Www.pspbc.ca Adult Mental Health Module An Organized Approach to Mental Health Issues in Realistic Time Learning Session 1 2015

www.pspbc.ca

Adult Mental Health Module

An Organized Approach to Mental Health Issues in

Realistic TimeLearning Session 1

2015

www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources

2

Psychiatrists and Mental Health Clinicians

Learn/understand module

Share resources

Comment/advise

Tell colleagues/Root for the PCPs

Support Team Advisor Roles


Hinada, Pamela

this is true for BC situation. confirm if true for NS re: first aid

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Office Assistants:

Understand module

Take course on Mental Health First Aid

Organize office scheduling, materials Flag patient issues

›



Hinada, Pamela


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Nurses

Absorb these tools through your own lens.

Think about your own scope of practice . Present your ideas during the action

period planning and strategize with your doc how you will implement today’s training



Hinada, Pamela


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GP Champ, OA, nurse

Psychiatrist

Mental Health Clinicians

PSP Coordinators

Data Analyst

PSP Tech Group

Bounce Back Coaches

Adult Mental Health Module Team

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Anyone NOT wishing their name and EMR information shared with our PSP Technology Partners

please let ___ know.

Request your Permission

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Faculty’s Name

Relationship with Commercial Interest

Faculty’s Name

Relationship with Commercial Interest

Faculty/Presenter Disclosures

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Housekeeping


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Welcome1. Roles2. Survey feedback3. Funding, CME credits 4. What are we trying to accomplish

Context, aims, goals, module pathway, CBT, QI, Results5. Physician, patient advocate testimonial6. Break7. Algorithm scavenger hunt8. Tools intro, tips, PL, RL, PLAP Separate: MOAs billing and scheduling9. BB10. Billing11. Action planning, Evaluations

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Thank you for your responses to the following questions. 1. What are your challenges or frustrations supporting patients

with mental health concerns?

2. How do you currently support these patients & how is this working?

3. What are you hoping to get out of the PSP Mental Health module?

4. Are you familiar with the PHQ 9 screening tool

5. Are you paper based or do you have an EMR?

6. Are you with a group practice or alone?

Where You are Now Where You Would Like to Be


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Results of pre-course assessment survey N=36What are your challenges and frustrations?


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How do you currently support MH patients?


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What do you hope to get from PSP training?


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Familiarity with the PHQ9 screening tool?


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Paper or EMR?


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Want to provide the best care for your patients with MH problems

Concerned about time efficiency in your practices Doing a lot of MH care already Some don’t feel confident in MH care they provide and

some feel emotionally drained by it Would like clearer and more timely access to mental

health specialists for your patients Here to learn skills and tools to help with diagnosis and

in-office management as well as learn about helpful resources

What did we learn about you?


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Funding for Modules

3 x ½ day (max)GP Session x 3 $ 1, 235.64

MOA 12 hrs $ 240

1 ►Planning & initial implementation in practice►Report on experiences and successes at LS2►Billable at or after LS2

$ 823.76

2 ►Refine implementation, embed and sustain the change►Report on experiences and successes at LS3►Billable at or after LS3

$ 610.72

Action Periods

Learning Sessions

Potential Total: $ 2,910.12

Participant Funding GPs: Mental Health Module

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10.5 Mainpro M-1 credits based on Attendance hours at all learning sessions (LSs) Fewer if not all sessions attended

IN ADDITION

10.5 Mainpro C bonus credits based on Completion of all 3 LSs plus an Action Period and post reflective survey (we will contact DocBC 3 months after

LS3 and AP1 completion to request them to send your

Reflective Questionnaire)

Details are found on all PSP Sessional Forms in bottom right box

Mainpro Credits for Primary Care Physicians

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“This event is an Accredited Group Learning Activity eligible for up to 10.5 (3.5 per session) Section 1 credits as defined by the Maintenance of Certification Program of the Royal College of Physicians and Surgeons of Canada.

This program has been reviewed and approved by the UBC Division of Continuing Professional Development.”

MOC for Psychiatrists

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M 1 Credits for Residents

Residents can claim a maximum of 30 M-1 credits during their residency. Residents are eligible to receive M1 credits for attending learning sessions (up to and within their maximum allowance of 30 M1 credits).

To obtain M1 credits please contact: [email protected]

mailto:[email protected]

CME and Compensation: Who to Contact?

