Colleen Fischer, Ph.D., Psychologist, Denver Health Medical Center

1. Session #C2c October 16, 2015 Expanding integrated care across the lifespan: Knowledge and skills for pediatric and geriatric practice Colleen Fischer, Ph.D., Psychologist, Denver Health Medical Center Christopher Sheldon, Ph.D., Psychologist, Denver Health Medical Center Alison Lieberman, Psy.D., Psychologist, Denver Health Medical Center Matthew Tolliver, M.A., Doctoral Psychology Intern, Denver Health Medical Center Collaborative Family Healthcare Association 17th Annual Conference October 15-17, 2015 Portland, Oregon U.S.A.

2. Acknowledgments • Amy Starosta, M.A., Doctoral Psychology Intern, Denver Health Medical Center • Jill Hersh, M.A., Doctoral Psychology Intern, Denver Health Medical Center • This project is supported by funds from the Bureau of Health Workforce (BHW), Health Resources and Services Administration (HRSA), Department of Health and Human Services (DHHS) under Grant No. D40 HP 26858, $278,780. This information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by the BHW, HRSA, DHHS or the U.S. Government.

3. Faculty Disclosure The presenters of this session: Have NOT had any relevant financial relationships during the past 12 months.

4. Learning ObjectivesAt the conclusion of this session, the participant will be able to: • Describe the way in which behavioral health can be integrated into pediatric and geriatric primary care • Identify specific evidence-based assessment and intervention strategies useful with these populations • Discuss some of the challenges and opportunities for growth with these specialized populations

5. Learning Assessment • A learning assessment is required for CE credit. • A question and answer period will be conducted at the end of this presentation.

6. Rationale Targeted Integrated Behavioral Care Diverse and low SES populations: High levels of behavioral health need Diverse and low SES populations: Low levels of behavioral health resources • Needs Assessment Gaps by Age: • Elderly: special needs, few BHCs trained • Pediatrics: unique presentations, few BHCs trained • Needs Assessment Gaps by Complexity: • High-need, high cost adults include geriatric patients • High-need, high cost children include developmental issues and obesity .

7. Denver Health Snapshot • 127,000 patients: Medicare, Medicaid or uninsured. • The CMMI target population is almost entirely low income (over 90% are below 150% FPL)

8. Mental Health in the Aging Population • Adults over 65 are predicted to represent 20% of the population by 2030 (Administration on Aging, 2009) • Higher co-morbidity of mental health issues with chronic illness, functional impairment • Complexity of the biopsychosocial assessment in the aging population • Risk assessment and changes in cognition (normal aging versus impairment)

9. Mental Health in Pediatric Primary Care (COLLEEN to ADD) • Adults over 65 are predicted to represent 20% of the population by 2030 (Administration on Aging, 2009) • Higher co-morbidity of mental health issues with chronic illness, functional impairment • Complexity of the biopsychosocial assessment in the aging population • Risk assessment and changes in cognition (normal aging versus impairment)

10. Geriatric Primary Care Clinic • Multidisciplinary treatment team • Diversity of patients

11. Pediatric Primary Care Clinic • Multidisciplinary Treatment Teams • Special Care Clinic • Healthy Lifestyle Clinic

12. Implementation • HRSA grant funding for attending psychologists and psychology residents • Building on existing integrated care model in primary care clinics at Denver Health • Referral sources • Clinic champion • Allocation of time, space, and resources • Utilizing provider strengths and importance of flexibility

13. What we do(Geriatrics and Pediatrics) • Taking all comers • Collaboration takes multiple forms (curbside, during medical visit, behavioral health visits) • Cultural and age sensitivity • Biopsychosocial assessment • Interventions • Additional functions (referrals, etc)

14. Assessment • Diagnostic evaluation • Screening measures • Risk assessment • Referrals for testing/long term therapy/outside agencies • Collaborative consultation

15. Interventions • Intro to behavioral health/warm hand off • Brief therapy • Crisis management • Curbside consultation • Telephone care coordination • Behavioral therapies • Health behavior interventions/change

