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in+care CampaignWebinar

January 10, 2013

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Ground Rules for Webinar Participation

• Actively participate and write your questions into the chat area during the presentation(s)

• Do not put us on hold• Mute your line if you are not speaking

(press *6, to unmute your line press #6)• Slides and other resources are available

on our website at incareCampaign.org• All webinars are being recorded

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Agenda

• Welcome & Introductions, 5min• Data Review and Discussion of Retention

Strategies Collected Through the Campaign, 15min

• Integrative Medicine: Mental Health & Retention, 25min

• Virginia Commonwealth University Process Map, 5min

• Q & A Session, 5min• Updates & Reminders, 5min

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Improvement Strategies Exercise

Michael Hager, MPH MANQC Manager

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in+care Campaign National Raw Data Snapshot

Dec 2011 – Dec 2012 Data as of 1/8/2013

12/11Average

(Patients)

12/11Sites

02/12Average

(Patients)

02/12Sites

04/12Average

(Patients)

04/12Sites

06/12Average

(Patients)

06/12Sites

08/12Average

(Patients)

08/12Sites

10/12Average

(Patients)

10/12Sites

12/12Average

(Patients)

12/12Sites

Measure 1: Gap Measure

16.26%(126,953) 209 16.11%

(132,199) 203 14.67%(132,006) 209 15.00%

(118,969) 188 14.12%(114,994) 177 15.64%

(116,396) 170 14.70%(92,505) 145

Measure 2: Visit Frequency Measure

63.09%(85,176) 155 65.79%

(90,025) 155 62.33%(103,954) 176 63.80%

(93,779) 167 65.64%(94,723) 163 64.70%

(94,627) 155 64.29%(78,176) 133

Measure 3: New Patient Measure

56.71%(7,792) 195 58.41%

(8,957) 193 58.57%(8,566) 198 59.67%

(7,369) 182 59.63%(7,277) 174 56.68%

(7,625) 167 57.42%(6,938) 141

Measure 4: Viral Suppression Measure

69.80%(137,564) 200 69.56%

(149,699) 195 70.47%(158,624) 201 71.89%

(143,363) 187 72.15%(136,059) 174 71.90%

(136,648) 166 72.21%(106,551) 142

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Improvement Strategies Discussion

Take Home Points – Participant Submissions• As a medical program, consistently review patient mental health status.

Conducting formal screenings annually will ensure quality assessment• Utilize community networks, planning council groups, etc to drill into

data for explanations/predictors why patients are at risk for dropping out of care. Have primary care and mental health groups meet together ocassionally

• Contractual requirement that retention is a focus of all funded services• Colocation of services / Sharing Space / Multi-Service Center model• Cross-training of medical and behavioral health providers on issues

related to patient retention in HIV care and mental health care• Interdisciplinary team meetings to discuss common threads/concerns• Medical providers keep special database for mental health patients for

tracking• Create PCMH teams based on competency/skill in working with various

pops

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Submit Improvement Updates!

Integrative Medicine: Mental Health and

Retention

“Agenda: Kevin Moore of AIDS Care Group in Philadelphia will present on the connection between

mental health and retention. He will focus on miscommunication between medical and behavioral

providers that leave patients in vulnerable situations. He will also describe opportunities for building mental health into HIV Patient Centered

Medical Homes.”- in+care Campaign Webinar Newsletter

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(Dual) Problem Statement

• Many people living with HIV suffer from mental illness and addictions, which impair their ability to participate in medical care.

• Mental health and substance abuse services are separate care systems with poor care coordination with HIV services.

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Solution: Integrative Medicine

Retention in HIV services is increased• co-locate mental health and substance abuse services at an AIDS Service Organization (ASO)•embed a psychotherapist as part of your primary care team•the therapist’s desired outcomes to include retention, medication adherence, and HIV health literacy

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Patient Centered Medical Home

A model of integrative medicine which attempts to provide all needed services in one location or one coordinated network. Endorsed by the American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American College of Physicians (ACP), and the American Osteopathic Association (AOA).

Resources on integrative medical models: Patient Centered Primary Care Collaborative: www.pcpcc.netCollaborative Care Research Network: www.aafp.org/nm/ccmCollaborative Family Healthcare Association: www.CFHA.netNational Council for Community Behavioral Health: www.thenationalcouncil.org

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Psychotherapist as teammate inpatient-centered medical home

• Embedded members of HIV primary care team

• Expanded role for psychotherapist: consult on diagnosis, provide health education information, explain treatment options, and provide an array of behavioral medicine interventions

• Mental health treatment offered ranges from brief, aperiodic interventions to long-term psychotherapy

• Generalist orientation

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Mental health care is primary care

• 84% of the time, the 14 most common physical complaints have no identifiable organic etiology (Kroenke & Mangelsdorf, 1989)

• 80% of people with a behavioral health disorder will visit a primary care provider at least one time in a calendar year (Narrow et al., 1993).

