Successful Integration of Behavioral Health into Medical Hypertension Management

1. Successful Integration of Behavioral Health into Medical Hypertension Management Session I5 – Tapas Saturday, October 29, 2011 University Family Medicine—Denver Health Lowry Family Health Center Hypertension Clinic Verena Roberts, Ph.D.

2. Learning Objectives Learn how to successfully integrate behavioral health into medical management of hypertension Learn innovative approaches to management of patient health Learn how to deliver brief evidence-based practices on hypertension in a time-limited Learn how to adapt an integrated approach to your clinic structure

3. Denver Health/CHS Rocky Mtn Center for Medical Response to Terrorism Denver Health Medical Center Rocky Mtn Regional Trauma Ctr 911 Public Health Regional Poison Center & Nurseline Community Health Services (CHS) School-based Health Centers Denver Health Medical Plan Correctional Care Denver Cares

4. Lowry Family Health Center Medical Director/Team Leader (MD) Program Manager (RN) 3 FT/3 PT MD Attendings 2 F-NPs 2-2-2 Family Medicine Residents 2 Behavioral Health Consultants (PsyD & PhD) 2 RNs PT Patient Navigator 6 Medical Assistants a/k/a Health Care Partners (HCPs) PT Pharmacy Dispensary Technician PT Family Planning Educator 3 Laboratory Technicians Clerical Supervisor 5 Clerks Residency Coordinator

5. From Idea to Implementation • How we got started: • PCHM project • Clinic split into two teams • Each team chose a “topic” • Hypertension (HTN) • Weekly “HTN Clinic” focused on medicalHTN management of patients with HTN who were already diagnosed by their PCP, but blood pressure was uncontrolled • 1 provider sees only HTN patients in 1 afternoon session • Medication assessment • Educational handout • NO BEHAVIORAL HEALTH

6. Aim Statement • We aim to improve the identification and management of patients with hypertension in Lowry Family Health Center. The process begins with the correct diagnoses of hypertension. The process ends with each patient having an individualized care plan. By working on the process, we expect: • improved health • decreased visits for patients • improved outcomes • patient and employee satisfaction • medication compliance • increased access • decreased cost. • It is important to work on this now due to: • 1. Access issues • 2. Expensive to health care system • 3. Decrease mortality and morbidity in patients.

7. Behavioral Health Integration • Metamorphose of the Lowry HTN clinic • Idea was introduced to team during monthly PCMH meeting • After initial “yes” – more detailed proposal • Logistics • Content • Continued discussion with medical provider who was conducting the HTN clinic • Develop and research evidence-based treatments that can be adapted to short primary care visits

8. Integrated HypertensionClinic Key Features Half-day scheduled with 8-10 HTN patients Visit limited to hypertension issues All patients seen by medical and behavioral health provider either together or one after another Medication adjustment for hypertension Self-management goal-setting/ Motivational Interviewing Follow-up during HTN clinic only Clinic is provider-driven

9. Clinic Flow Patient navigator selects patients from registry or PCPs refer patients - Patients have to have HTN dx - appointment is made by navigator or HCP PCP and BH see patient together Or alone, but tag team, so that each patient is still seen by both, PCP and BH - Use Vocera to communicate & manage flow Clerk checks patients in – HCP gets vitals and blood pressure, rooms pt. Check out via HCP (if non-English) or clerk and follow-up appointment is made

10. Extending the Team Work Clerks and HCPs manage visit flow and assist with check out and follow-up Patient navigator finds patients via registry and makes calls Other PCP’s make referrals to HTN clinic Remember – this is not a 2 person pony show, but a team approach

11. Action Plan Sheet

12. Challenges to Integration • Data collection • Clinic flow • Turf protection • Follow-up • Provider driven

13. Key Factors to Integration • Get your clinic on board! • Talk to leadership • Use PCMH as starting point • Start small • Be flexible • Be persistent • Show providers and patients how behavioral health can help • Have a plan • Do not take “no” for an answer, but come up with solutions – or better – think of possible problems that may occur and have an answer • Build positive relationships with providers • Regroup after each clinic – what works, what doesn’t? • Give positive feedback and point out your successes! • Involve the entire team as needed

14. Adaptations • Talk to PCP’s about behavioral health seeing patients with significant HTN issues via integrated care visits (PCP & BH present at same visit) • Each day, scout out patients and huddle with PCPs regarding which patients are appropriate for BH integrated visits • Advertise how BH can help PCP’s with HTN patients • If you happen to be unavailable, have patient see BH in individual visit or schedule future integrated visit

15. Questions/Discussion