Integrated Health Care

Internship in Integrated Health Care Practices: Opportunities for CounselorsRuss Curtis, PhD, LPC and Mehgan McNeil, M.S., LPCAWestern Carolina Universitycurtis@wcu.edu2.22.13Russ 1Table of ContentsIntegrated Care DefinedNeed for Integrated CareSupporting ResearchTraining Integrated Care ProfessionalsInternship in Integrated CareResourcesDateMedical ProcedureCost (2004)Cost (2013)12-24-04ER visit$1,178.37Labs$150.00Medical imaging$35.001-3-05Follow up labs$133.001-7-05Stress test$423.341-10-05Pulmonary specialist$150.002-052nd Stress test$423.002-05EEG #1 (approx.)$450.003-05EEG #2 (approx.)$450.009-05Trip to ER$1000.00Total$4,392.71$6,143.68Russ: Story about cost3Return on Investment of CBT for AnxietyCBT for Adult AnxietyTotal BenefitsCostsNet BenefitOdds of net present value$17,731$341$17,39097%Lee et al. (2012)http://www.wsipp.wa.gov/pub.asp?docid=12-04-1201

What IC can doFurther humanizes the medical cultureReaches people who would otherwise never seek counselingGets closer to preventionQuality relationships are good for our physical healthRuss and Mehgan5My Experience with ICMD: 60% of day was spent dealing with MH and SA issuesMental health, psychiatrist, and pneumoniaWCU student and Dr. Nicholas CummingsPsychiatrist asking me to check hospitalized client1. Integrated Care Defined

Integrated care is the seamless and dynamic interaction of PCPs and BHPs working within one agency providing both counseling and traditional medical care services. Curtis & Christian, 2012

8Models of Integrated CareNon-Targeted/Horizontal IntegrationProvides a broad array of services to clients with various health related needs and concerns Population focused

Examples: family medical practices, public health centers, Federally Qualified Health Centers (FQHC)

Mehgan talk about MAHEC, age range 18-70Primary care gate keeper, **look for research about primary care, less expensive9Models continuedTargeted/Vertical IntegrationProvides treatment for high risk clientele with specific concerns (i.e., diabetes, substance abusing pregnant women, cancer patients, & metabolic syndrome)

Example: Cancer Patient Support Program, Wake Forest University Medical CenterModels cont.Reverse IntegrationPhysical health physician working within mental health agencies to address the unmet physical heath needs of those with significant mental illness.SPMI patients often neglect their physical healthy issues ie. Metabolic SyndromeSMPI Severe and Persistently Mentally Ill112. Need for Integrated CareWhen looking to develop Internship sites this can be helpful information.12

Integrating services is increasingly recognized as important to achieving both the quality and cost-savings goals of health reform.

Kathleen Sebelius, 21st Secretary of the Department of Health and Human Sevices (in Butnett, CounselingToday, June 2012)Only 40% of clients needing mental health services are identified by primary care physicians (PCPs).

Of the 40%, only 10% seek mental health treatment.

A significant percentage of elderly clients who committed suicide had visited their PCP within one month prior to their deaths (Conwell, 2001).14Common clinical presentations dont fit neatly within medical or MH boxes 50% of all MH care is done by PCPs. 67% of all psychoactive drugs prescribed by PCPs Referral to MH/CD hard to navigate; often doesnt connect. 50-90% follow-through Escobar et al, 2006 Depression diminishes outcomes in medical conditions

CJ Peek, PhD15Up to 70% of primary care visits have a psychological basis

Approximately 25% of patients in a primary care setting have a psychiatric disorder.

Only 3-5% of the population sees a mental health professional in any given year

The Comorbidity StoryRobert Graham Center, Why there must be room for mental health in the medical home; NBGH: An Employers Guide to Behavioral Health ServicesFrank deGruy (2010). Kentucky Policy SummitFirst, comorbidity is commonmore than half of these patients with so-called chronic medical diseases meet criteria for a coexisting mental disorder.Second, as this graph shows, costs, even adjusted costs (looking at all patients in all clinics since some clinics can choose to work with less sick patients), are much higher in these patients.Third, if you treat them together, it is less expensive. Wayne Katon has nailed this one. Especially treat the depression in depressed diabetics.Fourth, if you treat them together, the health outcomes are better. Treat a depressed diabetics depression, and the diabetes gets better.Conclusion: wherever youre treating chronic illnesses, youd better be treating mental health problems.17Common Medical Illnesses and Depression Major DepressionStrokeMulti-condition SeniorsDiabetes23%11-15%30-50%Heart Disease15-20%18Ex) 11-15% of diabetic will have a dx mental illness. 50% will have depressive symptoms. Untreated Mental Health = More Healthcare UseDepressed patients use 3 times more healthcare servicesDepressed patients have 7 times more ED visitsDepression is associated with longer hospital staysOnly 50% diagnosed accurately in primary careOf those started on antidepressant treatment by their PCP, only 40% recover by 4 to 6 monthsOf those treated, < 1/2 receive recommended care

