PHARMACOLOGICAL MANAGEMENT IN THE INTEGRATED …eo2.commpartners.com/users/apna_kc/downloads/1011... · MANAGEMENT IN THE INTEGRATED BEHAVIORAL HEALTH SETTING ... • Primary Care–Posttraumatic

Session ID: 1011‐16 American Psychiatric Nurses Association

Laura K. Melaro, DNP, APRN, FNP/PMHNP‐BC 1

PHARMACOLOGICAL MANAGEMENT IN THE

INTEGRATED BEHAVIORAL HEALTH SETTING

Laura K. Melaro

DNP, APRN, FNP/PMHNP-BC

DISCLOSURE

• Professor & Assistant Professor at University

• Consultant/Promotional Speaker for Otsuka/LundbeckPharmaceutical

• Psychiatric Nurse Practitioner & Consultant in Integrated Behavioral Health program in three Federally Qualified Health Centers



OBJECTIVES

• Explain the correlation between Accountable Care Organizations (ACO) and Integrated Behavioral Health (IBH).

• Recognize the different levels of collaboration/integration for delivery of Integrated Behavioral Health services.

• Explore the role of prescribers in Integrated Behavioral Health settings.

• Identify evidence based psychiatric treatment appropriate for the Integrated Behavioral setting.

HEALTH CARE REFORM

• Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA)

• 2010 Physical and Medical Health Care Coverage Parity

(United States Department of Labor, 2010)

• Patient Protection and Affordable Care Act, as amended by the Health Care and Education Reconciliation Act of 2010

• 2010-2014 Patient Bill of Rights, Preventative Services, Accountable Care Organizations, Open Enrollment Insurance Marketplace

(U. S. Department of Health & Human Services, 2015)



MEDICAL HOME

• Model of the organization of primary care that delivers the core functions of primary health care

• Five Functions: Comprehensive Care, Patient-Centered, Coordinated Care, Accessible Services, Quality & Safety

• Primary Care focus (AHRQ, 2015)

• Meet the needs of high-risk/high-cost patients

• 2+ chronic illnesses & serious, persistent mental health condition

• Deliver comprehensive care management, care coordination, health promotion, comprehensive transitional care

• PCP consultant (PPACA, 2010)

HEALTH HOMES

ACCOUNTABLE CARE ORGANIZATIONS

ACCOUNTABLE CARE ORGANIZATIONS

National Medicaid Recommendations

Universal Screening

Navigators

Co-location

Health Homes

System-level integration

(Nardone, Snyder, & Paradise, 2014)



INTEGRATED BEHAVIORAL HEALTH

• Patients without Identified Mental illness

• 80% of people with a behavioral health disorder will visit a primary care provider at least once a year

• 50% of all behavioral health disorders are treated in primary care

• 48% of appointments for all psychotropic agents are with a non-psychiatric primary care provider

• 67% of people with a behavioral health disorder do not get behavioral health treatment

(Patient-Centered Primary Care Collaborative, 2015)


• Patients without Identified Mental illness

• 30-50% of patient referrals from primary care to an outpatient behavioral health clinic do not make the first appointment

• Two-thirds of primary care physicians report not being able to access outpatient behavioral health for their patients. Shortages of mental health care providers, health plan barriers, and lack of coverage or inadequate coverage were all cited by primary care providers as critical barriers to mental healthcare access

(Patient-Centered Primary Care Collaborative, 2015)




• Patients with Identified Mental Illness

• Link patients to primary care services

• Encourage lifestyle changes to improve their overall

health

• Identify and overcome barriers to receiving care

• Track clinical outcomes in a registry format

(Heath Wise Romero, & Reynolds, 2013)

I. Interpersonal Communication

II. Collaboration & Teamwork

III. Screening & Assessment

IV. Care Planning & Coordination

V. Intervention

VI. Cultural Competence & Adaptation

VII. Systems Oriented Practice

VIII. Practice-Based Learning & Quality

Improvement

IX. Informatics

INTEGRATED CARE CORE COMPETENCIES

ROLE OF PROVIDERS

(HOGE, MORRIS, LARAIA, POMERANTZ & FARLEY, 2014)



