jennifer s. funderburk, ph.d. stephen a. maisto, ph.d. anne dobmeyer, ph.d

Patients Seen, and Interventions Used by Behavioral Health

Providers Working in Different Models of Integrated Healthcare

in Primary Care Clinics Across the VA

Jennifer S. Funderburk, Ph.D.Stephen A. Maisto, Ph.D.

Anne Dobmeyer, Ph.D.Christopher Hunter, PH.D.

Acknowledgements•This study was funded by the Center for

Integrated Healthcare pilot grant•This study could not have been completed

without the generosity and hard work of behavioral health providers across the VA, leadership, and fellow research staff

Objectives• Describe the different integrated healthcare

models behavioral health providers reported working in across the VA nationally

• Describe the types of patients seen and clinical interventions used regularly across different integrated healthcare models.

• Discuss the implication of these results on the clinical practice of BHPs within integrated primary care settings.

• Discuss potential avenues for future clinical intervention research.

Purpose of the Study•National prospective descriptive web-

based study examining the types of patients seen and interventions used by VA behavioral health providers (BHPs) integrated into primary care

Method•Recruitment

▫Contacted implementation coordinators of PCMH (N=143) to obtain email addresses for BHPs in their VA

92 coordinators responded (71% response rate)▫33 forwarded recruitment email to BHPs▫8 scheduled a teleconference to present research to

BHPs▫40 provided BHP names and email addresses to

researchers▫Some provided listservs which included non-BHP staff

▫Sent 3 recruitment emails to each BHP asking them to contact us if they were interested

MethodProcedure:

Interested BHPs replied to the recruitment email and scheduled a 5-minute telephone call, where they completed informed consent, learned how to use the web-based questionnaire, and scheduled a day to complete the study

BHPs completed online questionnaires on one randomly assigned day of clinical service

Method•Measures:

▫Demographics & Background (filled out only once):

BHP’s background & clinical training Integrated healthcare setting elements

▫Appointment Questionnaire (filled out after each patient on day of study):

Patient Information: gender, age, presenting symptomatology

Types of Clinical Interventions Performed

Participants: BHPs•159 BHPs completed the study

▫ 21 VISNs represented▫452 eligible BHPs contacted▫Overall 35% response rate

Impacted by over-inclusive listservs Slightly higher than typical email response rate

33% (Shih & Fan, 2009)

Participants• Integrated Healthcare Models

▫Coordinated Care (N=4) Medical and behavioral health providers largely

function independently in separate facilities Maintain separate records, treatment plans, and

standards of care.▫Co-located (N=39)

Medical and behavioral health providers are located in same physical space and may share administrative personnel

▫Care Management (N=9) Model of care typically focused on a discrete

clinical problem (e.g., depression), incorporating specific pathways using a variety of components

Participants• Integrated Healthcare Models (continued)

▫ Co-located Collaborative Care (CCC; N=75) Population health-based model of care focused on all patient

populations Medical providers and BHPs share patient information, medical

record, treatment plan, and standard of care BHP is embedded within the primary care team, acts as a

consultant to PCP▫ Blended--Care Management / CCC (N=28)

Incorporates embedded care management aspect of CCC model Care manager and behavioral health consultant are part of

primary care team BHC is typically responsible for supervision of the care manager

▫ Blended--Co-located / CCC (N=4) Medical providers and BHPs are located in the same physical

space, share patient information, medical record, treatment plan, and standard of care

Results: BHP Demographics & Clinical Background by Model

Co-located (N=39 BHPs)

CCC(N=75 BHPs)

Blended-CCC+CM

(N=28 BHPs)Mea

n (SD)

Range

Mode

Mean

(SD)

Range

Mode

Mean

(SD)

Range

Mode

Provider age 41(9) 29-62 40 41(10)

24-63 30 42(9) 30-62 36

Yrs. of clinical experience in primary care

4(4) 0-17 1 4(4) 0-21 1 3(3) 0-18 1

No. of hrs/wk seeing patients

27(10)

4-40 40 29(12)

3-40 40 31(11)

6-40 40

Office distance from PCP (ft)

17(19)

1-100 15 25(60)

1-400 10 16(20)

0-75 5

Results: Provider Type by Model

Psyc

holog

ist

Socia

l Wor

ker

Psyc

hiatri

st NP RNOth

er0

102030405060708090

100

Co-locatedCCCBlended-CCC+CM

Other: MS in Psychology, Psychology

Interns, NPs, Advanced Practice

Nurses

Co-located CCC Blended-CCC+CM

Shared medical record 100% 100% 100%Patients use same waiting area as primary care