PSP Modules• Mainpro C and M1 credits

• Fax all Learning Session and Action Period Invoices to Doctors of BC (604.638.2939)

• Contact:

Physician Forums• Mainpro M1 credits

• MUST sign in so we can send your name to VIHA Physician Compensation for both reimbursement and CME tracking

• Contact:

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Who sees MH patients in Canada?Pan Canadian Survey 2011

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Hypothesis

Family docs need:

time efficient skills to increase their comfort and confidence in treating their mental health patients

fee codes that fit this mental health work


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CBIS manual – cognitive behavioral interpersonal skills manual.

This formed the core of the BC provincial practice support program adult mental health module

Weinerman R et al, Improving Mental Healthcare by Primary Care physicians In British Columbia. Healthcare Quarterly, 2011. 14:1, 36-38

MacCarthy,D;Weinerman,R:Kallstrom,L;Kadlec,H;Hollander,M;Patten,S;Mental Health Practice and Attitudes Can be Changed. The Permanente Journal, 2013, Summe; 17(3);14-17.

Developed Training tools


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1. Screening scales: ie PHQ9

2. CBIS Screening Assessment tools: ie Diagnostic Assessment Interview (DAI)

3. Three Supported Self-Management Cognitive Behavioural Therapy (CBT) skills options

CBIS Manual Bounce Back Antidepressant Skills Workbook

Key Components of the Adult Mental Health (AMH) Module


Results n=525 physicians

0

20

40

60

80

100

Further Results

Help pts retu

rn to

work

Help pts sta

y at w

ork

Increase

d pts se

nse of p

artnersh

ip

Reduced re

liance

on meds a

lone0

20406080

100

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Provide PCPs with effective tools to screen, diagnose, engage, partner with, manage their MH patients

Improve PCPs’ comfort, confidence and satisfaction

Improve patient experience and outcomes

Reduced healthcare provider stigma

Hope/Aim/Goals


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Depression used as Lens (Anxiety too) High prevalence in isolation/comorbid and comorbid with chronic diseaseLifetime prevalence of

Major Depressive Episode: 12.2%

Past-year episodes: 4.8%

Past-month episodes: 1.3% *

* Descriptive Epidemiology of Major Depression in Canada. Patten, SB; Wang, JL; Williams, JVA et al. Canadian Journal of Psychiatry; Feb 2006; 51, 2; 84.

** Twelve-month and lifetime prevalence and lifetime morbid risk of anxiety and mood disorders in the US. Kessler, RC, Petukhova, M, Sampson, NA, Zalavsky, AM, Wittchen, H-U. Int J Methods Psychiatr Res. 2012 Sep:21(3) 169-184

Ranked by frequency **

Major depressive disorder

Specific Phobia

Social phobia

PTSD

GAD

Separation anxiety

Panic

Bipolar

Agoraphobia

OCD

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Focus of this modulePatients that present with:

1.fatigue, depression, anxiety, panic, insomnia,psychosomatic symptoms

2. chronic pain, headache, chronic illness,

3. depressed demeanor, worrier a thick chart

and trigger you to generate a mental health screening.

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Plan: Ride my bike to work

Bike ride Improvement Ramp

• I was late• I was

sweaty• Bike was

rusty• I was stiff

• Rain/wind• Forgot soap• Still late• Too many

hills

• On time!!• Felt good!!• I Can do

this!• Get up• Get ready• Get bike• Go

• Fix bike• Stretch• Leave early• Take clothes/shower at

work

Attempt #3

• Check google for bike time

• Got poncho/glasses• Brought shampoo• Find straighter route• Leave earlier

Done!!

Attempt # 1

Attempt # 2

Always go back to why is this important! Get exercise Save on gas & wear/tear on car Contribute to carbon footprint Promote exercise/wellness in

community Lessen traffic flow by one

car………

• Confirm patient population• Locate tools on algorithm• Begin trying out tools• Review use of MH Log Sheet• Confirm MOA role• Billing questions/tech assistance

• Review Log Sheet progress• Use of DAI• Use of other resources• Discuss optimal office flow

(include MOA)

