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Primary Care Psychology & the Behavioral Health Lab. Memphis VAMC Robert Baldwin, Ph.D. Charissa Camp, Ph.D. November 1, 2012 Presentation for TPA Convention 2012. Background. Dr. Oslin and Philadelphia VA “Best Practice” Evidence and Readings Handout. Personnel.

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Primary Care Psychology & the Behavioral Health Lab


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    1. Primary Care Psychology &the Behavioral Health Lab Memphis VAMC Robert Baldwin, Ph.D. Charissa Camp, Ph.D. November 1, 2012 Presentation for TPA Convention 2012

    2. Background • Dr. Oslin and Philadelphia VA • “Best Practice” • Evidence and Readings Handout

    3. Personnel • Memphis Main Hospital Campus • Co-Located Collaborative Care and Care Management Staff • Copper Behavioral Health (PC-MHI Psychologist Dr. Robert Baldwin) • Blue Behavioral Health (PC-MHI Psychologist Dr. Charissa Camp) • Louisville Call Center • BHL Care Management Staff • Program Director (Psychologist Dr. Beth Scheu) • 2 RNs • 1 Supervisory Health Technician • 12 Health Technicians

    4. The PACT Model • Veteran Centered • Primary Care Patient Aligned Care Team • Veteran • PCP • RN • Clinical Associate • Clerical Associate • Auxiliary PACT Members • Psychologist <-> BHL • Nutritionist • Social Worker

    5. Fun with Acronyms (the VA way) • Psychologist = CCC • CCC = Co-located collaborative care • BHL = CM • BHL = Behavioral Health Lab • CM = Care Management • PC-MHI = CCC + CM • PC-MHI = Primary Care Mental Health Integration

    6. The Six Dispositions that follow CORE • Disease Management (Brief Counseling) • Depression Monitoring (BHL) • Watchful Waiting (BHL) • Referral Management (to MH, SA, PCT, SMI, other) • SMI Management • No Tx—Refusal of services/Not in need of services

    7. PC-MHI/BHL Clinical Process Patient Identification By screening or clinical assessment in PCC ** Initial PC-MHI Psychologist Contact BHL Core Assessment Review Results + Triage (by PC-MHI Psychologist) No Treatment Indicated Refusal of Services Referral Management to MH, SA, PCT, &/or SMI services Disease Management and/or Medical Consultation BHL Watchful Waiting or Depression Monitoring ** when possible

    8. In case of emergency…Access/Warm-Handoffs • Warm-Handoff • When pt is identified by PCP or self-identifies as having an urgent MH issue • PCC staff contacts Psychologist (individual teams have different methods of communication) • Pt is seen same-day, generally within 30 min or less due to protected schedule • Initial contact note is completed and initial triage made • CORE is scheduled to start parallel care management services (CORE if appropriate)

    9. Core Report • Structured Interview completed by HTs • Screening assessment • -Depression - Anxiety and Panic • -Trauma - Mania • -Psychosis - Substance Abuse • -Cognitive Impairment • Report summary generated for CPRS • Reviewed and disposition made by the appropriate PC-MHI Psychologist, depending upon clinic—Copper or Blue

    10. Now let’s review CCC and CM and then specifics of dispositions…Co-located Collaborative Care (CCC) • Initial Referral • Primary Care Staff refer to PC-MHI Psychologist via route agreed upon by that clinic (consults, additional signers, whatever) • Referral for BHL support • PC-MHI Psychologist sends basic info to a sharepoint to enroll Veteran in BHL for Core Assessment • Same day Assessment/Evaluation • If emergency or positive clinical reminders • Triage and Referral • Determine the recommended and Veteran directed level of care – refer as indicated (back to BHL or to specialty MH services) • Brief Therapy • Typically 1-6, 30 min visits • Goal directed/action oriented/MI or SMI management • Referral Management • Motivational interviewing is utilized to assist Veteran in referral process to specialty care such as MHC, PTSD, CDC, SMI programs

    11. Care Management (CM) • Health Technicians (HTs) in Louisville • Conduct the BHL phone services (structured interviews at intervals determined by protocol and/or clinical recommendation) • PC-MHI Psychologists (also the CCC provider in the Veteran’s Primary Care Clinic • Reviews all collected data and drafts of CORE reports edits them in CPRS with a disposition • Communicates with PC medical providers via CPRS or in person about dispositions and status of Veteran’s mental health issues

    12. The Dispositions:Disease Management (Brief Counseling/Brief Interventions) • Brief Therapy (1-6 sessions) • Cognitive Behavioral • Solution Focused • Motivational Interviewing • Use of Action Plans • Often concurrent with Depression Monitoring when the patent is placed on an Antidepressant by their PCP • Lose the couch  and (maybe) the do not disturb sign

    13. Depression Monitoring (DM) • PCP prescribed • new Antidepressant per MH-PC service agreement • Significant changes in their Antidepressant • Phone calls at week 2, 6, 9, by Health Techs to administer follow-up screeners • PHQ-9, Sub Abuse • If PCP is not comfortable prescribing necessary medication, patient is placed in Referral Management to psychiatry

    14. CM/BHL for Depression Monitoring • HT will alert psychologist that contact has been completed • Psychologist will review report, make edits, make treatment adjustments, and place the report in CPRS • If trend is static or depressive symptoms increase, psychologist contacts Veteran for phone contact/assessment or have their Prescribing Provider consultant look at case and make recommendations for PCP or PCP may refer to psychiatrist • Final Depression Monitoring report, paste into CPRS with determination • Often the psychologist will contact the Veteran to confirm determination is consistent with pt needs/desires • Closing summary note is completed if appropriate

    15. Watchful Waiting (WW) • Mild cases of mental health symptoms • Patients not willing/able to engage in treatment • 8 weekly phone calls: Health Techs will call to complete follow-up screening • PHQ-9, Sub Abuse • If conditions worsen, can be referred for disease management or referral management

    16. CM for Watchful Waiting • HT will alert psychologist of the completion of this contact (often with encrypted email as well) • Psychologistlogs into BHL software to review trend in PHQ-9 scores and substance abuse report • If trend is static or depressive symptoms/SA increases, psychologist contacts Veteran for phone contact/assessment • Final WW will elicit a BHL software report; access and edit similar to Core and paste into CPRS with determination • Often the psychologist will contact the Veteran to confirm determination is consistent with pt needs/desires • Closing summary note is completed if appropriate

    17. Referral Management (RM) • Facilitate transition between Primary Care and Specialty Mental Health Services • Offer interim appts/contacts as needed • VA system consults to specialty services as indicated • If high risk, psychologist will follow-up by phone or in person during interim and coordinate with Suicide Prevention Team as needed

    18. SMI Management • May or may not have CORE • Monthly supportive meetings for persons with serious mental illness that are not appropriate for other categories

    19. Let’s Review the Steps • Referral from PACT to PC-MHI Psychologist • CORE/Initial meeting with psychologist • Review of CORE and determine disposition(s) (6 possible) • Follow procedure for disposition(s) selected • Close As with PCP, Veteran/patient may be seen again in future as primary care psychology need arises.

    20. Questions???Thanks for your attention!Robert.Baldwin@VA.govCharissa.Camp@VA.gov