90% 92% 93%

Offices located within primary care clinic

90% 85% 86%

Daily open slots for same-day appointments

87% 87% 89%

BHPs attend primary care staff meetings

69% 77% 82%

Same staff schedules BHP appointments as primary care*

41%* 67%* 36%*

BHPs regularly present at primary care staff meetings†

36%† 52%† 61%†

PCP regularly asks BHP to join them on patient appointments

23% 29% 32%

Results: Integrated Care Elements by Model

* p < .05, † p < .10 in X2 analysis

Results: Theoretical Orientation by Model

CBT

Behav

ioral

Inter

perso

nal

Insigh

t-orie

nted ACT

0102030405060708090

100

Co-locatedCCCBlended-CCC+CM

“Other” orientations: Co-located (21%) CCC (35%)Blended (32%)

Results: Patient Demographics by Model

Co-located (N=151 patients)

CCC(N=311 patients)

Blended-CCC+CM

(N=105 patients)Patient gender

96% male 85% male 82% male

Initial session

40% 37% 32%

Session range

2-47, Mode:2 1-96, Mode: 2 2-28, Mode: 2

Mean

(SD)

Range

Mode

Mean

(SD)

Range

Mode

Mean

(SD)

Range

Mode

Patient age 54(15)

21-89 64 52(15)

22-85 62 54(14)

23-86 63

Visit length (min)

39(17)

5-95 30 40(16)

2-120 30 39(15)

7-90 30

Results: Top 3 Patient Presenting Problems by Model

Depression Anxiety Adjustment0

102030405060708090

100

Co-locatedCCCBlended-CCC+CM

Next 3 Most Commonly Reported Problems: Insomnia, Chronic Pain, & Coping with a Medical Condition

Clinical InterventionCo-located

(N=151)CCC

(N=311)Blended-CCC+CM(N=105)

Psycho-education about diagnosis 70% 64% 71%

Educate about CBT 62% 70% 82%Discuss current techniques for relief 76% 89% 91%

Importance of interpersonal relationships 73% 72% 80%

Pleasurable activities 66% 74% 76%

Behavioral changes 50% 62% 63%Plan to see patient again 72% 70% 79%

Results: Top Interventions by Model

Clinical InterventionCo-located

(N=151)CCC

(N=311)Blended-CCC+CM(N=105)

Educate about CBT 64% 68% 81%

Problem solving skills 48% 60% 71%

Discuss medication adherence 43% 52% 66%

Relapse prevention 22%* 25% 53%*Discuss communication style in relationships 43% 49% 60%

Cognitive distortions 33% 28% 51%

Results: Differences in Interventions for Depression

* Largest difference in how much an intervention is used

Clinical InterventionCo-located

(N=151)CCC

(N=311)Blended-CCC+CM(N=105)

Educate about CBT 67% 71% 84%

Problem solving skills 47% 58% 72%

Discuss medication adherence 38%* 44% 67%*

Relapse prevention 19% 23% 44%Educate about medications 55% 49% 72%Behavior change 48% 60% 68%

Results: Differences in Interventions for Anxiety

* Largest difference in how much an intervention is used

Results Overview: Similarities•BHPs most likely to be psychologists•CBT most common•Aspects of integrated healthcare context:

▫Shared medical record▫Patients use same waiting area as primary care▫Daily open slots for same-day appointments▫BHP offices located within primary care clinic

•Depression, Anxiety & Adjustment top problems•Most common interventions among the models:

▫Discussing current techniques for relief▫Importance of interpersonal relationships

Results Overview: Differences

• Aspects of integrated healthcare context▫Staff scheduling BHP and primary care appointments▫BHPs presenting at primary care staff meetings

• Top Interventions▫Co-located: Plan to see patient again▫CCC: Pleasurable activities▫Blended-CCC+CM: Educate about CBT

• Depression Interventions▫Relapse Prevention (used 22-53%)

• Anxiety Interventions▫Discussion of medication adherence (used 38-67%)

Limitations•Only 35% response rate from BHPs

▫Impacted by over-inclusive listservs•Only examined one day of primary care

▫Could be non-representative of typical care given

▫Future studies could examine several days and create averages of the data that more accurately reflect what is happening

•Limited numbers of all models represented▫Makes across-model comparisons difficult

Discussion•Majority of BHPs are psychologists

▫ BHPs can come from a variety of training backgrounds▫ Psychologists are increasingly being recruited to work in

integrated primary care settings (Cummings, O’Donohue, Hayes, & Follette, 2001; Frank, McDaniel, Bray, & Heldring, 2004)

•Depressive and anxious symptomatology are most common within primary care (Funderburk et al., 2011; Bluestein & Cubic, 2009)

•Evidence suggests the efficacy of problem-solving & CBT interventions; could be helpful to be utilized even more (Catalan et al, 1991; Churchill et al., 2001)

Conclusions•Need for effectiveness research

▫ Focused on the interventions regularly used by BHPs▫ Focused on comparing the efficacy in different models of

care•Need for research on barriers

▫ Exploring barriers to BHPs using recommended or preferred interventions (e.g., CBT, problem-solving techniques)

▫ Exploring barriers to sites becoming more integrated•Need for dissemination

▫ Examining how to disseminate findings on evidence-based treatment to providers to help improve practices

▫ Examining the current access to trainings on evidence-based treatments