• Overview of aims, CBIS, ASWBounceback and practice finding the tools (Scavenger Hunt)• Log sheet/AP requirements• Billing and EMR

optimization• Develop an action plan

• Share experiences (good & bad) w peers

• Use of tools• DAI role play• Log sheet/AP requirements• Update action plan

• Share experiences• Community Resource Cafe• Troubleshoot issues

for sustainability & improvement

• Sustainability Plan

AP1 AP2Pre-visit

Month 0 Month 7-8

Sustain

• Survey-barriers, desires• Orientation to Algorithm,• Review use of MH Log Sheet• Location of tools on

algorithm• Confirm use of EMR

• Ongoing Support• CME• Post Module Reflective

Questionnaire (mid-March)

Module Pathway

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Cognitive Behavioural Therapy (CBT): Setting the Stage


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Level 1 Evidence based. CBT prevention endures beyond tx cessation. If both CBT and meds stopped after successful acute treatment, patients who received CBT have lower rates of relapse **

Behavior/Activation oriented

Helps patients learn to change thought patterns/behaviors that negatively affect mood

Gives patients a sense of power and control

Retrains the brain!

You are the coach not the therapist

**CANMAT Clinical Guidleines for the management of major depressive disorder in adults: Kennedy SH, Lam RW, Prikh SV, Patten SB, Ravindran AV

What is a Cognitive Behavioral Approach?


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How does CBT and CBT skills work?Use this to introduce CBT skills

Situation Situation


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SITUATIONS

• Loss• Conflict• Isolation

SITUATIONS

• Loss• Conflict• Isolation

THOUGHTS • Harsh self-

criticism• Over-

pessimistic• Catastrophic

about future

THOUGHTS • Harsh self-

criticism• Over-

pessimistic• Catastrophic

about futurePHYSIOLOG

Y · Altered sleep· Low energy· Δ brain

chemistry

PHYSIOLOGY

· Altered sleep· Low energy· Δ brain

chemistry

ACTIONS · Withdrawal· Reduced

activity· Poor self-care

ACTIONS · Withdrawal· Reduced

activity· Poor self-care

EMOTIONS

· Sadness· Despair· Numbness

EMOTIONS

· Sadness· Despair· Numbness

Problem SolvingProblem Solving

Behavioural ActivationBehavioural Activation

Realistic ThinkingRealistic Thinking

How does CBT and CBT skills work?Use this to introduce CBT skills

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Helps on its own

Mild or moderate depression, mild and moderate anxiety disorders such as GAD, social anxiety, panic, stress, anger, self esteem, some personality disorders

As an adjunct with medications in primary care or collaborating with secondary care

Severe depression, anxiety disorders, obsessive compulsive disorder, bulimia, post-traumatic stress disorder, personality disorders, stable bipolar disorder and stable psychosis

Engages, empowers patients to work towards their recovery

Provides patients with coping skills & a sense of control

A non-pharmaceutical option/adjunct for treatment that is enduring and prevents relapse

The benefits of using CBT skills?


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“Before just jumping into pharmaceuticals you can start with other things like re-training your brain, I have some

strategies involving some homework to help you, what do you think about trying this?”

Dr. Howard Bright, Chilliwack

An alternate approach….consider saying to your patient….


Results n=525 physicians

0

20

40

60

80

100

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Giving practitioners and patients more coping tools reduced healthcare provider stigma against AIDS **

Family docs feel unequipped to deal with mental health issues ***

Novel hypothesisProviding tools for practitioners, patients to use will reduce healthcare provider stigma against mental health issues** Brown, L. Trujillo, L., Macintyre, K.; (2001)Interventions to Reducde HIV/AID Stigma: What have we learned?, Horizons Program/Tulane School of Public Health and Tropical Medicine, New Orleans, Louisiana, *** Clatney, L., MacDonald, H., & Shah, S.M. (2008). Mental health care in the primary care setting: Family physicians’ perspectives. Canadian Family Physician, 54,

New Hypothesis


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OMS-HC Total average scores: Both groups

4343

*Wilcoxen rank sum test was used to measure between group change from pre-test to follow-up, p<.001 **Wilcoxen sign rank test was used to measure within group change. Intervention group pre-test to post-test change, p=.002; post-test to follow-up change, p=.017. Control group, not significant.

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Why this module will change everything!

Dr. Fiza video

Perspective


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Break


Let’s Do it!

