Interdisciplinary Behavioral Interdisciplinary Behavioral Health Training in Health Training in

Primary Care Primary Care (A HRSA Allied Health (A HRSA Allied Health

Supported Grant)Supported Grant)Joseph H. Evans, PhD Joseph H. Evans, PhD

Munroe Meyer Institute Munroe Meyer Institute

University of Nebraska Medical University of Nebraska Medical CenterCenter

Omaha, NebraskaOmaha, Nebraska

Interdisciplinary Behavioral HealthInterdisciplinary Behavioral HealthTraining in Primary Care Training in Primary Care

• Behavioral Health Disciplinary Partners– MMI Psychology Department– Marriage & Family Therapy Program (Family

Medicine Department)– MMI Social Work Department

Counseling Programs (Statewide)

Rural Nebraska Mental Health Rural Nebraska Mental Health FactsFacts

• 88 of 93 counties are MH HPSAs• 74% of MH professionals practice in Omaha and

Lincoln• 38 counties have 0 or 1 MH professionals• Of 147 licensed psychiatrists, 113 are in Metro

areas and 15 are in State facilities• #s of NE MH professionals are lower than the

national average, per capita • Child-Adolescent therapists even fewer

One Solution: Integrated Behavioral One Solution: Integrated Behavioral Health in Primary Care Health in Primary Care

• Defined as – Provision of BH care within a primary health

care setting– Integration of behavioral and physical health

care services– Preventive and first line interventions for

common behavioral/mental health problems presenting in primary care offices

Interdisciplinary BH Training in Interdisciplinary BH Training in Primary Care GrantPrimary Care Grant

• Grant Program Objectives– Improve and Extend the BH Training Model – Provide “Learning through Service Delivery”

experiences in Underserved Areas– Evaluate Effectiveness of the Interdisciplinary

BH Training Model and Disseminate Results– Improve Recruitment, Placement and

Retention of BH professionals in Underserved Areas

Why Integrated BH Care?Why Integrated BH Care?

Physicians are “de facto” mental health providers.

– 60% of all care mental health visits occur in PC setting (Magill & Garrett, 1988)

– 25% pediatric PC visits include behavioral health concerns (Cooper, Valleley, Polaha, Begeny, Evans, in prep)

– Pediatricians rank behavior most common problem (over ear infections) (Arndorfer, Allen, & Aljazireh, 1999)

Interdisciplinary Community-Interdisciplinary Community-Oriented Behavioral Health Oriented Behavioral Health

TrainingTraining• Internship Training in community primary care

settings• Interdisciplinary Rotation in roles of physicians,

nurses, PTs, OTs, speech therapists, etc.• Community Rotation in rural or urban

underserved areas w/ docs, nurses, etc.• Participation in Interdisciplinary Clinics for

cerebral palsy, spina bifida, genetics, depression, neurobehavioral disorders, marital problems, etc.

Community-BasedCommunity-Based Training in Integrated Behavioral Training in Integrated Behavioral

Health in Primary Care Health in Primary Care Mission

• Provision of Behavioral Health Training & Services in Underserved Rural and Urban Areas

• Attraction, Recruitment, Training, Placement and Retention of Behavioral Health Providers

• Training for Physicians and other Health Care Professionals in Underserved Community Settings

• Evaluation of Effectiveness

Integration of Behavioral Integration of Behavioral Health into Primary Care Health into Primary Care

PracticePractice

• Advantages for Physicians:– Physicians have a “ready” referral source– Doctors can triage most “needy” patients– Coordinated care is possible– Patients are seen “in” the practice– 15-20% more practice productivity

Columbus Community Hospital Columbus Community Hospital PediatricsPediatrics

Integration of Behavioral Integration of Behavioral Health into Primary Care Health into Primary Care

PracticePractice• Advantages for Patients:

– Comfort in receiving MH care in your doctor’s office– Reduced stigmatization– Coordinated physical and mental health care– Reduced usage of inappropriate medical visits – Travel for rural patients/families is reduced

Integration of Behavioral Integration of Behavioral Health into Primary Care Health into Primary Care

PracticePractice• Advantages to MH Practitioners:

– Consistent referral stream– Coordination of psychotropic medication and

therapy approaches– Reduced/shared practice overhead– Physician availability for consultations

regarding medical conditions affecting behavior

Hastings Behavioral Health Hastings Behavioral Health ClinicClinic

Barriers to an Integrated Barriers to an Integrated Primary Care ModelPrimary Care Model

• Few MH training programs with interdisciplinary primary care focus

• MH training programs not located in university medical centers

• Scarcity of MH professionals interested in rural practice• Lack of available incentives for rural MH practice• “Carve out” MH insurance programs• “Start-up” costs can be prohibitive

The UNMC/MMI Integrated The UNMC/MMI Integrated Behavioral Health ModelBehavioral Health Model

• Rural Locations (1997-2004):– Columbus (1997-present)– Hastings (1999-present)– Fremont (1999-2002)– Plattsmouth (2000-present)– Nebraska City (2004-present)– Valley (2003-present)– Kearney (2004-present)– Chadron/Crawford/Gordon (2004-present)

The UNMC Integrated The UNMC Integrated Behavioral Health Model(cont’d)Behavioral Health Model(cont’d)• New Outreach Behavioral Health Clinics

(introduced in 2005-06)– Crete (2005-present)– Lincoln (2005-present)– Creighton University Pediatrics (2005-present)

The MMI Integrated Behavioral The MMI Integrated Behavioral Health ModelHealth Model

• Urban Locations (cont’d):– One World CHC (w/ FM) 2000-pres– Eagle Run (w/FM) 2002-present– Charles Drew CHC 2002-2005– Papillion 2001-present – SONA Clinic (w/FM) 1998-present– Summit Plaza (w/FM) 1996-present– Lincoln Complete Childrens’ Care (2005)– Council Bluffs (IA) Cogley clinic (2002)

Behavioral Health ClinicsBehavioral Health Clinics

Nebraska City Behavioral Health ClinicEst. 2004 at Physicians Clinic

Kearney Behavioral Health Clinic

Est. 2004 at Kearney Clinic, P.C.

Chadron Behavioral Health ClinicEst. 2004 at Chadron HealthGordon Behavioral Health ClinicEst. 2004 at Gordon Clinic

The MMI Integrated Behavioral The MMI Integrated Behavioral Health ModelHealth Model

• Components:– Co-location in the primary practice– Frequent contacts re: referrals with physicians and

nurses– Cross-training sessions with the practice and the

community– Relationships with community schools, courts,

agencies, other providers– Provision of dx assessment info and clinical data for

physicians (e.g., ADHD diagnostic protocols)

The MMI Integrated Behavioral The MMI Integrated Behavioral Health ModelHealth Model

• Administrative Issues:– MH services are “value added” to the primary care

practice– Licensing, credentialing, paneling, pre-authorizations,

billing, collections -independent from rural office @ 1st

– Space and staff imposition minimal– Goal is to establish the “importance” of available MH

services to physicians and their practices

Rural Impact - 2002Rural Impact - 2002

BHC Outreach Patient VisitsBHC Outreach Patient Visits

0

1000

2000

3000

4000

5000

6000

1998-99

1999-00

2000-01

2001-02

2002-03

2003-04

2003-04

2004-05

2005-06

Visits

MMI Behavioral Health Outreach MMI Behavioral Health Outreach Clinics - OutcomesClinics - Outcomes

Training and Retaining Providers• 54% trainees work in rural area after

graduation• 11 of 13 current rural outreach clinics

directed/staffed by graduate of this training program - 9 at Ph.D. level

• Monthly meetings via teleconferencing to improve communication, decrease isolation, increase retention.

Outcome - Behavioral Health Outcome - Behavioral Health Trainees (2001-06)Trainees (2001-06)

• Psychology- U Nebraska at Lincoln- Mississippi State U- Syracuse U- Illinois State U- U Southern Mississippi- Xavier U- U Kansas- U Western Michigan

• Social Work – U Nebraska at Omaha

• Counseling– Wayne State College– U Nebr at Kearney– Chadron State College– Doane College

• Mar & Family Therapy– U Nebraska at Lincoln– BYU

Outcome-Physicians Use of Outcome-Physicians Use of Empirical Assessment Empirical Assessment

