBH Manual (continued)
– Clinical Activities
• Practice Support Tools
– Scripts for RNs, PCCs, clinical guides for BHCs
• Outcome Assessment Tools and Screeners
• Clinical Policies and Procedures
– Patient access, Informed consent, clinical assessment standards
• Quality Assurance of Charting and Documentation
• Providing Feedback to PCC
• Medication Consultations, Psychiatric Consults
The PBCH Tool Kit
• The PCBH Manual (continued)
– Administrative Procedures (BHC appointment
template, revenue/billing, performance measures
including staffing guidelines and productivity
standards)
– Core Competencies
The PBCH Tool Kit
• The PCBH Manual Appendices
– Performance Measures (A – Tab 2)
– Core Competency Tools (B – Tab 3)
– Self Assessment Tools (C – Tab 4)
– Pathway Program Examples (D & E – Tabs 5 & 6)
– Practice Supports: Referral scripts, referral form,
interview note form, chart not example, intervention
quick guide, interventions for 7 common referrals,
PCBH Introduction (F – Tab 7)
The PBCH Tool Kit
• The PCBH Manual Appendices (continued)
– Assessment and Screeners: List, Outcome, As
Indicated (G – Tab 8)
– Patient Brochure Example (H – Tab 9)
– Quality Management Chart Tool (I – Tab 10)
– PCBH Model References (J – Tab 11)
Patient Education Protocols (Tab 12)
• ADHD
• Adherence Using Meds Successfully
• Alcohol & Low Risk Drinking
• Anxiety & Coping with Panic Attacks
• Anxiety
• Chronic Pain
• Depression – Postpartum
• Depression
• Exercise & Physical Activity
• Grief
• Headaches
• Hypertension
• Parenting Protocol
• Relationship Problems
• Relationship Sexual Problems
• Sleep & Insomnia
• Sleep Apnea
• Sleep Behavior Change & Diary
• Sleep Class Packet
• Stress
• Substance Misuse & Maintaining Behavior Change
• Weight Management
Content Quiz on Manual
• True / False
• Score as we discuss
• There are a lot of grey areas
The Initial Visit
• Clinical Competencies (this morning)
– Goals of initial visit
– Case conceptualization
– Receiving a referral
– Your introduction
– Completion of outcome tools
– Review of screeners
– Identifying a target problem
The Initial Visit
• Clinical Competencies (this morning)
– Problem severity rating
– Conducting a target problem analysis
– Case conceptualization during the visit
– Problem summary statement
– Offering options
Case Conceptualization:
What is Your Philosophy?
PCBH Philosophy Your Philosophy
Maladaptive behaviors are
learned and maintained by
various external and internal
factors
Many maladaptive behaviors occur
as a result of skill deficits
Direct behavior change is the most
powerful form of human learning
Write out your philosophy; discuss in groups of four.
Factors to Consider in Conceptualizing
• Distress level
• Life as a context for problem
• Impact of problem on functioning
• Antecedents / consequences
• Efforts to address problem, workability
• Values Connection
• Stance: Approach, Avoidance
Case Conceptualization
How do skills play into patient’s current
situation?
Has skill but
avoids action
Doesn’t have a
skillHas disability
Exposure
Instruction
(modeling,
guided
rehearsal)
Principles of
Reinforcement
Case Conceptualization
What have you learned about the patient?
Two
types of
patient
behavior
Too Much Not enough
PublicImpulsive,
numbing action
Lack of action
consistent
w/values
Private
Lost in thoughts,
emotions,
thoughts - high
struggle
Desire, passion,
belief in better
future
Intervention Target(s)?
Access and Receiving a Referral
• Access to BHC
– Discussion:
• How can patients access the BHC?
• How can the BHC reduce potential barriers?
• Receiving a Referral
– Clarifying Question or Target Problem
Goals of Initial Visit
• Assessment
– Can patient be served in PC?