19Patients with MH disorders use more medical services. One study found that depressed patients use 3X more health care services and 7X more ER visits compared with non-depressed patients.Medical patients mental health impacts the treatment and recovery process. Multiple studies have shown increased length of stays for hospitalized patients with co-occurring psychological problems.There is a growing body of evidence demonstrating that integrated care produces better health outcomes and does it in a cost-effective manner.

Untreated MH = lost productivityAbsenteeismDepressed workers miss work 2x as often as non-depressed workersPresenteeism (reduced productivity while at work)Depressed workers have 7x greater odds of decreased workplace effectiveness

Druss et al. Am J Psychol, May, 200120Associations of Mood Disorders with Work PerformanceBipolar Disorder 65.5 lost work days per worker per yearUS civilian labor force yielded 96.2 million lost work days (> $14 billion salary-equivalent productivity per year)

Major Depressive Disorder27.2 lost work days per worker per yearUS civilian labor force yielded 225 million lost work days (> $36 billion salary-equivalent productivity per year)

Kessler, Akiskal, Ames, et al. Am J Psychiatry, 200621Top 10 Health Conditions Driving Full Costs for Employers (Med + RX + Absenteeism + Presenteeism) Costs/1000 FTEsLoeppke, R., et al., "Health and Productivity as a Business Strategy: A Multi-Employer Study. JOEM. 2009;51(4):411-428.

Presenteeism I show up to work but Im not effective. Drug cost of drugs employers pay for drugs in healthcare plan.22

Number of physical symptomsFrank deGruy (2010). Kentucky Policy SummitThis is from the PRIME-MD validation study. 1000 primary care patients. (felliti study)There is a strong positive linear relationship between the number of physical symptoms and the likelihood of a mental diagnosis.The curve is identical for the number of physical symptoms and the number of psychological symptoms.So if you have one, you have both. They run together. They are inextricableinseparable. Comorbidity is the only condition there is!What do we think we are doing?OUR PATIENTS ARE COMPLEX233. ResearchPC is Preferred Location50-90% of referrals to BHPs outside of clinic setting did not result in therapy (Glenn 1987, Cummings 1990)

Depressed patients are more likely (91%) to accept care in primary care setting, which is significant when considering only 50% show up for first appointment with referral to an outside office (Katon 1995)

Russ and MehganLadys story25Research: ICImproving client and physician satisfaction with care (Kates, Crustolo, Farrar, & Nikolaou, 2001; Kenkel, Deleon, Mantel, & Steep, 2005)More likely to receive counseling (Kessler, 2012)Improving client outcome (Wang et al., 2007) Reducing over health care costs (Katon et al., 2002).Adolescent DepressionDepressed adolescents in IC reported significantly less depressive symptoms, increased quality of life and were more satisfied with the care they received at the 6 month follow up compared to a treatment as usual group (Asarnow et al., 2005). Behavioral IssuesChildren (5-12 years old) with behavioral problems demonstrated significant improvement among those treated in an integrated care practice compared to treatment as usual (Kolko, Campo, Kilbourne, & Kelleher, 2012).

Decrease in Depression over timeIncrease in Mental Functioning over TimeFewer missed work days in Past 3 Months Due to Emotional Reasons

Buncombe County Health Center Integrated Care Project29Over 15,000 clients with 40,000 visits annuallyTo be included in study the patients had to have 5 contacts with BHP. (Vincent and Mims studyget this study)

4. Training Integrated Care Professionals30Training students IC InternshipTraining Manual for Behavioral Health InternsCommunity Mental Health ContactsElectronic Medical Record (EMR)DSM-IV Criteria for most common mental health diagnosisCommon Psychiatric medications rxd by physiciansEvidence-based therapeutic techniques Assessment instrumentsShadowing Behavioral Health Providers, Psychiatrist and ResidentsConsultation, Intake, Psychotherapy sessions

Mehgans slide31IC Core CompetenciesStrosahl (2005)Clinical SkillsPractice Management SkillsConsultation SkillsDocumentation SkillsTeam Performance SkillsAdministrative Skills

