BEHAVIORAL HEALTH LAB

1. BEHAVIORAL HEALTH LAB

2. Goals of the BHL Instill Hope

3. How? • Provide • the right care • at the right time • at the right place • With Empathy and Compassion

4. Research to Practice:Behavioral Health Laboratory • BHL is designed to provide clinical services to support providers in Primary Care and Behavioral Health • It is intended to be analogous to Clinical Chemistry or Radiology Laboratories • The BHL is an automated telephone assessment, triage, and monitoring service for patients identified by primary care providers as having depressive symptoms or at-risk drinking. • The BHL conducts a brief telephone (20-30 minutes) assessment generating a report for the PCP including diagnosis, severity, and general treatment recommendations.

5. How it works at the PVAMC • Mechanisms for requesting an assessment • Screening • Annually – PCPs are required to screen for depression and at-risk alcohol use (2 question screen for depression – 3 for at-risk alcohol use). • For patients who screen positive, the clinician is responsible to assess the need for immediate care. However, a consult request is automatically generated. • Referral • A BHL assessment can be ordered with any frequency by primary care providers. • Disease management • A package of assessments related to a new episode of treatment • The BHL receives a printed consult request. • The BHL reports findings, provides interpretation, and recommendations. • Where appropriate, BHL staff facilitate referral.

6. What does the Service Provide? • Assessment of major illnesses – depression, anxiety, substance use • Screening for other domains – cognition, smoking, psychosis, mania • Initial Treatment recommendations • Patient engagement • Monitoring of initial treatment for depression – adherence, adverse effects, symptoms

7. The BHL as a Platform of Care • Watchful Waiting • Referral Management • Disease Management (e.g. depression, alcohol, suicide) • Research

8. A Platform for other activities • Telephone disease management for problem drinking • Supported by VA HSR&D • Developing watchful waiting strategies • Supported by Robert Wood Johnson Foundation • ExTENd – Use of naltrexone in managing alcohol dependence • Supported by NIAAA – R01 • DIADS – depression of Alzheimer’s disease • Supported by NIMH R01 • Family caregiver Support • Depression Treatment Monitoring • PTSD • Referral Management

9. Roll out over several different settings

10. Referrals

11. 5 Month Referral Success

12. Characteristics of Patients

13. Does the BHL change practice? • 25% reduction in the number of patient not screened for depression • 10% increase in the screen positive rate for depression • Significant increase in the identification of patients with suicidal ideation • Possible improvement in EPRP measures for depression

14. Engagement in Care

15. Barriers to service • Skepticism regarding validity of assessments • Skepticism regarding treatment • Limited treatment choices anyway • Low frequency of patient problems - 1 or 2 patients/week • Novelty • Doesn’t meet needs • Interventions for mild behavior/disease may not be accepted • ? • ?

16. Two Ways of thinking about screening and treatment initiation Outcome Monitoring Treatment Z Treatment Adjustments Systematic Screening Initial Assessment And Triage Clinical Exam Outcome Monitoring Treatment Q Treatment Adjustments

17. BHL Flow Annual Screening Direct consult New treatment for depression Consult request Full Assessment Recommendations to PCP and Patient Referral to BHC Referral to Specific Research No Treatment Recommended Enroll in Depression monitoring Brief Intervention Referral Management Watchful Waiting – 8 weeks

18. Starting a New Practice • Identify a thought leader / Champion • Define practice specific needs – screening, referral, resources • Define practice specific procedures • Announce the availability of the service • Face-to-face • Email • Letters / Brochures

19. Other Initial Practices • Business cards for patients • Business cards for providers • ELM interface • Listing of providers • Staff in practice / Screening of patients • 877 number • ?

20. Ongoing or new stuff • Pens • Sticky pads • Business size card for computer • Monthly email reminders • Clinic feedback • Inservice by staff on MH topics • Website • ?

21. Conclusions • BHL is a flexible, evidence based program • Fills gaps in the VHA system • Provides valid information and documentation • Acceptable to veterans • Valued by provider • Can function at low cost across diverse settings • Useful for outreach • Can provide coordination as well as assessment • Disease Management • Referral Management • Valuable as a tool for improving system performance