• Target problem analysis
• Intervention
• Recommendation to Patient, PCC
Initial Consult; Follow-up As Needed
Introduction
5 minutes
Snapshot
5 minutes
Functional Analysis
5 – 10 minutes
Problem Summary/Behavior Change Plan
5 – 10 minutes
Charting/Feedback to PCP
5 minutes
Physician refers to BHC for specific
problem / question
Clinician review recommendations;
retains full responsibility for patient care
decisions
Patient implements behavior change
plan, returns for follow-up as needed
Clinical Practice Skills:
The 30-Minute Consult
Informed Consent
• When patients sign their consent to receive
primary care treatment, they are also
signing consent for PCBH services
• PCBH providers will provide a brief
description of PCBH services at the first
patient visit. This description will be
consistent with the PCBH brochure
– Read PCBH brochure
– Practice introduction and giving PCBH
brochure
The 30 Minute Consult:
Introduction
• Your profession & title
– psychologist/SW/other & Behavioral Health Consultant
• Explain BHC role
– Enhance usual care; consultant to PCC and patient, biopsychosocial care
• Structure of appointment
– 15 to get a snapshot of your life and look at the referral concern, then 5
minutes to offer suggestions to help you improve your quality of life and
make a follow-up plan
• Commonalities with PCM
– chart to medical record, same reporting requirements)
• Linkage back to PCC
DUKE & PSC PRACTICE
• See Duke
and PSC
• Model
• Practice
with partner
• Quick look
at screeners
in manual
appendix
Duke Health Profile (The DUKE) Copyright 1989, 1994 by Dept of Community & Family Medicine, Duke Univ Medical Center, Durham, NC. For a manual and for
permission to use, contact George R. Parkerson, Jr, MD, MP; (919) 634-3620, Ext 452; E-mail: [email protected].
Patient Sex: [ ] Female [ ] Male Date of Visit: _______________ Last 4: ________
INTERVIEWER: Give these instructions: “I’ll ask you some questions about your health and feelings. Please listen to each question
carefully and give me your best answer. You should answer the questions in your own way. There are not right or wrong
answers.”
Interviewer: Read each question verbatim and circle
response number.
Yes, describes me
exactly.
Somewhat
describes me.
No, doesn’t
describe me at all.
1. I like who I am. 2 1 0
2. I am not an easy person to get along with. 0 1 2
3. I am basically a healthy person. 2 1 0
4. I give up too easily. 0 1 2
5. I have difficulty concentrating. 0 1 2
6. I am happy with my family. 2 1 0
7. I am comfortable being around people. 2 1 0
“TODAY would you have any physical trouble or
difficulty:
None Some A Lot
8. Walking up a flight of stairs?” 2 1 0
9. Running the length of a football field?” 2 1 0
“DURING THE PAST WEEK, how much trouble have
you had with…”
None Some A Lot
10. Sleeping?” 2 1 0
11. Hurting or aching in any part of your body?” 2 1 0
12. Getting tired easily?” 2 1 0
13. Feeling depressed or sad?” 2 1 0
14. Nervousness?” 2 1 0
“DURING THE PAST WEEK, how often did you…” None Some A Lot
15. Socialize with other people (talk or visit with
friends or relatives)?” 0 1 2
16. Take part in social, religious, or recreational
activities (meetings, church, movies, sports, parties)?” 0 1 2
“DURING THE PAST WEEK, how often did you…” None Some A Lot
17. “Stay in your home, a nursing home, or hospital
because of sickness, injury, or other health problem?” 2 1 0
QUALITY OF LIFE SCORE: Physical Health ________ Mental Health ________ Social Health ________
Snapshot Questions
• Where do you live? How long? With whom?
How’s that going?
• Relationships with
spouse/partner/roommate/children?
• Relationship with friends?
• Work? What do you do? Do you like it? Attend
school? How’s that going?
Snapshot Questions
• What do you do for fun? Relaxation?
• Spiritual practice or community involvement?
• Health status (chronic disease, meds)
• Health risk / health protection behaviors?
(Excessive TV, video games, tobacco, drugs,
alcohol, exercise, sports, outside play, clubs)
Love, Work, Play – Interview Tool
Love Where do you live? With whom?
How long have you been there?
Are things okay at your home?
Do you have loving relationships with your family or friends?
Work Do you work? Study? If yes, what is your work?
Do you enjoy it? If no, are you looking for work?
If no, how do your support yourself?