Today: Start with Algorithm and 4 Basic tools

CBIS Manual

Bounce Back

Coaching/DVD

Anti-Depressant

Skills Workbook

PHQ9/GAD7

Updated Algorithm Available

‘Google’ this:

www.gpscbc.ca

Click PSP

Scroll to this:

• Scroll down• Click Adult Mental Health • Select • Algorithm for Mental Health (pdf) • Right click select "Save target" to

download to your desktop

Algorithm Scavenger Hunt

(locating the tools quickly)

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MH Tools Scavenger Hunt

Form groups of 2-3, each with at least one laptop with downloaded MH Algorithm

OR Google www.gpscbc.ca click PSP, scroll down click Adult Mental Health Module, select Algorithm, right click save target

http://www.gpscbc.ca/

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FormatEach Pair:

Will review 2 Case Studies (Anxiety, Depression) Must complete each task to receive next task One person to bring completed task to Coordinator

Each Group Member: Will receive an Action Period log to fill in (keep at your

table until the end of the Scavenger Hunt)

Bonus Tasks = Prizes

Coordinators will be circulating to provide assistance

Algorithm Scavenger Hunt

Discussion and “Treasures”

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MOA Tasks to discuss Reschedule MH patients

in blocks Organize relevant

resources – forms, booklets, other materials

Provide patient follow-up calls

Identify how Action Period logs will be completed and faxed

Complete the CMHA Mental Health First Aid course

Contact the Practice Support Team for support

Ensure Algorithm is loaded on each computer

Today: Start with 4 Basic tools

CBIS Manual

Bounce Back

Coaching/DVD

Anti-Depressant

Skills Workbook

PHQ9/GAD7

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PHQ-2 & PHQ-9


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Need one or both questions endorsed as “2” or “3”(“More than half the days” or “Nearly every day”)

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PHQ-9 Scoring

Major Depressive Disorder: Need 5 or more questions endorsed as “More than half the days” or “Nearly every day” (i.e. in shaded areas)

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8 91

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PHQ-9 Scoring

Is functional impairment endorsed as “Somewhat difficult” or greater?

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8 91


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DSM 5 Confirming Diagnosis of Major Depressive Episode

Criteria A: reflected in PHQ9 nine questions1 symptom is either

depressed mood or loss of interest or pleasure

(PHQ9 1st 2 questions) 5/more symptoms

present in same 2 week

period/change of function

Criteria B: Reflected in PHQ9

function question

Criteria C: episode is not due

to a substance or other medical condition

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Bereavement

May resemble a major depressive episode Use your clinical judgment depending on

your knowledge of the individual and their cultural norms

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Manual Overview

Assessment FlowDAIProblem ListAction PlanResource ListSAQAnxiety Dx

SkillsActivationCognitionRelaxationLifestyleAnxiety

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WHAT & HOWFour Ways To Flow

1. Problem list action plan2. Symptoms

3. SAQs 4. Specific anxiety diagnosis

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Tools – use according to your needs

Be selective

Use all, some, now, later

Be strategic

Flexibility of Use - Key Strategy


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Shift in How we Work

Shift to shared patient responsibility

Chronic problemsNo quick fixAll tools to engageBuild partnership

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General

Breathe, relaxNo right or wrongPDSACan’t hurtNegotiate,

demonstrate and soft sell

Validate, encourage and praise

Skills

• Activation - first• Cognition – prepare• Relaxation/Anxiety –

demonstrate• Lifestyle – always good• Anxiety disorders -

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Organizing Tips

Handouts availableOne at a timeSmall goals Chart homework

givenRegular follow-upPractice

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Problem List

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Resource List (Reslience)

About the patientShift to strengthChallengingHelp Internal and

externalWellspring

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Problem List Action Plan

All knownPatterns, not

solutionsChaos organizedBeing heardValidatedPrepares for action

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Ask patient:

What action do you think would be helpful for this problem….? Activation? Relaxation? Thought changing? lifestyle changes? medications ? referrals to other resources

Small Group Activity – Problem List Action Plan 10 min

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WHAT & HOWFour Ways To Flow

1. Problem list action plan2. Symptoms

3. SAQs 4. Specific anxiety diagnosis

Summary• Just do it!• Jump in!• Use favorites!• Own it!