16. Case example (Geriatric clinic) • 76yo divorced Caucasian female seen in the Geriatric primary care clinic referred for mood instability and anxiety in the context of functional decline. • Medical problems: Macular degeneration, complicated hip replacement, collagenous colitis, hypothyroidism, COPD, osteoarthritis • Cultural considerations: Living situation, aging, complex medical conditions • Diagnoses: Bipolar disorder, Anxiety disorder, Mild cognitive impairment/Previous mental health treatment • Case conceptualization/interventions • Collaboration with PCP

17. Case example (Pediatric clinic) • 15-year-old, Hispanic female, seen in the pediatric primary care clinic • Referred by her PCP for suicidal ideation, depression, anxiety/panic, extensive bullying, Medical problems: Obesity • Cultural considerations, family factors (sibling of special needs children), gender identity issues • Case conceptualization/interventions • Transition from primary care to outpatient setting

18. Provider Needs Assessment Survey How helpful have the psychologists or psychology resident been in addressing the following clinical areas? (1-5 Likert scale) Clinical Areas Assessed BHC Functioning within the Clinic

19. Lessons learned one year in • Timing of grant funding • Buy in from clinics and staff teaching and marketing • Provider variability • Logistical challenges • Need for modification/adaptation of interventions specific to the population • Underestimation of substance use disorders in the geriatric population • Importance of baseline screening measures to identify changes in cognitive functioning and mood

20. Opportunities • Additional coverage • Social work and psychiatric support • Group Therapy • Trainings for providers • Need for bilingual behavioral health providers

21. References Becker Herbst, R., Margolis, K. L., Millar, A. M., Muther, E. F., & Talmi, A. (2015). Lost in Translation: Identifying Behavioral Health Disparities in Pediatric Primary Care. J Pediatr Psychol. doi: 10.1093/jpepsy/jsv079. Carey, W.B., & McDevitt, S.C. (2012). Child behavioral assessment and management in primary care: Theory and practice. Scottsdale, AZ: Behavioral-Developmental Initiatives. Cohen, D. J., Davis, M., Balasubramanian, B. A., Gunn, R., Hall, J., deGruy, F. V., 3rd, . . . Miller, B. F. (2015). Integrating Behavioral Health and Primary Care: Consulting, Coordinating and Collaborating Among Professionals. J Am Board Fam Med, 28 Suppl 1, S21-31. doi: 10.3122/jabfm.2015.S1.150042. Hall, J., Cohen, D. J., Davis, M., Gunn, R., Blount, A., Pollack, D. A., . . . Miller, B. F. (2015). Preparing the Workforce for Behavioral Health and Primary Care Integration. J Am Board Fam Med, 28 Suppl 1, S41-51. doi: 10.3122/jabfm.2015.S1.150054. Hill, J. M. (2015). Behavioral health integration: Transforming patient care, medical resident education, and physician effectiveness. Int J Psychiatry Med, 50(1), 36-49. doi: 10.1177/0091217415592357. Karel, M., Gatz, M., & Smyer, M. A. (2012). Aging and mental health in the decade ahead: What psychologists need to know. American Psychologist, 67(3), 184-198. Lichtenberg, P.A., Mast, B.T., Carpenter, B.D., Loebach Wetherell, J. (2015). APA handbook of clinical geropsychology, Vol. 2: Assessment, treatment, and issues of later life. Washington, DC: American Psychological Association. Kapalka, G.M. (2011). Internship and fellowship experiences: Preparing psychology trainees for effective collaboration with primary care physicians. In G.M. Kapalka (Ed.), Pediatricians and pharmacologically trained psychologists: Practitioner’s guide to collaborative treatment. New York, NY: Springer-Verlag. Segal, D. L., Qualls, S. H., & Smyer, M. A. (2011). Aging and mental health (2nd edition). Hoboken, NJ: Wiley.

22. Session Evaluation Please complete and return theevaluation form to the classroom monitor before leaving this session. Thank you!