Primary Care - Behavioral Health Integration on Our ...Primary Care - Behavioral Health Integration on Our Campuses: Results of a National Survey Kevin Readdean, MSEd, LMHC Associate

Primary Care - Behavioral Health Integration on Our Campuses: Results of a National Survey

Kevin Readdean, MSEd, LMHCAssociate Director, Student Health, Rensselaer PhD Student, Rutgers [email protected] @IntegrationDNA

October 2018

Learning Objectives

▰ identify the variety of organizational models and evidenced-based practices that surround the delivery of primary care behavioral health services in college health

▰ discuss the implications of the findings as they relate to their organizations and the existing literature on primary care behavioral health integration.

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Participants will be able to:

Conflicts of Interest

▰ I have no actual or potential conflict of interest in relation to this educational activity or presentation.

▰ However… potential bias…

▻ SUNY at Cobleskill: 13 years in integrated heath/counseling service

▻ Rensselaer: 10 years in integrated health/counseling service

▻ ACHA White paper: Considerations for integration of counseling and health services on college and university campuses

▻ Rutgers University: PhD student, Health Sciences – studying the fundamental, distinctive characteristics of the practice of integrated primary care behavioral health

▰ Married, Cohabitating, or Dating?@IntegrationDNA

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▰ The interconnected double-helix of physical and mental health care with the sequence of the four “bases” (ATCG) shaping the design of the organization.

▻ Administration – procedural and financial integration

▻ Technology – EHR integration

▻ Clinical – treatment coordination and integration

▻ Geographic – how space is shared to support collaboration and reflect integration

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Integration Defined

For this project, the term ‘integration’ is used to describe both organizations and care practices

▰ Organizational – connections in administration

▻ Integrated/non-integrated (Organizational Chart)

▰ Clinical – connections in care delivery

▻ continuum (Practice Integration Profile)

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Primary Care Behavioral Health Survey

Research Questions1. To what extent has there been an increase in the percentage of

integrated health and counseling centers in the past decade? 2. Is there a relationship between organizational structure and integrated

care practices, as measured by the Practice Integration Profile?3. Is there a relationship between Behavioral Health (BH) FTE staff and

integrated care practices, as measured by the Practice Integration Profile?

4. To what extent is the primary care behavioral health (PCBH) model of integrated care (non-prescribing behavioral health clinician within primary care) being implemented by non-integrated college health centers?

5. Is there a relationship between the levels of behavioral health clinician FTE (PCBH/Non-PCBH) and levels of practice integration?

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Thank You!

▰ ACHA, Section Leaders, Rutgers Advisors, Respondents

▻ Pilot survey – Emeriti Directors: n=13

▻ Final survey:

▻ 716 ACHA RMI’s invited, 189 responses (26% response rate), good representation of the population of ACHA institutions

▻ 54 items: demographics, organizational structures, and the Practice Integration Profile (PIP)

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Demographics

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Demographics

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Demographics

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Demographics

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Demographics








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Organizational Models - Integrated

22%

4%

9%

10%

1% Integrated Contracted Health & Counseling @IntegrationDNA

Organizational Models: Non-Integrated

2%

41%11%

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Survey Data Comparison

54%

46%

26%

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Organizational Model Integration2007

Survey2018

SurveyHealth director and counseling director report to a single senior administrator

Not Integrated

74%

41%Health director and counseling director report to different senior administrators 11%Contracted/Outsourced - Primary Care Only 2%Center Director with Director of Health and Director of Counseling

Integrated

8% 22%Single chief health and counseling director reports to a senior administrator 6% 9%

Health director reports to the counseling director who reports to a senior administrator 4% 4%

Counseling director reports to the health director who reports to a senior administrator 8% 10%

Contracted/Outsourced - Primary Care and Counseling Services. - 1%

Survey Data Comparison

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74%

54%

26%

46%

0%

10%

20%

30%

40%

50%

60%

70%

80%

2007 Survey 2018 Survey

Non-integrated vs Integrated Organizational Models 2007 to 2018

Not Integrated Integrated

More Survey data on Integration

*AUCCCD Directors Survey**ACHA Mental Health Best Practices Taskforce***Primary Care Behavioral Health Survey

26% 25% 25%28%

46%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

2007** 2011* 2013* 2015* 2018***

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Factors Driving Integration

▰ 2007 – Top three factors that drove the integration:

▻ Improve continuity of care

▻ Philosophy of care

▻ Upper administrative directive

▰ 2018 – Factors driving the planned integration:

▻ Improve continuity of care

▻ Philosophy of care

▻ Physical facilities

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Small Group Discussion

▰ Regardless of your organizational model:

▻ In what ways are your primary care and behavioral health services integrated?