Mehgans slide325. Internship in Integrated CareTypical IC Internship dutiesConducting Clinical EvaluationsAssessmentsConduct Individual Psychotherapy SessionsConsult with Physicians and ResidentsComplete Case Notes Using EMRProvide Behavioral Health ConsultationsCase ManagementAttend BH DidacticsMehgans slide34Snapshot: An Integrated Care ProgramNurse screens clients to establish care and annual appointmentsPhysician sees client and validates screeningPhysician introduces client and counselor Physician and counselor provide team approach for coordinated care ScreeningAssessmentBrief supportive counselingTherapyCase managementMedication monitoringCoordinated team careBehavioral Health Services integrated with Primary Health Care:35Mehgan: How it IC could operate in PC.PHQ -9Mehgan36Depression ProtocolMedication ManagementPHQ-9Self Care Action PlanCounseling?Appointment reminderMehgans37Integrated Care for Depressed Patients Barrett & Landis, 20123 groups of patients: No consulting or CM (grp N); Consulting services but no CM (grp C); full IPC (consulting and CM-grp IPC)Grp N: 9/1/04 - 5/31/05 N=169 with PHQ9 of 10 or moreGrp C: 1/1/09 - 10/8/09 N=350Grp IPC: 1/1/10 - 2/5/10 N=33

Preliminary dataGroup C: meet with BHP but no follow upIPC: Integrated primary care38Three Measures of PHQ9 Improvement, by Group (Barrett & Landis, 2012)

Make a major impact with a skilled clinician making phone calls to patients and giving brief interventions. Depression protocol.Last PHQ-9 is decreased by half. Depression has decreased.39Establishing IC InternshipLPCA billing, Incident to the physicianHospitals (possibly chaplaincy department)PediatricsFederally Qualified Heath Centers (FQHC)University health centersVeteran AffairsPersistent and consistent406. ResourcesPositive Psychotherapy in Integrated Care Class

My hope is that other universities will offer classes, or incorporate into existing classes, But WCU offers this class.42It has often been pointed out that in healthcare it is 20 years after the proven effectiveness of a treatment before it is fully adopted. In this point of view, it will be 10 more years before integrated care is mainstream.

Cummings, ODonohue, & Cummings, 2009Emerging trend, counselors need to be aware.43ResourcesPodcast, Video and Books:Curtis, R., & Christian, E. (American Counseling Association). (2012, August). Integrated Care: Applying theory to practice [Audio podcast]. Retrieved from http://www.counseling.org/Counselors/TP/PodcastsHome/CT2.aspxCurtis, R., & Christian, E. (Routledge). Integrated Care in Action [DVD]. Available from http://www.routledge.com/books/details/9780415891325/ also available from Alexander Street Press http://www.emicrotraining.com/product_info.php?cPath=22_82_116&products_id=539 Blount, A. (Ed.). (1998). Integrated primary care. The future of medical and mental health collaboration. New York, NY: W. W. Norton.Curtis R., & Christian, E. (Eds.). (2012). Integrated Care: Applying Theory to Practice. New York: Routledge. ODonohue, W. T., Byrd, M. R., Cummings, N. A., & Henderson, D. A. (Eds.). (2004). Behavioral integrative care. Treatments that work in the primary care setting. New York, NY: Brunner-Routledge.Patterson, J., Peek, C. J., Heinrich, R. L., Bischoff, R. J., & Scherger, J. (2002). Mental health professionals in medical settings. New York, NY: W. W. Norton & Company, Inc.Robinson, P. J., & Reiter, J. T. (2006). Behavioral consultation and primary care: A guide to integrating services. New York, NY: Springer.