1. Identify and assess behavioral health needs as part of primary care team

2. Engage and activate patients in their care

3. Work as a primary care team member to create and implement care plans that address behavioral health factors

4. Help observe and improve care team function and relationships

5. Communicate effectively with other providers, staff, and patients

6. Provide efficient and effective care delivery that meets the needs of the population of the primary care setting

7. Provide culturally responsive, whole-person and family-oriented care

8. Understand, value, and adapt to the diverse professional cultures of an integrated care team

CORE COMPETENCIES FOR BEHAVIORAL HEALTH PROVIDERS WORKING IN PRIMARY CARE

ROLE OF PROVIDERS

OFFICE-BASED SCREENING

• Conflicts between DSM-5 “emerging measures” versus IBH/HEDIS recommended screenings

• Primary Care recommended

• Patient Health Questionnaire (PHQ)-9 for depression

• Generalized Anxiety Disorder (GAD)-7 for anxiety disorders,

• Primary Care–Posttraumatic Stress Disorder Screen (PC-PTSD) for PTSD

• Audit as part of SBIRT for alcohol use (Narayana & Wong, 2014)

• Proposed HEDIS measures:

• SBIRT & PHQ-9 all patients 12 y/o and older



DEPRESSION

• Presenting Physical Symptoms

• Fatigue or loss of energy

• Significant change in appetite (weight loss or weight gain)

• Sleep disturbances (insomnia or hypersomnia)

• Leaden paralysis

• Pain: headache, musculoskeletal, abdominal/pelvic

• Changes in sexual drive

• Decline in physical function and overall health

DEPRESSION

PHQ-9 Score Depression Severity Initial Tx Considerations

0 – 4 None – Minimal None

5 – 9 Mild Monitor/repeat PHQ-9 at F/U

10 – 14 Moderate Consider counseling, ±pharmacotherapy, f/u 4-6wks

15 – 19 Moderately Severe Active treatment w/pharmacotherapy, f/u 2-4wks

20 - 27 Severe Address acute safety concerns.Immediate initiation of pharmacotherapy, f/u 1wkConsider PMH referral

Adapted from: The Patient Health Questionnaire (PHQ) Screeners. Available at: http://www.phqscreeners.com/overview.aspx?Screener=02_PHQ-9



DEPRESSION

Comorbid Disease StatesHypertension

Diabetes

COPD

Acute MI

Chronic Kidney Disease

Delirium

Sleep Disorders

Work-UpCBC

CMP

Liver Function Tests

TSH

Vitamin D

Pregnancy Test

Sleep Study

DEPRESSION

• Treatment in Primary Care

• Pharmacotherapy

• Initial Treatment with SSRIs

• Sertraline & Escitalopram = Efficacy/acceptability (Cipriani, et al, 2009)

• Lack of superiority in efficacy among antidepressants, selection based on:

(APA, 2010)

Safety

Side Effect Profile

Specific Symptoms

Comorbid Illnesses

Drug Interactions

Ease of Use

Pt Preference/Expectations

Cost

Patient Prior Response



DEPRESSION

• Psychotherapy

• Motivational Interviewing, CBT, Interpersonal Therapy

• Lifestyle Interventions

• Exercise

• Relaxation techniques

BIPOLAR DISORDER

• Presenting Physical Conditions

• Sexually Transmitted Diseases

• Substance Abuse

• Infections r/t drug use

• Social Issues

• Financial problems

• Relationship/marital problems

• Erratic employment history



BIPOLAR DISORDER

• Screenings

• The Mood Disorder Questionnaire (MDQ)

• Bipolar Spectrum Diagnostic Scale (BSDS)

• STandards for BipoLar Excellence (STABLE): Composite

International Diagnostic Interview 3.0 (CIDI)

• Young Mania Rating Scale

• Mania-DIGFAST

BIPOLAR DISORDER

Work-Up

CBC

CMP

Liver Function Tests

TSH

Urinalysis

Pregnancy Test

Drug Screen

Comorbid Disease StatesHypertension and Cardiovascular disease

Migraines

Thyroid Disease

Obesity

Diabetes

COPD

HIV

Hepatitis C



BIPOLAR DISORDER

• Treatment in Primary Care• Management of associated medical conditions• Initial Treatment for Bipolar Depression/Hypomania

• Lurasidone, Olanzapine & Quetiapine Monotherapy• Lamotrigine, Lithium & Depakote• Adjunct Omega-3 fatty acids (Stovall, 2015)

• Emergent referral for Mania/Psychosis• Medication Monitoring:

• Mood Stabilizers• Atypical Antipsychotics

ANXIETY

• Presenting Physical Symptoms• Headache

• GI complaints

• Muscle tension

• Palpitations

• Dyspnea

• Dizziness

• Pain



ANXIETY

• Screening

• Generalized Anxiety Disorder 7-item (GAD-7)

