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Psychological Practice in Primary Care or Other Medical Settings. Robert J. Ferguson, Ph.D. Eastern Maine Medical Center & University of Maine Maine Psychological Association, Fall Conference, November 2 , 2012. Theoretical underpinnings. Where is behavioral care delivered?.

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psychological practice in primary care or other medical settings

Psychological Practice in Primary Care or Other Medical Settings

Robert J. Ferguson, Ph.D.

Eastern Maine Medical Center

& University of Maine

Maine Psychological Association, Fall Conference, November 2, 2012

contributing factor to healthcare cost inflation inefficiencies due to mental health carve out
Contributing Factor to Healthcare Cost Inflation: Inefficiencies due to Mental Health “Carve Out”
  • 50% of high utilizers psychologically distressed (Katon, et al., 1990)
  • 1 month prevalence of disorders in high utilizers
    • Mood (dysphoric) 40.3%
    • GAD 21.8%
    • Somatization 20.2%
    • Panic Disorder 11.8%
    • ETOH Abuse 5.0%
contributing factor to healthcare cost inflation inefficiencies due to mental health carve out1
Contributing Factor to Healthcare Cost Inflation: Inefficiencies due to Mental Health “Carve Out”
  • High healthcare utilizers account for:
    • 29% of Primary Care Visits
    • 52% of all Specialty Visits
    • 40% of in-hospital days
    • 26% of all prescriptions

(Katon, et al., 1990)

example panic disorder
Example: Panic Disorder
  • Attributed Physical Causes for Panic Sx’s after ED discharge:
    • Heart Attack 45%
    • CVA, Allergy, Hyperthyroid 40%
    • Overall Medical Cause 85%

Lerner et al., 1995 (N = 46)

why integration not just mental health but health behavior
Why Integration?....…not just “mental health” but “health behavior.”
  • 60% HMO visits made by individuals with no diagnosable disorder (Cummings & Follette, 1968).
  • 12-25% of Healthcare use accounted for by objective morbidity (Berknovic, Telsky, & Reeder, 1981).
  • Review of 1,000 GIM patient records over 3 years found less than 16% of cases had detectable pathology for chief bodily complaint (Kroenke & Mangelsdorff, 1989).

“Health rests on daily behavioral routines”

(Rotheram-Borus, 2012; Wesner, 2002)

  • 5 habits lead to 70% of morbidity and mortality:
    • How much we eat
    • What we eat
    • Exercise
    • Smoking
    • Alcohol use

(de Vol& Bedrosian, 2007)


Delivering care for chronic illnesses resulting from these habits account for 75% of medical care costs

(CDC, 2009)

health behavior and mental health
Health Behavior and Mental Health
  • Why this dichotomy?
  • More than psychiatric or substance abuse comorbidity…
  • Know the contributions of behavior to health
Psychiatric comorbidity is not the only behavioral factor contributing to utilization inefficiencies...
  • Adherence to post-AMI medication regimens 45% (Carney, et al., 1995) (Behavior Change)
  • Diabetes self-management regimens adhered to at about 15-20 %
  • 1997 prevalence…798,000 new cases annually
  • $ 2.1 Billion allotment by CBO for 5 year Medicare self-management plan (Behavior change arm)

- CDC, October, 1997


Crude and Age-Adjusted Percentage of Civilian, Noninstitutionalized Population with Diagnosed Diabetes, United States, 1980–2010----CDC

From 1980 through 2010, the crude prevalence of diagnosed diabetes increased by 176% (from 2.5% to 6.9%). During this period, increases in the crude and age-adjusted prevalence of diagnosed diabetes were similar, indicating that most of the increase in prevalence was not because of changes in the population age structure.

why integrate
Why Integrate ?