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BOUNCE BACK: SELF-HELP DVD & TELEPHONE‐COACHING FOR LOW MOOD, STRESS, & WORRY

Supported Self Management Cognitive Behavioral Skill Building Mood Improvement

Program


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Brief ‘Little Booklet’ format with less text

Accessibility Alternatives

Cantonese versions + Coaching also available

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To learn more about Bounce Back in general: Visit our Website: www.bouncebackbc.ca

Bounce Back toll-free #s:Phone: 1-866-639-0522Facsimile: 1-877-688-3270

Additional Information


http://www.bouncebackbc.ca/

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Advocate Perspective

Importance of

being heard

being asked the questions

Short term more time, long term less time/gain

Stigma experience

Other experience


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Discussion


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Funding for Modules

3 x ½ day (max)GP Session x 3 $ 1, 235.64

MOA 12 hrs $ 240

1 ►Planning & initial implementation in practice►Report on experiences and successes at LS2►Billable at or after LS2

$ 823.76

2 ►Refine implementation, embed and sustain the change►Report on experiences and successes at LS3►Billable at or after LS3

$ 610.72

Action Periods

Learning Sessions

Potential Total: $ 2,910.12

Participant Funding GPs: Mental Health Module

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CBIS tools

• DAI 2 counseling visits 00120 x 2 1 counseling visit finish with MH planning fee 00120, 14043

• Problem List Action Plan Counseling visit 00120

• Skills Office Visit 00100 Tel Fup 14079

MSP Compensation

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Impact of using the tools: Dr. Egan’s Renewed Practice

Visit 1 PHQ9/GAD & PL/RLBill 0010 or if >20 minutes, bill 00120 worth 1.5 of a 00100 up to 4 times

a year

Visit 2 Review PL/RL & create Action Plan, choose Skill sheet

Bill 0010 or if >20 minutes, bill 00120 worth 1.5 of a 00100 up to 4 times a year

Visit 3 Review and add ASW (pt may choose Bounce Back too)

Bill 0010 or if >20 minutes, bill 00120 worth 1.5 of a 00100 up to 4 times a year

Visit 4 May need more in depth Diagnostic Assessment Interview

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Visit 4 May need more in depth Diagnostic Assessment Interview

Bill 14043 MH planning fee, and after this is billed, this generates 4 more counseling visits giving access to 8 prolonged visits in one calendar year in addition to the planning visit 14043 worth $100 once a year. Plan must include a screening assessment and a planning document to keep on chart. If you take 2 sessions to do this bill 00120 for first and 14043 for second giving you the time to discuss with patient easily.

More about Visit 4

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Action Period Planning

• Confirm patient population• Locate tools on algorithm• Begin trying out tools• Review use of MH Log Sheet• Confirm MOA role• Billing questions/tech assistance

• Review Log Sheet progress• Use of DAI• Use of other resources• Discuss optimal office flow

(include MOA)

• Overview of aims, CBIS, ASWBounceback and practice finding the tools (Scavenger Hunt)• Log sheet/AP requirements• Billing and EMR

optimization• Develop an action plan

• Share experiences (good & bad) w peers

• Use of tools• DAI role play• Log sheet/AP requirements• Update action plan

• Share experiences• Community Resource Cafe• Troubleshoot issues

for sustainability & improvement

• Sustainability Plan

AP1 AP2Pre-visit

Month 0 Month 7-8

Sustain

• Survey-barriers, desires• Orientation to Algorithm,• Review use of MH Log Sheet• Location of tools on

algorithm• Confirm use of EMR

• Ongoing Support• CME• Post Module Reflective

Questionnaire (mid-March)

Plan Your Pathway

PSP Mental Health Log

Successful planning

for achieving Action Period

activities

To complete Action Period 1Replace this box: With your practice ideas

• Scheduling options• Create/Review patient registry• Select specific patient criteria…

complex care, migraine, others?• Organize relevant resources –

forms, booklets, other materials• Follow up with patients (MOA can

follow up with patients on homework and goals agreed to in action plans)

• Identify changes to work processes and office re-design

• Record overall progress on log sheets

Paperwork

• Learning Session Evaluation

• KEEP Invoices to FAX to Doctors of BC (FAX # at lower R side)

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What is your proof that this stuff works???

How will you know that what you are doing is an improvement???

My appointments will be faster

Some of my patients may not need to see psychiatry

My patients will progress and respond to my approach

My appointments will be proactive

My income will increase

My MOA will have an

enhanced role and a workflow

in place

My communications with Mental Health and Addictions will improve

Thanks for Attending


Lunch Info

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Documents

Www.pspbc.ca Adult Mental Health Module An Organized Approach to Mental Health Issues in Realistic Time Learning Session 1 2015