• Beck Anxiety Inventory (BAI)

• Hamilton Anxiety Rating Scale (HAM-A)

ANXIETY

Comorbid Disease StatesTachycardia

Dyspnea

Irritable Bowel Syndrome

Migraines

Sleep Disturbances

Fatigue

Work-Up

CBC

CMP

TSH

EKG

Holter Monitor



ANXIETY

• Treatment in Primary Care• SSRIs (First Line)

• SNRIs

• Adjunctive Treatments (Symptomatic)

• Buspirone

• Benzodiazepines

• Hydroxyzine

ANXIETY


• Psychotherapy

• CBT

• Behavioral (Relaxation)

• Simple breathing exercises

• Progressive muscle relaxation

• Grounding techniques

• Physical, Mental, Soothing

• Mindfulness exercises



TRAUMA DISORDERS

• Presenting Physical Conditions• Anxiety

• Sleep disturbance

• Concentration difficulty

• Fatigue

• Weight gain

TRAUMA DISORDERS

• Screening• Primary Care PTSD Screen (PC-PTSD)

• PTSD Checklist (PCL-C)

• Life Event Checklist (LEC)



TRAUMA DISORDERS

Work-Up

CBC

CMP

TSH

EKG

UA/UDS

Comorbid Disease StatesAnxiety/Depression

Dyspnea

Irritable Bowel Syndrome

Multiple Somatic Complaints

Sleep Disturbances

Substance Use

TRAUMA DISORDERS

• Treatment in Primary Care• SSRIs (First Line)

• SNRIs

• Buspirone

• Benzodiazepines

• Hydroxyzine

• Prazosin (Nighmares, Co-Occuring HTN)

• Psychotherapy: TF-CBT, Behavioral, Grounding Techniques



SCHIZOPHRENIA

• Presenting Physical Symptoms• Negative Symptoms

• Cognitive Dysfunction

• Disorganized Speech

• Motor System Abnormalities

• Affective Symptoms

• Delusions and Hallucinations

• Extrapyramidal symptoms

• Symptoms of Comorbid medical conditions

SCHIZOPHRENIA

• Work-up/Screening

• No specific screening tool except mental status exam

• Work-up to rule out associated medical conditions that would cause secondary psychosis

• Screenings for Alcohol and Drug use

• Medication monitoring

• Routine screening for CVD, DM, Respiratory Disease



COMORBID DISEASE STATES

• Diabetes

• Hyperlipidemia

• Cardiovascular Disease

• Obesity

• Lung Cancer

• Osteoporosis

• Anticholinergic Effects of Medications

• Extrapyramidal Symptoms

• Hyperprolactinemia

SCHIZOPHRENIA

SCHIZOPHRENIA


• Referral followed by Collaborative Care: communication between Primary Care Providers and Psychiatry

• Monitor for comorbid medical conditions associated with lifestyle factors and side effects of antipsychotic medications

• Ongoing screening for Comorbid Diseases

• Family/Caregiver psychoeducation

• Knowledge of medication side effects to prevent unnecessary medical referrals



SUBSTANCE ABUSE

• Presenting Physical Symptoms/Comorbid Disorders

• Dermatologic: skin abscesses

• Cardiovascular: essential hypertension, angina, myocardial infarction, heart failure, arrhythmias, infective endocarditis, cardiomyopathies

• Respiratory: nasal septal perforation, COPD, asthma

• Gastrointestinal: viral hepatitis, hepatic carcinoma, peptic ulcer disease, IBD, pancreatitis, gastritis, cirrhosis, cirrhotic varices

• Hematologic: anemia, thrombocytopenia, coagulopathies

• Neurologic: stroke, encephalopathy, traumatic brain injury, epilepsy, epidural abscess, peripheral neuropathy, Wernicke/Korsakoff syndrome

• Endocrine: hypo/hyperthyroidism, type 2 diabetes mellitus, hypogonadism

• Immunologic: HIV, immune suppression leading to opportunistic infections (eg, TB, pneumonia), necrotizing vasculitis

• Metabolic: electrolyte abnormalities, hypoxia, dehydration

(Merrill & Duncan, 2014)

WORKUP

Audit-CCAGE

CRAFFT

DAST-10

ASSIST

Screening, Brief Intervention & Referral to Treatment (SBIRT)

SCREENING TOOLS

SUBSTANCE ABUSE

UDS

UA

CMP

CBC

HIV, RPR, Hepatits Panel, Tb Skin test



SUBSTANCE ABUSE


• SBIRT

• Motivational Interviewing

• Harm Reduction

• Cognitive Behavioral

• 12-Step

SOMATIC DISORDER

• Presenting Physical Symptoms

• Chest pain

• Fatigue

• Dizziness

• Headache

• Dyspnea

• Back pain



SOMATIC DISORDER

• Screening

• 8-Item Somatic Symptoms Scale (SSS-8)

• Depression and Anxiety Screenings

• BATHE Technique

• B=Background “What is going on in your life?”, “What brings you in today?”