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Practice Integration Profile

▰ Kessler and colleagues

▰ Used with permission

▰ Demonstrated face, content and internal validity

▰ Operationalizes key elements of the Agency for Healthcare Research and Quality (AHRQ) Lexicon for Behavioral Health and Primary Care Integration

▰ Quantifies levels of integration

▻ 6 dimensions and overall PIP score

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Practice Integration Profile

▰ 30 items; 6 dimensions (subscales)

1. Practice Workflow (protocols, registries, coordination of care)

2. Clinical Services and Providers (BH clinicians and BH interventions)

3. Workspace Arrangement (co-location and shared records)

4. Integration Method (collaboration on treatment plans)

5. Identification of Need (screening methods)

6. Patient Engagement and Retention (systematic follow-up for BH)

▰ Scoring: 5-point Likert scale (0-25-50-75-100)

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Summary of PIP Results

▰ 85% of respondent surveys (160 of 189) included useable, or in some cases imputed*, Practice Integration Profile (PIP) scores

▰ Total PIP scores ranged from 1.7 to 84.5 on a possible range from 0 to 100. ▰ The average (SD) total PIP score was 44.8 (18.7)▰ Differences in total PIP scores did not reach statistical significance when

compared by:

▻ institution size (enrollment)

▻ institution type (public/private)

▻ title or discipline of the respondent

▰ However, interesting differences were found among:

▻ Behavioral health staff and PIP scores

▻ Organizational integration and PIP

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Summary of Results – PIP/Integration

▰ Significant differences were found between integrated and non-integrated organizations for total PIP scores and all PIP subscales except two: Practice Workflow and Identification of Need.

▻ non-integrated college health centers are identifying patients in need of behavioral health services, making referrals to specialty mental health care, and coordinating care at similar levels to integrated health and counseling centers.

▻ non-integrated centers collaborate clinically through shared information and treatment plans at lower levels than in integrated centers where primary care and behavioral health clinicians share the same workspace and record keeping systems.

Integrated Health and Counseling Centers Have Higher Practice Integration Profile Scores

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Summary of Results – BH Staff

▰ Administratively integrated centers reported higher average FTE behavioral health (BH) staff than non-integrated centers (see graph below)

▰ The top three BH staff groups for both types of organizations (integrated/non-integrated) were:

▻ Psychologists

▻ Master’s trained clinicians

▻ Prescribing clinicians (Psychiatrist and Psychiatric Nurse Practitioner)

10.1

3.5

0

2

4

6

8

10

12

Integrated Non-integrated

Average FTE Behavioral Health Staff

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Summary of Results – BH Staff/PIP

▰ As FTE of BH staff increased, total Practice Integration Profile (PIP) scores increased. This statistically significant correlation was found among all institution sizes and structures

▰ The total Practice Integration Profile scores of organizations with BH staff was significantly higher than the PIP scores of organizations without BH staff

0

10

20

30

40

50

0 10 20 30 40 50 60 70 80 90

Tota

l Beh

avio

ral H

ealt

h F

TE

Total Practice Integration Profile Scores

Total BH Staff by Total Practice Integration Score Integrated Centers

30.0

49.4

0.0

10.0

20.0

30.0

40.0

50.0

60.0

No BH Staff BH Staff

Tota

l Pra

ctic

e In

tegr

atio

n P

rofi

le S

core

Behavioral Health Staff

Practice Integration Profile Scores by BH Staffing

Interpretation: The presence of BH staff is an important driver of collaborative care practices. @IntegrationDNA








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Interpretation: Almost half of non-integrated centers are employing a primary care behavioral health model (PCBH) in which a non-prescribing BH clinician is embedded within the primary care setting.

46%

54%

Percent of Non-Integrated Centers Reporting BH Clinicians on Staff

BH Clinicians No BH Clinicians








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Summary of Results – PCBH/PIP

▰ A one-way between groups ANOVA - there was a statistically significant difference in PIP scores for the three groups (F (2, 166) = 11.1, p < .05, Ƞ2 = 0.13).

▰ Tukey HSD test indicated that the mean PIP score for non-PCBH organizations was significantly different from PCBH organizations (M = 45.0, SD = 19.7) and integrated organizations (M = 50.2, SD = 18.1). There was no statistically significantdifference in mean scores between PCBH organizations and integrated organizations.

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Overall Findings

1. Marked increase in Administratively Integrated Health and Counseling Centers over the past decade

2. Clinical and administrative integrative care practices are higher in integrated centers than non-integrated centers

▻ Similarities in protocols, screening and referrals for patients needing behavioral health services

3. The presence of behavioral health staff is an important driver of collaborative care practices

4. Primary Care Behavioral Health model has a strong presence in college health.

5. PCBH increases integrative care practices without embarking on full administrative integration between primary care and specialty mental health.