Play What do you do for fun? For relaxation?
For connecting with people in your neighborhood or community?
Health Do you use tobacco products, alcohol, illegal drugs?
Do you exercise on a regular basis for your health?
Do you eat well? Sleep well?
Target Problem Analysis
• Not a diagnostic assessment
• Focus referral question/problem/concern
• Onset
• Triggers
• Duration, Intensity, Frequency
• Impact on functioning
• Coping Efforts
• Workability
The Three T Interview Questions
Time When did this start? How often does it happen? Does it happen at a particular time? What happens just before the problem? Immediately after the problem?
Trigger What do you think is causing the problem? Is there anything or anyone that seems to set it off?
Trajectory What’s this problem been like over time? Have there
been times when it was less of a concern? More of a
concern? What have you tried in the past?
Workability How have the things you’ve tried worked in the short run? In the long run or in the sense of being consistent with what really matters to you?
Potential Issues & Useful Questions
• Potential clinical issues that may require further attention from PCC:
– Medication related issues
– ETOH or drug use
– Domestic violence, child abuse
• Often useful:
– What does a typical day look like?
– What does a typical weekend day look like?
An Important Transition from Target Problem Focus
to Behavior Change / Brief Intervention Focus
Problem Summary
• Express empathy / engage the patient
– “This sounds very difficult and I can see that you’ve
tried…”
• Strategic Reframe: Simplify and reduce the
magnitude of the problem
– “So, you’ve been feeling a lot of stress since loosing your
job and it appears to be affecting your ability to relax and
to sleep at night.”
Problem Summary
• Help patient generate new strategies
– “If a miracle happened…”
• Create a do-able framework for change
– “Let’s take it one step at a time. I think the first step could
be x or y; what makes sense to you?”
• Offer options
The Initial Visit
• Clinical Competencies (after lunch)
– Educational and Skill Building Interventions
– Community Linkage
– Behavioral health prescription pads
– Confidence rating
– Planning follow-up
– Helpfulness rating
Behavior Change Basics
• Focus on function, not cure
– “My job is to help you and your doctor improve your overall
quality of life; often one or two small changes in our daily
routine can make a big difference over time.”
• Process Check
– “So at this point you are interested in…?”
• Assess patient values related to problem
– “In terms of what you think is really important in life--your
core values--why does this change seem important at this
time?”
Behavior Change Plan
• Look for patient strengths to use in plan
• Emphasize idea of small positives
• Use external supports to promote success
• Frame plan as an “experiment” & collect data
• Assess patient confidence in plan
• Does patient lack a pre-requisite skill?
• Provide a written copy of plan (RX pad or PCBH
brochure)
BHOP RX Pad Example
Susie Smith, Behavioral Health Consultant
Your Clinic Phone: 123-456-7890
Plan Week 1
Sun Mon Tues Wed Thur Fri Sat
1.
Week 2
Sun Mon Tues Wed Thur Fri Sat
2.
Your notes about behavior change experiment:
Please return: ____________ For Visit With: ____________
BHOP RX Pad Example
Susie Smith, Behavioral Health Consultant
Your Clinic Phone: 123-456-7890
Plan:
The Bulls-Eye PlanA Team-Based Behavior Change Intervention
Action Steps
1.
2.
3.
Value
Statement Love, Work, Play
Practice
• Forming a Plan
• Using RX Pad
• Asking Confidence
Question
• Planning Follow-Up
• Asking Helpfulness
Question
• Timed Practice Initial
Visit
• Participant
presentations
• Daily review
PCBH
Foundations
Day 4: Charting,
Communication,
Follow Up,
Groups and Other
Interventions
Presented By: Patricia Robison, PhD
Mountainview Consulting Group
Communications
• Non-verbals
• How to interrupt when you need to
• Brief, focused, specific
• Giving Feedback
– Same day and face-to-face if possible (close the loop)
– Problem, your impression, recommendation to
patient and to PCC, your follow-up plan
BHC Charting
• Chart note includes:
1. Referring PCC, referral question
2. Patient given standard information about PCBH
3. Pertinent history, functional analysis data
4. Results of any self-report measures administered
5. Risk evaluation results, as indicated
6. Clinical impression / Referral response
7. Recommendations for PCC (& given to PCC)
8. Recommendations for patient; BHC f/u plan
Demonstration
• Initial visit role play (your
choice)
• Watch and . . .