• A=Affect “How do you feel about that?’

• T=Trouble “What bothers you the most about this situation?”

• H=Handling “How are you handling that?”

• E=Empathy

SOMATIC DISORDER

Comorbid Disease States

Cardiovascular Disease

COPD

Chronic Pain Disorders

Depression

Anxiety

Work-Up

Physical Examination

Diagnostic testing determined by objective evidence of potential disease process

Avoid unnecessary, repetitive, or invasivediagnostic testing



SOMATIC DISORDER


• Education: Interaction of psychosocial stressors and symptoms

• Treatment of Comorbid Psychiatric Disorders

• SSRIs and SNRIs

• Psychotherapy

• Collaborative Care

• Actively involve the patient in treatment goals

DEVELOPMENTAL DISORDERS

• Screening (9, 18 & 24-30 months)• Ages and Stages Questionnaire (ASQ-3)

• Parent Evaluation of Developmental Status (PEDS)

• Child Development Inventory (CDI)

• M-Chat-R

• Adults• Decision-Making Capacity; Surrogate Decision Makers

• Screen for polypharmacy, chemical restraint, abuse/victims violence, Reflux/Swallowing issues, Epilepsy, Undiagnosed pain/atypical illness presentation, disease risk specific to types of DD/medications, anxiety, depression, sleep disturbances (Daaieman, 2016; Nicolaidis, Kripke & Raymaker, 2014)

• Health Care for Adults with Intellectual and Developmental Disabilities: Toolkit for Primary Care Providers (Vanderbilt Kennedy Center, 2016)



CHILD & ADOLESCENT ISSUES

(Foy, 2010)

CHILD & ADOLESCENT ISSUES

• American Academy of Pediatrics (2016) Bright Futures Recommendations for Preventive Pediatric Health Care, Age appropriate Questionaires and Parent Education

• Early Childhood Materials for Early Identification, Substance Abuse and Mental Health Services Administration

• Pediatric Symptom Checklist (This checklist can be used with children and youth ages 3-16.)

• American Academy of Child & Adolescent Psychiatry: Resources for Primary Care (2016)



MEDICAL CONDITIONS WITH NEUROPSYCHIATRIC SYMPTOMS

(Isaac & Larson, 2014)

GERIATRIC ISSUES

• Delirium• Confusion Assessment Measures (CAM)

• Polypharmacy, medications, metabolic imbalance, and infections

• Dementia• Mini-Mental State Examination, Mini-Cog, Montreal Cognitive

Assessment, Saint Louis University Mental Status Examination

• Substance Use

• Beer Criteria

• Comorbid Disease Coordinated Treatment

• Caregiver Support/Screening



REFERENCES

American Academy of Child & Adolescent Psychiatry. (2016). Resources for primary care. Retrieved from http://www.aacap.org/aacap/resources_for_primary_care/Home.aspx

American Academy of Pediatrics. (2016). Bright Futures: Clinical Practice. Retrieved from https://brightfutures.aap.org/clinical-practice/Pages/default.aspx

American Psychiatric Association:. (2010. ). Practice Guideline for the Treatment of Patients with Major Depressive Disorder, Third Edition,. Retrieved from http://psychiatryonline.org.ezproxy.uthsc.edu/guidelines.aspx

Bentley, S. M., Pagalilauan, G. L., & Simpson, S. A. (2014). Major depression. Medical Clinics of North America 98(2014), 981-1005. http://dx.doi.org/10.1016/j.mcna.2014.06.013

Bystritsky, A. (2016). Pharmacotherapy for generalized anxiety disorder. In M. B. Stein (Ed.), UpToDate. Retrieved from http://www.uptodate.com/home

Cipriani A, Furukawa TA, Salanti G, Geddes JR, Higgins JP, Churchill R, Watanabe N, Nakagawa A, Omori IM, McGuire H, Tansella M, Barbui C. (2009). Comparative efficacy and acceptability of 12 new-generation antidepressants: a multiple-treatments meta-analysis. Lancet. 373, 746-758.