Selected ReferencesAitken, J.B., & Curtis, R. (2004). Integrated health care: Improving client care while providing opportunities for mental health counselors. Journal of Mental Health Counseling, 26, 321-331.Conwell, Y. (2001). Suicide in later life: A review and recommendations for prevention. Suicide and Life Threatening Behavior, 31(Suppl), 32-47.Doherty, W. J., McDaniel, S. H., & Baird, M. A. (October, 1996). Five levels of primary care/behavioral healthcare collaboration. Behavioral Healthcare Tomorrow, 5(5) 25-28. Escobar, J. I., Gara, M. A., Diaz-Martinez, A. M., Interian, A., Warman, M., Allen, L. A., Woolfolk, R. L., Jahn, E., & Rodgers, D. (2007). Effectiveness of a time-limited cognitive behavior therapy-type intervention among primary care patients with medically unexplained symptoms. Annals of Family Medicine, 5(4), 328-335.Frank, R. G., McDaniel, S. H., Bray, J. H., & Heldring, M. (Eds.). (2004). Primary care psychology. Washington, DC: American Psychological Association.Kates, N., Crustolo, A., Farrar, S., & Nikolaou, L. (2001). Integrating mental health services into primary care: Lessons learnt. Families, Systems & Health, 19(1), 5-12.Katon, W., Russo, J., Von Korff, M., Lin, E., Simon, G., Bush, T., Ludman, E., & Walker, E. (2002). Long-term effects of a collaborative care intervention in persistently depressed primary care patients. Journal of General Internal Medicine, 17(10), 741-748.Mauer B. (2006). Behavioral health/primary care integration: the four quadrant model and evidence- based practices. Rockville, MD: National Council for Community Behavioral Healthcare.Mims, S., & Vinson, N. (2007, November). Dollars and sense: One communitys experience with integrated care services and costs data. Paper presented at the annual meeting of the Collaborative Family Healthcare Association, Asheville, NC.Rasmussen, N. H., Furst, J. W., Swenson-Dravis, D. M., Agerter, D. C., Smith, A. J., Baird, M. A., & Cha, S. S. (2006). Innovative reflecting interview: Effect on high-utilizing patients with medically unexplained symptoms. Disease Management, 9(6), 349-359.Wang, P. S., Simon, G. E., Avorn, J., Azocar, F., Ludman, E. J., McCulloch, J., Petukhova, M. Z., & Kessler, R. C. (2007). Telephone screening, outreach, and care management for depressed workers and impact on clinical and work productivity outcomes. JAMA, 298(12), 1401-1411.Chart169194697555941725492348140282908

With MH DxNo MH Dx

Sheet1With MH DxNo MH DxSeries 3Heart Disease$6,919$4,6972Diabetes$5,559$4,1722HBP$5,492$3,4813Asthma$4,028$2,9085To resize chart data range, drag lower right corner of range.

Chart10.070.220.350.610.81

Column1Number of Physical Symptoms and Likelihood of Mental Diagnosis

Sheet1Column1Column2Column10-17%2.402.002-322%4.402.004-535%1.803.006-861%2.805.00>881%To resize chart data range, drag lower right corner of range.

&CNumber of Physical Symptoms and Likelihood of Mental Diagnosis

Chart317.265454545511.20568039959.73326359838.7416225758.079601998.98030303038.63690476199.26923076928.5925925926

Average ScoreMonths of ServiceAverage Score

Work&SchoolMissedN=9N=14N=13N=7N=5WeeksBefore ServicesMonths 1-2Months 3-4Months 5-6Months 7+Emotional reasons69.230769230858.33333333335233.333333333327.7777777778

Work&SchoolMissed00000

Emotional reasonsMonths of Service

BHQ ChangesMonths of Behavioral Health ServiceBefore ServicesMonth 1Month 2Month 3Month 4Month 5Month 6Month 7Month 8Average Score17.265454545511.20568039959.73326359838.7416225758.079601998.98030303038.63690476199.26923076928.5925925926

BHQ Changes000000000

Average ScoreMonths of ServiceAverage Score

Sheet1

Sheet117.265454545511.20568039959.73326359838.7416225758.079601998.98030303038.63690476199.26923076928.5925925926

Average ScoreMonths of ServiceAverage Score

SF12 ChangesN= 226N= 89N= 13N= 22N= 35N=33N=33N=25N=1901 to 45 to 89 to 1213 to 1617 to 2021 to 2425 to 2829 to 32Physical43.915948141743.963952485943.305887014440.681310935241.704866250442.189689757340.049957934641.59004712439.0592336619Mental25.646084159330.045617411139.220139277236.12892280242.348696317642.474892583141.380591765440.615586393740.0544071242N= 226N= 89N= 13N= 22N= 35N=33N=33N=25N=19Before ServicesMonth 1Month 2Month 3Month 4Month 5Month 6Month 7Month 8Mental Functioning25.646084159330.045617411139.220139277236.12892280242.348696317642.474892583141.380591765440.615586393740.0544071242

SF12 Changes000000000

Mental FunctioningMonths of ServicesAverage Score

Chart525.646084159330.045617411139.220139277236.12892280242.348696317642.474892583141.380591765440.615586393740.0544071242

Mental FunctioningMonths of ServiceAverage Score

Work&SchoolMissedN=9N=14N=13N=7N=5WeeksBefore ServicesMonths 1-2Months 3-4Months 5-6Months 7+Emotional reasons69.230769230858.33333333335233.333333333327.7777777778

Work&SchoolMissed00000

Emotional reasonsMonths of Service

BHQ ChangesMonths of Behavioral Health ServiceBefore ServicesMonth 1Month 2Month 3Month 4Month 5Month 6Month 7Month 8Average Score17.265454545511.20568039959.73326359838.7416225758.079601998.98030303038.63690476199.26923076928.5925925926