– Time components of
interview and total time
– Chart note
– Use chart review tool to
evaluate note
– Give FB to PCC
Goals of Follow-Up Visit
• Re-assessment
– Improving, Stable, Deteriorating
• Experience with implementing plan
– Impact of Plan
• Development of new plan (or support of initial
plan)
• Teach additional skills; provide additional
information
Demonstration
• Follow-up visit role play
(your choice)
• Watch and . . .
– Time components of
interview and total time
– Chart note
– Use follow-up chart review
tool to evaluate note
– Give FB to PCC
Practice Management
• Staying on-time, using groups to deepen skill training
• Missed appointments– All missed appointments with the BHC will be
documented in the progress note section of the patient’s medical record
– Additionally, the BHC will attempt to telephone a patient who does not show for a scheduled follow-up visit and, if possible, provide services by phone when the patient is reached
– Charting ensures that the PCc knows that the patient did not follow through with a scheduled appointment or received BHC services by phone
Class Visits in Primary Care
• Goals
– Provide more skill training
– Better management of a
population (e.g., chronic
condition)
• Better use of resources
• Measure outcomes
• Improve outcomes (e.g., pt
& PCM satisfaction, pt
confidence in self-
management, pt’s rate of
behavior-value
consistency)
• Approaches
– The QOL or Life
Satisfaction Class (a
generic class)
– Open Access for high
impact pops (e.g., LEARN
adapted for PC)
– Group Medical Visits,
including Group Clinics
(standard care for a
specific group, e.g., older
adults, ADHD, chronic
pain) & DIGMA
Classes
• Generic
• Open Access
• Psycho-educational
• Continuity statements
• Usually 1 hour
• Use feasible assessment and chart
• Announce in Exam Room Posters
Groups
• Monthly
• On-going management
• On-going skill training
• Measurement of outcomes over time
• Often related to pathway
• May be drop-in or required
• May be lead by BHC / BA alone or co-led with PC Team members
Typical PC Group Agenda /Activities
Time Topic
5 minutes Assessments
5 minutes Introductions, Updates (continuity statement)
10 minutes Lecture
10 minutes Skill Training
10 minutes Discussion/Application of Skill & Individualized
Homework Plans
10 minutes Wrap-Up
30 minutes Charting (1 – 3 minutes, 10 patients)
Group or Individual Visits
PCBH Foundations
Day 5:
Administrative
Procedures,
Pathways, Meds,
Interventions &
Graduation
Presented By: Patricia Robison, PhD
Mountainview Consulting Group
Administrative Procedures
• BHC Productivity Standards
– 10 face to face / day
• PCCs will refer between two and eight patients
per day to the BHC
• BHCs will receive monthly feedback similar to that
provided to PCCs
– eg. encounters per clinic hour
Template
TimeActivity
Type
8:30 RT
9:00 RT
9:30 RT
10:00 RT
10:30 RT
11:00 RT
11:30 RT
TimeActivity
Type
1:30 RT
2:00 RT
2:30 RT
3:00 RT
3:30 RT
4:00 RT
4:30 RT
PCBH Pathway Services
• Targets a patient population that has high impact (by numbers or by way or presentation)
• Applies the evidence for the care of the targeted population
• Respectful of local resources
• Seeks to improve efficiencies
• Specifies outcomes used to evaluate processes and outcomes
WHAT PATHWAYS MIGHT BE USEFUL
IN YOUR CLINIC? WHY?