• 50% of all behavioral health disorders are currently treated in primary care (Kesslet et al., 2006).

• 48% of the appointments for all psychotropic medication are with a non-psychiatric primary care provider (Pincus et al., 1998).

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Mental health care needs more primary care

• People with severe mental illness have diminished life expectancy, e.g. schizophrenia 12-15 years less, due to increased physical health problems (van Os & Kapur, 2009).

• People with major depression have increased risk for nearly every physical health condition including heart disease and diabetes (Lehman & Boyer, 2008).

• People with panic disorder need a medical rule out for co-occurring physical disorders, which is typically unavailable.

• Metabolic syndrome has become a major concern for anyone taking anti-psychotic medication.

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Mental health care is not available enough in underserved communities

• 57% of people with a behavioral health disorder do not get behavioral health treatment (Kessler et al, 2005).

• 30-50% of referrals from primary care to outpatient behavioral health do not attend an initial appointment (Fisher & Ramson, 1997).

• Two-thirds of primary care physicians (N=6,660) reported not being able to access outpatient behavioral health for their patients (Hoge et al, 2006).

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Patient-centered medical homes have demonstrated better clinical outcomes

• depression (Gilbody et al., 2006; Williams et al, 2007)

• panic disorder (Butler et al, 2008; Craven et al, 2006)

• tobacco, alcohol, diabetes, irritable bowel syndrome, generalized anxiety disorder, chronic pain, primary insomnia, and somatic complaints (Hunter et al, 2009).

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How can embedding a psychotherapist improve retention in HIV medical care?

• Meeting unmet need

• Improving quality of medical care by properly delegating behavioral health functions to psychotherapists

• Truly coordinated care

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Since so much of HIV primary care is behavioral in nature, why is treatment

primarily biologically based?

HIV primary care would provide more than primarily biologically-based interventions if the primary care team had the skills to provide behavioral medicine interventions.

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If everyone acclaims integrative medicine, why is so little of it in

existence?

Integrative medicine is difficult and complex but can be accomplished by a generalist, multidisciplinary team with an evidence-based approach and strong practical leadership.

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But how do I pay for a therapist?

The conventional sources of revenue:

1. Fee-for-service reimbursement2. Ryan White awards for psychosocial or

substance abuse services3. Public and private grants for mental

health services

And there is another way….

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My recommendation: create a graduate student practicum placement

• Very low cost• They desire real world training in a

model that is the future of healthcare• Flexibility in how they practice• More easily incorporated into a primary

care team than an established therapist• Benefit from not knowing what isn’t

conventionally thought “possible”

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Graduate Student Cons

• May not have developed all the professional skills for the variety of demanding clinical situations

• Need strong supervision from a licensed professional who is competent in an HIV population and/or has a health psychology background

• Require professional development feedback and mentoring from a senior person on-site

• Typically stay for 10 or 12 months and some clients find this frequent change disruptive

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How to create a graduate student practicum placement

1) contact the practicum coordinator at a local graduate program who is interested in an HIV patient-centered medical home model (most will jump at the opportunity) and learn their supervision and programmatic requirements2) hire a supervisor that meets the requirements and understands the patient-centered medical home model

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Primer on psychotherapy training

• Psychology- Masters, Doctoral; Clinical, Counseling, Neuropsychology (but not School, Organizational)

• Social Work- Masters; Applied, Micro (but not Admin, Macro)

• Marriage and Family Therapy- Masters• Pastoral Counseling- Masters• Free-standing psychotherapy institutes

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How low is low cost?

• Typically first and second year graduate students will take a good practicum site gratis for 2 days a week, i.e. up to 10 clients a week plus care coordination

• Most graduate programs will require one hour of individual supervision from an approved, licensed supervisor per 2 days of work. Supervision cost is generally somewhat less than an hourly session rate: $80-$120 depending on area

• Estimate of a 12 month practicum: 50 weeks x $100= $5,000 annual cost + office space

• $5K annum to significantly expand type of service is within the reach of every ASO in the country

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How to think about using graduate student practicums

• Psychotherapy is listening, understanding, creating rapport, and offering a helpful intervention

• Most people (but not all) who go to graduate school to learn psychotherapy are already gifted in these skills and are primarily only learning new interventions

• Unlike medical students who follow a training model of close supervision, grad students learning psychotherapy are successful working independently and clients will never meet the supervisor

• I recommend calling the student a “therapist” in the workplace and treat them like a part-time employee, i.e. they are professionals responsible for the services they provide

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Tips for working with graduate students

• Ditch bad fits- two kinds of people apply to graduate school to be a psychotherapist

• Collect mental health-medical release of information as a standard practice so the client knows it is a team approach

• Client will need to receive written notification of intern status and how to contact the licensed supervisor

• Identify on-site mentor• If no in-house education program for new staff to

learn about HIV, use internet resources:1. www.aids-ed.org2. www.aids.gov3. www.thebody.com4. www.teach-online.org/description.html