BHQ Changes000000000

Average ScoreMonths of ServiceAverage Score

Chart40.0249.517.670.516.225.725.732.426.525.622.225.631.727.320.220.836.425.820.517.428.734.31324.129.828.62516.723.432.821.921.928.33422.615.1

RemissionPartial ResponseDepressionMajor DepressionMonths of ServicePercentage of Patients

Sheet2Before ServicesMonth 1Month 2Month 3Month 4Month 5Month 6Month 7Month 8Remission2.4%16.226.531.736.428.729.823.428.3Partial Response9.525.725.627.325.834.328.632.834Depression17.625.722.220.220.5132521.922.6Major Depression70.532.425.620.817.424.116.721.915.1N550253234183132108846453

Sheet1

Sheet117.265454545511.20568039959.73326359838.7416225758.079601998.98030303038.63690476199.26923076928.5925925926

Average ScoreMonths of ServiceAverage Score

SF12 Changes25.646084159330.045617411139.220139277236.12892280242.348696317642.474892583141.380591765440.615586393740.0544071242

Mental FunctioningMonths of ServiceAverage Score

N= 226N= 89N= 13N= 22N= 35N=33N=33N=25N=1901 to 45 to 89 to 1213 to 1617 to 2021 to 2425 to 2829 to 32Physical43.915948141743.963952485943.305887014440.681310935241.704866250442.189689757340.049957934641.59004712439.0592336619Mental25.646084159330.045617411139.220139277236.12892280242.348696317642.474892583141.380591765440.615586393740.0544071242N= 226N= 89N= 13N= 22N= 35N=33N=33N=25N=19Before ServicesMonth 1Month 2Month 3Month 4Month 5Month 6Month 7Month 8Mental Functioning25.646084159330.045617411139.220139277236.12892280242.348696317642.474892583141.380591765440.615586393740.0544071242

000000000

Mental FunctioningMonths of ServicesAverage Score

Chart669.230769230858.33333333335233.333333333327.7777777778

Months of ServicePercentage

Work&SchoolMissedN=9N=14N=13N=7N=5WeeksBefore ServicesMonths 1-2Months 3-4Months 5-6Months 7+Emotional reasons69.230769230858.33333333335233.333333333327.7777777778

Work&SchoolMissed00000

Emotional reasonsMonths of Service

BHQ ChangesMonths of Behavioral Health ServiceBefore ServicesMonth 1Month 2Month 3Month 4Month 5Month 6Month 7Month 8Average Score17.265454545511.20568039959.73326359838.7416225758.079601998.98030303038.63690476199.26923076928.5925925926

BHQ Changes000000000

Average ScoreMonths of ServiceAverage Score

Chart40.0249.517.670.516.225.725.732.426.525.622.225.631.727.320.220.836.425.820.517.428.734.31324.129.828.62516.723.432.821.921.928.33422.615.1

RemissionPartial ResponseDepressionMajor DepressionMonths of ServicePercentage of Patients

Sheet2Before ServicesMonth 1Month 2Month 3Month 4Month 5Month 6Month 7Month 8Remission2.4%16.226.531.736.428.729.823.428.3Partial Response9.525.725.627.325.834.328.632.834Depression17.625.722.220.220.5132521.922.6Major Depression70.532.425.620.817.424.116.721.915.1N550253234183132108846453

Sheet1

Sheet117.265454545511.20568039959.73326359838.7416225758.079601998.98030303038.63690476199.26923076928.5925925926

Average ScoreMonths of ServiceAverage Score

SF12 Changes25.646084159330.045617411139.220139277236.12892280242.348696317642.474892583141.380591765440.615586393740.0544071242

Mental FunctioningMonths of ServiceAverage Score

N= 226N= 89N= 13N= 22N= 35N=33N=33N=25N=1901 to 45 to 89 to 1213 to 1617 to 2021 to 2425 to 2829 to 32Physical43.915948141743.963952485943.305887014440.681310935241.704866250442.189689757340.049957934641.59004712439.0592336619Mental25.646084159330.045617411139.220139277236.12892280242.348696317642.474892583141.380591765440.615586393740.0544071242N= 226N= 89N= 13N= 22N= 35N=33N=33N=25N=19Before ServicesMonth 1Month 2Month 3Month 4Month 5Month 6Month 7Month 8Mental Functioning25.646084159330.045617411139.220139277236.12892280242.348696317642.474892583141.380591765440.615586393740.0544071242

000000000

Mental FunctioningMonths of ServicesAverage Score

Chart10.120.2520.4210.460.5480.6840.360.4070.474

P=.02No IPCConsulting, No CMFull IPC