Example: Chronic Pain

  • Pain is the most common chief complaint presented to Primary Care
  • 70 million PC visits due to pain (Lawrence & McLemore, 1981)
  • Behavioral-Biomedical treatment of chronic pain reduces patient distress, decreases medical costs (Caudill, et al., 1991)

Models of Integration…

  • Coordinated
    • pcp-screen treat, community resources used outside
  • Co-Located
      • Behaviorist and PC located in same facility
  • Integrated
    • Behaviorist and PC located in same facility, team approach with stepped care

(Blount, 2003; Millbank report 2010)

what is primary behavioral healthcare distinctions in direct services
What is Primary Behavioral Healthcare?- Distinctions In Direct Services
  • Specialty MH
    • 50 Minute hour
    • # Sessions free to vary or based on research validated methods
    • formal intake assessment tx planning
    • high intensity tx
    • visits not related to PCP
    • long term f/u encouraged for most
  • Primary Behavioral Healthcare
    • 15-30 minute hour
    • 1-3 visits in typical case
    • Informal: revolves around PCP goals
    • low intensity; between session interval longer
    • visits coordinated with PCP
    • long term f/u rare; reserved for “high risk”
what is primary behavioral healthcare distinctions
What is Primary Behavioral Healthcare? – Distinctions
  • Specialty MH
    • Deliver primary treatment to resolve condition
    • Coordinate with PC Physician “At arms length”
    • Teach patient core self-management skills
    • Manage more serious disorders over time as primary provider
  • Primary Behavioral Healthcare
    • Support PCP decision making
    • Build on PCP interventions
    • Teach physician “core” MH skills
    • Educate patient in self-management skills
    • Improve pt.-PCP relationship
    • Monitor with PCP “At Risk Patients”
    • Assist in Team Building
how to integrate
How to Integrate?
  • Identify your skill set– Inventory what rapid assessment and treatment offerings you have
  • Identify the practice and the liaison/leader/practitioner who is like-minded
stepped care
Stepped Care

Specialty ReferralFamily or Individual Consultations, brief visits Shared Medical Appointments, Workshops, ClassesCurbside Consultation/Conjoint Visit, Coaching PCP

clinical behavior for pc colleagues
Clinical Behavior: For PC Colleagues
  • Again… “our patient” say these words…
  • Coach the smooth handoff, coach the language of stating the problem clearly (the “referral question”)
  • Know the staff, ask how you can make their job better, how they can contribute, praise when all is smooth, not just for extra effort…

Introduction and quick rationale:

    • Hi, I am____ I am part of your primary care team
    • Our job is to help change behavior in practical ways to help people be as healthy as they can be– no matter what the condition
    • Dr. ___ indicated you are dealing with (headaches, anxiety, sleep problems, depression, hypertension…”
  • Motivational Interviewing
pdq motivational interviewing
PDQ Motivational Interviewing
  • Summary/Reflection
  • Stating the Extreme
  • Reconciling Disparate Sides of the Conflict
  • mi_rationale_techniques.pdf
daily work the schedule
Daily Work: The schedule
  • Primary care providers may typically work 55 hours per week
  • The intent is to move a lot of people a little way, not a few a long way (specialty care)
  • As such, patients are scheduled on 15 or 30 minute blocks in some settings, 20 min in others
  • Behaviorists fit the PC schedule
some handoff script tips
Some handoff script tips:
  • “a recommended step is to meet with Dr./Ms./Mr.___ who is an expert in this problem and can help you manage this.”
  • “they can help you change that health habit –and stick to it-- with practical methods…”
  • “he/she has expertise to help you meet the challenge…boost emotional strength…”
  • “he/she is a coach for health behavior change…”
  • AVOID: “you need to talk to someone…”
    • “This is psychological, you need psych…”
    • “talking with ____ will help you resolve this…”
    • “you need mental health… this is a mental thing…”
daily work conjoint visits
Daily Work: Conjoint visits
  • A brief meeting with the patient and PCP, usually in an exam room
  • Intended to “break the ice” (begin to establish rapport and therapeutic alliance)
  • Can happen unexpectedly, on a moment’s notice and rapidly. Be prepared.
  • If you see distress, anger, resentment, simply state, “I understand, you don’t have to make any decision, but know I am here and the door is open…” “talk more with Dr. __ if you wish… call with questions….”
daily work tracking activity
Daily Work: Tracking activity
  • Why? To identify the needs of practice
  • What to track:
  • Track provider behavior:
    • Frequency of…
      • How many times each provider “refers” per month
      • How many times each provider curbsides
  • Track problems:

Of patients- billing/diagnostic records, categorize

daily work tracking activity1
Daily Work: Tracking activity
  • Outcomes Monitoring
    • Will depend on the preferences of the practice
    • Do you want to track program outcomes?
    • Do you want to track general health of the panel served?
    • This can be time consuming and expensive
      • Will you use commercially available or public domain measures?
      • Usually a psychologist in charge: Is he or she being paid for the time it takes?
      • Who will manage the data base? Enter the data? Analyze the data? Who will oversee data safety and monitoring plan?
daily work tracking outcomes
Daily Work: Tracking outcomes
  • Public domain resources:
    • Patient Reported Outcomes Measurement Information System

  • Functional Assessment of Chronic Illness Therapy (

daily work framing the behavioral health visit
Daily Work: Framing the behavioral health visit

1. Warm introduction

  • State purpose of the visit: evaluate the and make a plan
  • Indicate when the visit will end
  • Give a 5 minute warning
daily work the initial interview
Daily Work: The initial interview
  • After the frame…
  • Rapid assessment
    • Use the referral question and previous note of PCP to identify the problem
    • Use reflection, summarization and Socratic questioning to validate the person’s experience
    • Use the template of questions of specific problem (discussed later)
daily work the initial interview1
Daily Work: The initial interview
  • After rapid assessment…
  • Set a specific, measurable goal
    • (daily activity schedule, approach supervisor, ask friend for assistance, call specialty service)
    • Establish a follow-up visit
more motivational interviewing methods
More motivational interviewing methods

1) “Asking permission”

  • “do you mind if we talk about…?”
  • “so now that you are here, should we talk about ?”

2) “Eliciting change talk”

  • “what would you like to see different about your situation” or “what makes you think you need to change?

3) “Exploring importance/confidence”

“- What would it take to move from – to --?”

“- How would you life be different?”

daily work scheduling the follow up
Daily Work: Scheduling the follow-up
  • Assure an appointment is made upon leaving
  • Set up the system to do this
  • It should be identical to any other PC appointment!
  • All staff must be aware of this system– good, helpful, customer service with enthusiastic social skills
  • “When is a convenient time to check in– a week would be good for behavioral momentum but what is preferred… ?” 10 days?”
daily work documentation and other unsettled challenges
Daily Work: Documentation and other unsettled challenges
  • Privacy
    • Each institution is different in policies
    • Integrated care IS primary care ROI is for outside entities (e.g., if seeing someone on one day in specialty MH, then release is needed at that facility)
    • HIPAA (Health Insurance Portability and Accountability Act of 1996)
    • The act continuously changes and balances the tension between continuity of care and privacy of private health information(PHI)
daily work documentation and other unsettled challenges1
Daily Work: Documentation and other unsettled challenges
  • Documentation-- considerations that others have used
    • Assumption: notes on medical record
    • Keep them succinct
    • Avoid “states secrets”
    • Assure compliance with your compliance officer
    • Document:
      • Time begin, end, date
      • Status of the patient– were they able to understand, participate?
      • What was the procedure
      • Diagnosis, assessment
      • Plan


what can be done in primary integrated care
What can be done in primary (integrated) care?
  • Shared Medical Appointments (aka, “drop-in”“group..”)
    • Not group therapy– billed with a medical code
    • Alternative, addition to 1:1 medical appointment
    • Leverages physician and other provider time
    • Patients– more time with Dr.
    • Increases physician, patient, staff satisfaction
    • Not for everyone (40%??)
    • Requires set-up, buy-in with ALL staff
  • Workshops: Penzien, et al.
    • See
  • See also

Jonathan Borkum, Ph.D. “Chronic Headache: Biology, Psychology and Behavioral Treatment”

medical problems
Medical Problems
  • Chronic Non-malignant pain
  • Headache
  • Coping with and managing chronic illness
  • Adherence to medical regimens
    • Anti coagulant clinics, e.g. Coumadin (warfarin)
  • Cancer Survivorship
    • Medical checks, imaging, blood work, medical vulnerabilities (cardiac, metabolic, cognitive)
  • Essential Hypertension