PROGRAM EXAMPLE: INTEGRATED PRIMARY

CARE IN DEPARTMENT OF FAMILY MEDICINE AT

BROWN UNIVERSITY

Justin M. Nash, PhD

Professor

Departments of Family Medicine and Psychiatry and Human Behavior

Warren Alpert Medical School of Brown University

Director of Behavioral Health in Primary Care

Memorial Hospital of Rhode Island

Robert – presents with grief reaction

• 76 year old whose 28 year old granddaughter was killed late at night with two unknown males when SUV rolled down embankment in a remote wooded area where vehicles do not normally travel.

• Frail, uses walker, sad affect and tearful during visit

Robert – relevant history

• Type II diabetes; Carotid artery stenosis and repair

• Peripheral vascular disease; TIA’s and ischemia

• Chronic pain (CRPS); Lumbar spinal stenosis; Herpes zoster

• Multiple medications including alprazolam and Vicodin • Depression noted in history

• Denies ETOH and drug use

• No previous therapy

Robert – relevant history • ‘Family is important to him.’ One of 17 children. 3 children

of his own.

• Many family relationships have fallen apart. No contact with one daughter, never meeting her children

• Lost 40 people to death over past 5 years

• Only social support for him is his committed partner of 10 years – ‘we live for each other’

• Former police officer

• Sexually abused from ages 9-15 by

older male family member. Never shared with any family member

Robert – his unanswered questions and

unresolved issues

• How did she end up in that location?

• Who were these guys and did they have intentions of

hurting or abusing her?

• Did her drinking have something to do with the

situation?

• Her words when she last saw him

were ‘where have you been for the past 8 years?’

• “I don’t have much time left and don’t know what this time will be like.”

Robert – targets of targeted treatment

• Grief considering context • Shocking death under unexplained circumstances

• Unresolved relationship with granddaughter

• ‘Family is important’ in family with estrangement and discord

• Isolation with minimal support

• Reexperiencing of his own vulnerability and past trauma

• Frail individual with chronic conditions and unclear timeframe

• Will there be increased reliance on opiods and benzodiazepines?

• Cognitive functioning?

• Followup in primary care with

consideration of referral to longer term

treatment by therapist in the community.

Dimensions of collaborative primary care behavioral

health

Different settings but with more seamless interface between the settings

Separate care but within the same location, sharing staff and facilities

One treatment plan with behavioral and medical elements

Blount, A. (2003). Integrated primary care: Organizing the evidence. Families, Systems & Health, 21, 121-134.

Integrated Care Co-located Care Coordinated Care

Patient centered medical home in a family

medicine residency program

• Hospital-based.

academic teaching

practice that provides

training to medical

students, residents,

and fellows

• 13 faculty + 39

residents; 27 exam

rooms

• Serves 12,500 active

patients 30,000

visits annually

Diverse socioeconomic,

ethnic, and racial

patient population;

32% identifies as Latino

and 12% as Black

Trainees in the service

Psychology • Externs from URI doctoral program

• Interns from Brown University internship

• Fellows from Brown University postdoc

Social work • MSW students from Rhode Island

College social work program

Family medicine • Residents from Brown University Family

Medicine Residency Program

Medical • Medical students from Brown University

Undergraduates • Brown university premed, psychology,

and neuroscience major in a support

capacity

Attendings/faculty/other health professionals

connected to the service

Psychology

• Psychologist supervisors

Social work

• Social worker supervisor

Psychiatry

• Psychiatrist preceptor

Family

medicine

• Family medicine physician perceptors

Nursing

Pharmacy

• Team leader nurses

• Care manager nurses

• Academic pharmacist

Structure of the behavioral health integration and

services provided

Behavioral

health open

access

• Patient walk in service

• Warm handoffs

• Screening/triage/referral, assessment, brief

treatment

Consultation

service

• Curbside

• Warm handoffs

• Pager/Flag system

Scheduled

clinics

• Psychology/social work therapy

• Psychiatry medication

• Including spanish speaking clinic

Group

treatment

• Depression/anxiety group

• Chronic pain group medical visit

• Diabetes group medical visit

Patients utilizing the BH service

Age 14-74; mean: 37, SD=15.14

Gender 70.3% Female

Ethnicity 74.3% White

12.2% Latino

10.8% Black

1.4% Asian

Marital status 66.2% Single

Insurance 55.4% Medicaid

18.9% Medicare

17.6% Private

8.1% Uninsured

Group visit for depression and anxiety

Personnel • 1 clinical psychology post-doc, family

medicine resident

Coverage • 1 group every 2 weeks

Visits • Scheduled 60 min

• Rolling admission, continuity not

expected

Reach • 17 group sessions to date

• 23 patients total

• 5.3 patients per group

Utilization of BH service over 2 months

# of visits: 2.8 (SD =

.99)