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Primary Care Behavioral Health (PCBH)

▰ Behavioral Health Clinicians embedded in primary care

▻ Accessible (same day)

▻ Team-based (shared space, records, treatment plan)

▻ Generalist (any patient, any condition, brief BH interventions)

▻ Educator (helps improves PC team’s biopsychosocial assessment and intervention skills)

▰ Veterans Administration; Patient Centered Medical Homes; Community Primary Care; College Health Centers

▰ Differs from SBIRT and Chronic Care Model

▻ Team-based, population focused approach

▰ Face validity as promising approach but robust evidence base is lacking

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Call to Action - PCBH

▰ Hunter, C.L., Funderburk, J.S., Polaha, J. et al. J Clin Psychol Med Settings (2018) 25: 127.▻ Patient Outcomes (satisfaction, symptoms, functioning)

▻ Provider Outcomes (satisfaction, burn-out, training)

▻ Implementation Outcomes (acceptability, adoption, cost, fidelity, reach)

▰ Practice is ahead of the science▻ What works, for whom, under what conditions, for what cost

▻ Robust, standardized measures

▻ Practice-Based Research Networks

▻ Pragmatic trials

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References

▰ American College Health Association (2010). Considerations for integration of counseling and health services on college and university campuses: An ACHA White paper. Journal of American College Health, 58(6):583-596.

▰ Blount, A., Integrated Primary Care: Organizing the Evidence. Families, Systems & Health, 2003. 21(2): p. 121-133.

▰ Cohen, D. J., Davis, M. M., Hall, J. D., Gilchrist, E. C., & Miller, B. F. (2015). A Guidebook of Professional Practices for Behavioral Health and Primary Care Integration: Observations From Exemplary Sites. Rockville, MD: Agency for Healthcare Research and Quality.

▰ Funderburk, J. S., Fielder, R. L., DeMartini, K. S., & Flynn, C. A. (2012). Integrating behavioral health services into a university health center: Patient and provider satisfaction. Families, Systems, & Health, 30(2), 130-140.

▰ Hunter, C. L., Funderburk, J. S., Polaha, J., Bauman, D., Goodie, J. L., & Hunter, C. M. (2017). Primary care behavioral health (PCBH) model research: Current state of the science and a call to action. Journal of clinical psychology in medical settings, 1-30.

▰ Kessler, R. S., Auxier, A., Hitt, J. R., Macchi, C. R., Mullin, D., van Eeghen, C., & Littenberg, B. (2016). Development and validation of a measure of primary care behavioral health integration. Families, Systems, & Health, 34(4), 342-356.

▰ Macchi, C. R., Kessler, R., Auxier, A., Hitt, J. R., Mullin, D., van Eeghen, C., & Littenberg, B. (2016). The Practice Integration Profile: Rationale, development, method, and research. Families, Systems, & Health, 34(4), 334.

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References

▰ Peek, C. J. (2009, June). A collaborative care lexicon for asking practice and research development questions. Paper presented at the Collaborative Care Research Network Research Development Conference, Denver, Colorado. Retrieved from https://archive.ahrq.gov/research/findings/final-reports/collaborativecare/collab3.html

▰ Pratt, K. M., DeBerard, M. S., Davis, J. W., & Wheeler, A. J. (2012). An evaluation of the development and implementation of a university-based integrated behavioral healthcare program. Professional Psychology: Research and Practice, 43(4), 281-287.

▰ Reiter, J. T., Dobmeyer, A. C., & Hunter, C. L. (2018). The primary care behavioral health (PCBH) model: An overview and operational definition. Journal of clinical psychology in medical settings, 25(2), 109-126.

▰ Reetz, D., Barr, V., & Krylowicz, B. (2013). The Association for University and College Counseling Center Directors annual survey. Retrieved from http://files.cmcglobal.com/AUCCCD_Monograph_Public _2013.pdf.

▰ Reetz, D., Krylowicz, B., Bershad, C., & Lawrence, J. M. (2015). The Association for University and College Counseling Center Directors annual survey. Retrieved from http://www.aucccd.org/assets/ documents/aucccd%202015%20monograph%20-%20public%20version.pdf.

▰ Reetz, D., Bershad, C., LeViness, P, & Whitlock, M. (2016). The Association for University and College Counseling Center Directors annual survey. Retrieved from https://www.aucccd.org/assets/ documents/aucccd%202016%20monograph%20-%20public.pdf.

▰ Spiegelhoff, S. F., & Luke, M. (2015). Integration of College Counseling and Health Services: A Phenomenological Study. The Wisconsin Counseling Journal, 22-36. @IntegrationDNA

Primary Care - Behavioral Health Integration on Our Campuses: Results of a National Survey

Kevin Readdean, MSEd, LMHCAssociate Director, Student Health, Rensselaer PhD Student, Rutgers [email protected] @IntegrationDNA

Documents

Primary Care - Behavioral Health Integration on Our ...Primary Care - Behavioral Health Integration on Our Campuses: Results of a National Survey Kevin Readdean, MSEd, LMHC Associate