Integrated Behavioral Health and Rural Factors

1. Integrated Behavioral Health and Rural Factors

2. Health Center Program Overview (Calendar Year 2010) • 19.5 Million Patients • 38% uninsured • 93% below 200% poverty • 62% racial/ethnic minorities • 1,052,000 homeless • individuals • 77 Million Patient Visits • 1,124 grantees • 8,100+ service sites • Over 131,000 Staff • 9,592 physicians • 6,362 NPs, PAs, & CNMs Source: HRSA, Uniform Data System, 2010

3. Health Centers: Behavioral Health Workforce • 4,200+ Behavioral Health Workforce • (2010 UDS Data) • 394 Psychiatrists • 360 Psychologists • 1,265 Social Workers • 958 Other Licensed Behavioral Health Providers • 1,264 Other Behavioral Health Staff

4. Health Center Services and Access2010

5. Benefit of Behavioral Health in Primary Care Behavioral health factors play a significant role in prevention, diagnosis, treatment in 70% of chronic illnesses 70% of primary care visits have a significant psychological component Depression is prevalent in over 20% of patients with chronic and or terminal illnesses Multiple physical, emotional and interpersonal problems are associated with substance abuse - Screening and intervention in primary care is shown to reduce use

6. Benefits Continued Access – At least 50% better access to MH care if offered in primary care. (Bartels, et al. Am J Psych, 2004) Care in medical setting is a better cultural fit for many patients Behavioral Health Clinicians free up time for primary care physicians to spend with other patients, while enhancing patient satisfaction Care management is more effective when done by professionals with behavioral health skills. (Pincus, Pechura et al. Administration & Policy in Mental Health, 2006)

7. Services Provided by behavioral health professionals Administration of psychological assessments Evaluation and diagnosis Counseling/Psycho-Ed Behavioral interventions Psychotherapy Group therapy/family therapy Manage depression-chronic illnesses Psychopharmacological Rx (some states) Consultation to primary and specialty care providers Research skills for identifying best practices

8. The Behavioral Health Clinicians in Primary Care – Characteristics, Skills and Orientation Flexible, Independent & Action Oriented Solution Rather than Process Oriented Impact Functioning, Not Personality Prevention Oriented Finely Honed Clinical Assessment Skills Cognitive Behavioral Intervention Skills Group and Educational Intervention Skills

9. Primary Care Clinical Model Embedded Behavioral Health Consultant on the Primary Care Team Real time behavioral and psychiatric consultation available to PCP Focused behavioral intervention in primary care Behavioral medicine scope of practice Encourage patient responsibility for healthful living A behaviorally enhanced Healthcare Home

10. Rural Factors Accessibility – tough to identify when, where and how to access services Availability – some travel hundreds of miles for care Acceptability – stigma is particularly detrimental in rural areas where there is no anonymity

11. Robust Program Characteristics Relevance to Rural specificity to community, adaptation to rural area Impact on Rural addresses a barrier to services not previously available Sustainability and Expansion Capacity reliance on multiple funding sources

12. Robust Program Characteristics Capacity obtain and maintain quality staff and resources Documentation of Program Information describe, advertise and communicate to key audiences Effectiveness track and use data for decision-making Engagement involve multiple stakeholders from community

13. HRSA - Rural Health • Publications on behavioral health and substance use in rural America, including: • Rural and Frontier Mental and Behavioral Health Care: Barriers, Effective Policy Strategies, Best Practices; • Mental Health Care in Rural Communities: the Once and Future Role of Primary Care; • Integrating Primary Care and Mental Health: Current Practices in Rural Community Health Centers • www.raconline.org

14. HRSA Resources for Grantees on Primary and Behavioral Health Integration Bureau of Primary Health Care BPHC Grantee Technical Assistance (TA) Resource page for Behavioral Health Integration This page provides current links to documents and other web resources to assist health centers in the process of integrating primary and behavioral health http://bphc.hrsa.gov/technicalassistance/taresources/index.html#B

15. HRSA Partnerships on Behavioral Health • SAMHSA and HRSA Joint Initiative: Center for Integrated Health Solutions • HHS Behavioral Health Coordinating Committee (HRSA and AHRQ) • White House Office of National Drug Control Policy

16. HRSA Resources for Grantees on Primary and Behavioral Health Integration Bureau of Health Professions Training Grants with Behavioral Health Focus: Graduate Psychology Education Grant Program Funds the planning, development, operation and maintenance of accredited graduate programs that foster an integrated approach to health care services by training psychologists to work with underserved populations http://bhpr.hrsa.gov/grants/psychology/index.html

17. HRSA Resources for Grantees on Primary and Behavioral Health Integration SAMHSA Screening Brief Intervention and Referral to Treatment (SBIRT) Grants Integrated approach to the delivery of early intervention and treatment services for those at risk for substance use disorders. http://www.samhsa.gov/prevention/SBIRT/index.aspx Center for Integrated Health Solutions, funded by SAMHSA and HRSA, promotes integrated primary and behavioral health services to address the needs of individuals with mental health and substance use conditions, whether seen in specialty behavioral health or primary care provider settings. http://www.thenationalcouncil.org/cs/center_for_integrated_health_solutions

18. National Health Service Corps (NHCS) Loan Repayment Program Full-Time Clinical Practice: NHSC will pay up to $60,000 for an initial 2 years of full time clinical service defined as no less than 40 hours per week for a minimum of 45 weeks a year. Half time Clinical Practice: Minimum of 20 hours per week (not to exceed 39 hours per week), for a minimum of 45 weeks per year Psychologists must spend at least 11 hours per week providing direct patient care at the service site and 9 hours per week providing clinical services, teaching or performing administrative duties Up to $60,000 loan repayment for 4-year commitment or $30,000 for 2 year commitment Flexible hours

19. Federal Tort Claim Act (FTCA) Medical Malpractice Program Supports patient access by offering medical malpractice liability protection to health centers – Avoids the need to purchase coverage in the commercial marketplace for sites and services within the scope of the grant project – Eliminates the cost of premiums and allows health centers to redirect the cost avoidance to support their programs and patients – Supports the ability to attract and recruit workforce by offering malpractice coverage thus expanding access for vulnerable populations • FTCA Website: http://bphc.hrsa.gov/FTCA/

20. Other Federal Resources • Administration for Children & Families, Office of Planning, Research, and Evaluation: The Program Manager’s Guide to Program Evaluation http://www.acf.hhs.gov/programs/opre/other_resrch/pm_guide_eval/index.html • CDC Evaluation Working Group http://www.cdc.gov/eval/index.htm • Drug Abuse Treatment Cost Analysis Program http://datcap.com/ • Eastern Tennessee State University Department of Psychology • http://www.etsu.edu/cas/psychology/graduate/programs/clinicalphd/mission.aspx

21. Other Federal Resources • Grants.gov http://www.grants.gov/ • Institute of Behavioral Research - Community Treatment Forms http://www.ibr.tcu.edu/pubs/datacoll/commtrt.html - ComTreatmentCosts • National Organization of State Offices of Rural Health http://www.nosorh.org/ • Office of Rural Health Policy http://www.hrsa.gov/ruralhealth/ • Rural Assistance Center – rural health and rural human http://www.hrsa.gov/ruralhealth/

22. Contact Information Christopher Bersani, Psy.D., ABPP Captain, US Public Health Service (USPHS) Sr. Public Health Analyst/Behavioral Health Lead Office of Regional Operations (ORO) Health Resources Services Administration (HRSA) 617 565-1470; cbersani@hrsa.gov