REFERENCES

Combs, H., & Markman, J. (2014). Anxiety disorder in primary care. Medical Clinics of North America 98(2014), 1007-1023. http://dx.doi.org/10.1016/j.mcna.2014.06.003

Croicu, C., Chwastiak, L., & Katon, W. (2014). Approach to the patient with multiple somatic symptoms. Medical Clinics of North America, 98(2014), 1079-1095. http://dx.doi.org/10.1016/j.mcna.2014.06.007

Daaieman, T. P. (2016), Primary care of adults with intellectual and developmental disabilities. Southern Medical Journal, 109(1), 12-16.

Foy, J. M. (2010). Enhancing pediatric mental health care: Algorithms for primary care. Pediatrics, 125, (Suppl. 3), S109-S125.

Hoge, M.A., Morris, J.A., Laraia, M., Pomerantz, A., & Farley, T. (2014). Core competencies for integrated behavioral health and primary care. Washington, DC: SAMHSA-HRSA Center for Integrated Health Solutions.



REFERENCES

Isaac, M. & Larson, E. B. (2014). Medical conditions with neuropsychiatric manifestations. Medical Clinics of North America, 98, 1193-1208.

Merrill, J. O., & Duncan, M. H. (2014) Addiction Disorders. Medical Clinics of North America, 98, 1097–1122. http://dx.doi.org/10.1016/j.mcna.2014.06.008

Narayana, S., & Wong, C. J. (2014). Office-based screening of common psychiatric conditions. Medical Clinics of North America (2014)98, 959-980. http://dx.doi.org/10.1016/j.mcna.2014.06.002

Nicolaidis,C., Kripke, C. C. & Raymaker, D. (2014). Primary care for adults on the Autism Spectrum. Medical Clinics of North America, 98, 1160-1191.

Novick, J. S., Stewart, J. W., Wisniewski, S. R., Cook, I. A., Manev, R., Nierenberg, A. A., … Rush, A. J. (2005). Clinical and demographic features of atypical depression in outpatients with major depressive disorder: Preliminary findings from STAR*D. Journal of Clinical Psychiatry, 66, 1002-1011.

Patient-Centered Primary Care Collaborative. (2016). Benefits of integration of behavioral health. Retrieved from https://www.pcpcc.org/content/benefits-integration-behavioral-health

REFERENCES

Pilling, S., Anderson, I., Goldberg, D., Meader, N., & Taylor, C. (2009). Depression in adults, including those with a chronic physical health problem: Summary of NICE guidance. British Medical Journal, 339. http://doi.org.ezproxy.uthsc.edu/10.1136/bmj.b4108

Saltz, R. (2015). Screening for unhealthy use of alcohol and other drugs in primary care. In R. Hermann (Ed.). UpToDate, Retrieved from http://www.uptodate.com/home

Stovall, J. (2015). Bipolar disorder in adults: Pharmacotherapy for acute depression. In D. Solomon (Ed). IUpToDate, Retrieved from http://www.uptodate.com/home

U. S. Department of Health & Human Services. (2015). Key features of the Affordable Care Act by year. Retrieved from http://www.hhs.gov/healthcare/facts-and-features/key-features-of-aca-by-year/index.html#

U.S. Department of Labor,. (2010). The mental health parity and addiction equity act of 2008 (MHPAEA),Retrieved from http://www.dol.gov/ebsa/newsroom/fsmhpaea.htm

Vanderbilt Kennedy Center. (2016). Health Care for Adults with Intellectual and Developmental Disabilities: Toolkit for Primary Care Providers. Retrieved from http://vkc.mc.vanderbilt.edu/etoolkit/



REFERENCES

Vermani, M., & Katzman, M. (2011). Rates of detection of detection of mood and anxiety disorder in primary care: A descriptive, cross-sectional study. Primary Care Companion CNS Disorder 2011: 13(2). http://dx.doi.org/10.4088/PCC.10m01013.

Wittchen, H. U., & Hoyer, J. (2001). Generalized anxiety disorder: Nature and course. Journal of Clinical Psychiatry, 62(Suppl 11): 15-9 [discussion: 20-1].

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PHARMACOLOGICAL MANAGEMENT IN THE INTEGRATED …eo2.commpartners.com/users/apna_kc/downloads/1011... · MANAGEMENT IN THE INTEGRATED BEHAVIORAL HEALTH SETTING ... • Primary Care–Posttraumatic