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Retention Outcomes

• Define position to include retention in medical care, medication adherence, and improved health literacy

• Use your CQI process and your HRSA performance measures to give feedback to the primary care team including psychotherapist

• Consider targeting a list of lost-to-care or at-risk patients and offering them therapy first before your medical providers fill your therapist with referrals (typically within one or two weeks)

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Interdisciplinary Collaboration- Part 1

Even ASO staff who have had training in behavioral interventions, sometimes revert to a “medical model” mindset where the medical provider tells the patient what s/he needs to do for their health and they are expected to do it or be judged “non-compliant.” Therapists take a patient-centered approach needed to establish rapport and be effective in psychotherapy. Sometimes, the therapist has sensitive information, e.g. drug relapse, which the patient chose not to share with other staff. Should the therapist share this information?

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Interdisciplinary Collaboration- Part 2

• Follow mandatory reporting laws• Talk to supervisor about how medically

necessary the information may be: who might be harmed? How could it impact medical decision-making?

• As a general rule, share all information that isn’t deemed to likely be detrimental to clients

• Some mismatches between staff and patient can be minimized by withholding non-vital information, though this is the exception to the rule and should only be done with clear rationale and supervisor approval

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Interdisciplinary Collaboration- Part 3

• A therapist is not an enforcer to demand the patient take a medically recommended course of action, e.g. “get them to take their meds”

• A therapist has the time to listen and understand a patient’s point of view

• Therapy is a separate service which allows for education, in-depth motivational interviewing, and other techniques to facilitate change such as medication adherence and healthy living

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Misinformation between medical providers and therapists

• The power differential, especially between a seasoned infectious disease physician and a green graduate student intern, can be very great.

• Medical providers should attempt to include the therapist as a full member of their team, while the therapist should show appropriate respect and follow the team leader.

• Misinformation occurs when teams members are not allowed to disagree or voice different points of view.

• A diversity of opinions is what is gained by making a team more multidisciplinary.

• What psychology and other disciplines add to medical practice is precisely a different way of viewing behavior.

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My contact info

Kevin Moore, Psy.D.Director of Integrative Medicine

AIDS Care Group907 Chester Pike, Sharon Hill, PA, 19079

610-715-0127kevinmoore@aidscaregroup.org

All citations available upon request and I’m happy to have follow up conversation or

offer technical assistance.Thank you!

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Mike Rollison, LCSW

Virginia Commonwealth University

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Click Link below for full-size version

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Time for Questions and Answers

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Announcements

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• Next Meet-the-Author Webinar: M.Vyavaharkar – How Can We Increase Initiation of and Retention in Care Among People Living with HIV? January 30, 2013 at 2pm ET

• Dual Partners in+care and Campaign Webinar: Working with Individual Patients to Improve Retention Date Pending – to be announced!

• Campaign Webinar: Social Service Providers Have a Role in Retention! Date Pending – to be announced!

Upcoming Events

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• Campaign Office Hours: Mondays & Wednesdays 4-5pm ET

• Monday, January 14 - Open Space, no set topic• Wednesday, January 16 - Hurdling Over Individual Barriers to

Care• Monday, January 21 - Campaign Offices Closed, No Office

Hours• Wednesday, January 23 - Building Infrastructure to

Personalize Care• Monday, January 28 - Open Space, no set topic• Wednesday, January 30 - Open Space, no set topic• Monday, February 4 - Open Space, no set topic• Wednesday, February 6 - Aligning Care Services Under a

Single Message

• Data Collection Submission Deadline: February 1, 2013

• Improvement Update Submission Deadline:January 15, 2013

Upcoming Deadlines and Office Hours

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MedScape Retention in HIV Care Series

• Technical Working Group working on articles for a new Medscape Today News Series.

• We recommend that you subscribe to HIV/AIDS MedPlus to be informed of new and exciting articles in this series!

• Published Pieces:• Implementing QI in HIV Clinics to Improve Retention in Care• Monitoring Rates of Retention in HIV Care Across the State• How Health Departments Promote Retention in HIV Care• Improving Retention in HIV Care: Which Interventions Work?• Engaging in HIV Care: What We Learned from AIDS 2012• How Should We Measure Retention in HIV Care? • Retention In HIV Care: The Scope of the Problem

http://www.medscape.com/index/section_10285_0

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Partners in+care

• Partners in+care Private Facebook Group is live! • Share tips, stories and strategies• Join a community of PLWH and those who love them• Email michael@nationalqualitycenter.org for more

details

• Partners in+care website is live!• http://www.incarecampaign.net/index.cfm/77453 • Join our mailing list (a list-serv version of the FB

Group)

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Campaign Headquarters:National Quality Center (NQC)90 Church Street, 13th floorNew York, NY 10007Phone 212-417-4730incare@NationalQualityCenter.org

incareCampaign.orgyoutube.com/incareCampaign