ProtocolsProtocolsMeasure % Present

Pre-Protocol(N=76)

% Present First Year After Training(N=28)

% Present ThirdYear After

Training(N=26)

CBCL/Parent BASC

1% 93% 93%

TRF/Teacher BASC

0% 88% 93%

CPRS-R:S 1% 93% 93%

CTRS-R:S 1% 93% 88%

Parent ADHD-IV 3% 88% 93%

Teacher ADHD-IV 1% 88% 93%

ECBI 3% 93% 88%

MMI Behavioral Health Outreach MMI Behavioral Health Outreach Clinics - OutcomesClinics - Outcomes

• 2005-06 Data– 3 Publications in Refereed Journals– 2 Journal Articles/Chapters in press– 10 Presentations at National/Regional Conferences– 3 Presentations at State Conferences– 5 Presentations to Physician Groups– 32 Community Presentations (Schools, Agencies,

Parent Groups, etc)– 11 Courses taught at Colleges/Universities (7 Rural)

Patients Seen at Rural BHC - Patients Seen at Rural BHC - Percent In and Out of TownPercent In and Out of Town

0

10

20

30

40

50

60

70

HastingsColumbus Omaha CouncilBluffs

Valley Fremont

In Town

Out of Town

Per

cen

t

Fiscal Support for the MMI Fiscal Support for the MMI Integrated Behavioral Health ModelIntegrated Behavioral Health Model

• HRSA Allied Health Training grant (2001-2007)• HRSA Graduate Psychology Education grant

(2004-2007)• HRSA Quentin Burdick grant (1999-2002)• Americorps State Formula grant (2004-2007)• HRSA SEARCH grant (support from AHEC)• Clinical revenue support• University Faculty-time contributions

Integrated Behavioral Health Integrated Behavioral Health Necessities:Necessities:

• Interested Primary Care partner• Willingness to participate in an education

program for trainees• Space (docs’ days off)• Referrals available (Clinical experience is that 3

docs needed to support one MH professional)• Administrative supports that can eventually be

shifted to the practice

The UNMC/MMI Integrated The UNMC/MMI Integrated Behavioral Health ModelBehavioral Health Model

Adjunct Service:

The Pediatric Behavioral Telehealth Clinic– Initiated March, 2005– 60+ families served in 200+ visits to date– 6-10 visits provided weekly– From 20+ remote sites as far as 452 miles

from Omaha– Males and females ages 3 to 21 years

UNMC/MMI Rural Outreach Behavioral UNMC/MMI Rural Outreach Behavioral Health Care ProgramHealth Care Program

Fremont Pediatric

Partners**

Fremont Pediatric

Partners**

Kearney Pediatrics

Kearney Pediatrics

RequestedCrete Comm Hosp

RequestedCrete Comm Hosp

Requested LincolnLMEP

Requested LincolnLMEP

Requested Blair

Comm Hosp

Requested Blair

Comm Hosp

RequestedNorfolkPeds

RequestedNorfolkPeds

RequestedGrand Island Peds

RequestedGrand Island Peds

ChadronFam Med

Clinic

ChadronFam Med

Clinic

Nebraska City

FamilyMed

Nebraska City

FamilyMed

PlattsmouthNMC

Pediatrics

PlattsmouthNMC

Pediatrics

Columbus CCH

Pediatrics

Columbus CCH

Pediatrics

HastingsChild/Adol

Clinic**

HastingsChild/Adol

Clinic**

MMI Rural Beh HealthOutreachProgram

MMI Rural Beh HealthOutreachProgram

Integrated Behavioral Health Integrated Behavioral Health NecessitiesNecessities

• Dedicated faculty/preceptors willing to travel to rural sites

• Students/graduates interested in rural practice (preferably from rural towns/training programs)

• Fiscal support for faculty and trainees

• Revenue support for travel/billing/ required equipment and supplies

Contact InformationContact Information

Joe Evans, PhDDirector, Psychology Department at Munroe-Meyer Institute (MMI) and Professor, Dept of Pediatrics

University of Nebraska Medical Center

985450 Nebraska Medical Center

Omaha Nebraska 68198-5450

Phone: (402) 559-5758

E-mail: jevans@unmc.edu

QUESTIONS ?QUESTIONS ?