PCBH Pathways
• High Impact Population Surveys
• Forming a Pathway Committee
• Developing a Pilot
• Selecting Outcomes / Measures
• Revising and Expanding
Small Group Discussion
Pathway ideas and applying evidence-based interventions
Generate pathway target list and interventions for each
Report to larger group
Medication Consults
• Explore patient preference for treatment,
assess symptom severity and adherence
coaching
– See Adherence Using Medications Successfully
Patient Education HO
• Coaching involves exploring the patient’s
experience of beneficial and side effects;
identifying barriers to adherence including
personal beliefs, problems remembering to
take the medication, cost of the
medication, etc.; and, developing specific
behavioral strategies to address barriers
• Regarding patient use of all medications,
not just psychotropic medicines
Prescribers and BHCs
• May assist PCC with consultations with
specialty prescribers, as requested
• May assist with linkage to specialty
prescriber services, as clinically indicated
• May assist with tele-specialty prescriber
services
Interventions for Common Problems
• Eating, Sleeping, Engaging in Social Activities, Engaging in Exercise
• Medical Problems: Basic Interventions – Addressing stigma
– Creating a values context
– Recognizing primacy of psychosocial stresses
– One step at a time
• Overweight / obesity; diabetes; hypertension; ADHD
• Substance Abuse
• PTSD
• Medication Issues
Interventions: Depression (or fatigue, insomnia, loss of interest)
� Demystify depression, focus on symptom of concern
� Ask about patient’s world view
� Use PHQ-9 to identify sx of concern to patient
� Explain the “lethargy cycle”
� Make behavioral activation plan, particularly social
activities
� Problem solving
� Relapse prevention plan
� Mindfulness training
� QOL Drop in Class
Interventions: Anxiety
• Teach relaxation / mindfulness / acceptance strategies
• Square breathing for panic
• CALM or diaphragmatic breathing
• Set up self-guided exposure (based on values)
Lunch
Participant Presentations
Alcohol / Drugs
• Community based reinforcement approach
• Harm reduction
• Use MI in assessment
• AA, Alanon
• Specialty care
Decisional Balance Sheet
ChangingNot
Changing
Costs of
Benefits of
Interventions:
Chronic Disease / Lifestyle
• Motivational Interviewing
– Decisional Balance Sheet
• Team-based support of specific goals
– Bulls-Eye or SMART goals
• Classes and workshops
• Internet-based with BHC phone call support
• Bibliotherapy
– The Diabetes Lifestyle Book by Gregg
Interventions: Sleep, Smoking
• Use Handouts
• Review Sleep Hygiene Guidelines
• Sleep diary
• Very common and high impact problem,
so offer monthly workshops
• See Patient Handouts for Smoking Class
packet of materials
Chronic Pain
• Bull’s Eye RX Pad
– to prevent, to intervene
• Educate regarding the chronic pain cycle
• Teach skills that address barriers to improved
QOL
– pacing, relaxation, defusion, mindfulness,
acceptance, committed action
Interventions: Relationship Problems
• Marital Dissatisfaction
– See Relationship Couples Handout
– Use Problem Solving
– Caring Bank Account
• Parenting Stress
– Parenting Protocol (play, positive and descriptive
praise, ignoring)
– Enuresis (The Good Kid Book)
– Overweight / obesity prevention
Parent/Child or Child Problems
• Parenting
– Explain proper use of rewards, Timeout, guidelines for play
– PC Parenting Protocol
– Triple P Parenting Program
• Sleep problems
• Enuresis
• Overweight / obesity prevention
• School problems
Other Common Interventions
• Self-monitoring
• Recommend pamphlet – One page vs. multiple page
• Suggest self-help book– Living with Children
(Patterson)
– I Can If I Want To (Lazarus)
– Living Life Well: New
Strategies for Hard Times
(Robinson)
– Just One Thing (Hanson)
• Refer to support /
educational classes
• Recommend App – Sleep, breathing
• Internet programs– Insomnia, UCANPOOP2, Mild
depression
Marketing PCBH Services
• Place posters and brochures in community locations
• Place posters and brochures in clinic waiting areas and exam rooms
• Talk with local CCO
• Talk with local hospital
• Talk with local CMHC
• Brief presentation to board, HC system leadership team
• And . . .
Are You Interested?
• Sustainability & BHCM (MENTOR) Training
• Manual
• BHCM Core Competency Tool
– Excellence in all basic core competencies (5 on 95%)
– Additional domain: Teaching (with evaluation by BHCs
mentor trains)
Closing
• PCBH FoundationsTraining Certificate
• Re-rate your Competency Levels on CC Tool
• THANK YOUR TRAINING PARTNERS!