Range = 2-6

• 80% of patients seen for issues having a depression or anxiety component

• 74 patients were seen for at least 1 BH visit

• 53% of patients were only seen for 1 visit

• 126 follow-up visits scheduled

No showed

22%

Cancelled

30%

Attended

48%

Depression screening

• Program the Electronic Medical Record to prompt medical

assistants to administer PHQ-9 when a patient:

Screened positive on the PHQ-2 and

Had not had a PHQ-9 in the previous month

• PHQ-9 administration increased from 5% to 48%

Challenges experience in the service

• Access remains limited Patients who are not seeking service are not having needs

addressed

• Challenges to providing comprehensive, coordinated care Brief visit with individual clinician having limited impact given

complexity of psychosocial and medical problems

No mechanism to easily connect patients to needed medical and community resources

• Limits to population management

BH metrics like the PHQ-9 not routinely administered and recorded

Next steps in the service – creation of an

interprofessional behavioral health e-consultation

Non-urgent consultation requests sent through flag

system in EMR

Team members meet on Wednesday morning

E-consultations are discussed and triaged

Patients entered in behavioral health registry and

progressed monitored over time

Quality indicators are developed to evaluate service

E-consultation

team members

Family medicine

resident

Psychiatrist

Social work trainee

Psychology trainee

and psychologist

supervisor

Nurse care manager

Medical student

Pharmacy student

Undergraduate

E-Consultations

Guide referring

physician and

medical staff on

behavioral health

management

Refer to behavioral

health open access

clinic for assessment

and followup

Refer to outside

behavioral health

service

Schedule patient in

psychiatrist clinic for

medication

consultation

Guide nurse care

manager in

coordinating care

Connect patient to

appropriate

community resource

Roles and functions

in primary care

Team participation

and facilitation

Leadership

Interdisciplinary

systems

Teacher, trainer and

supervisor

Teaching Supervision

Interprofessionalism

Consultant to

physician and

medical staff

Consultation

Teaching

Provider of patient

care service

Assessment

Treatment

Diversity

Developer and

evaluator of

integrated care

Leadership

Practice management

Connector to

resources in health

care system and

community

Advocacy

Manager of

population health

Science, research,

evaluation

Geropsychology competencies

Family medicine residents, who address health from birth to end of life, receive formal geriatric training including competencies connected to geropsychology (e.g., home visits). Psychology and social work trainees do not receive structured formal training in geropsychology but address geropsychology competencies as needed depending on cases Neuropsychology interns who are on the primary care services help with our understanding of older adult issues and competency development

Resources

• Croghan, T. W., & Brown, J. D. (2010). Integrating mental health treatment into the patient centered medical home. (Prepared by Mathematical Policy Research under Contract No. HHSA2902009000191 T02.). AHRQ Publication No. 10-0084-EF. Rockville, MD: Agency for Healthcare Research and Quality

• Hunter, C., Goodie, J., Oordt, M., & Dobmeyer, A. (2009). Integrated behavioral health in

primary care: Step-by-step guidance for assessment and intervention. Washington, DC: American Psychological Association.

• McDaniel, S., Grus, C., et al (2014) Competencies for psychology practice in primary care. American Psychologist 69:409-429.

• Nash, J.M., Masters, K., McKay, K., Vogel, M. (2012). Functional roles and foundational characteristics of psychologists integrated primary care. Journal of Clinical Psychology in Medical Settings. 19:103-104.

• Nash, J.M., Khatri, P., Cubic, B.A., Baird, M.A. (2013). Essential competencies of

psychologists in patient-centered medical homes. Professional Psychology: Research and Practice. 44:331-342.

• Rollnick, SR, Miller, WR., Butler, CC. (2008). Motivational interviewing in health care: Helping patients change behavior. New York: The Guilford Press

Acknowledgements

Rhode Island Foundation Grant

Cara Fuchs, PhD

Samuel Hubley, PhD

Lisa Uebelacker, PhD

Risa Weisberg, PhD

Judith DePue, EdD