presentation at APNA 2011 Conference in Anaheim CA. Looks at development of a consultation service, the ed/training required and an example of a curricula to address this at the DNP level.

1. American Psychiatric Nurses Association 25 th Annual Conference Disneyland Hotel, Anaheim CA Primary Care Behavioral Health Consultation Services: What it is and How to Make it Happen in Your Organization Saturday October 22, 2011 Block 2: 10:25 – 11:15 AM Integrated Physical/Mental Health Track Michael Terry, DNP, APRN-PMH/FNP THE SPEAKER HAS NO CONFLICTS OF INTEREST TO DISCLOSE

6. Spectrum of Options for Mental Health Services in Primary Care

7. Practice Model 1: Improving Collaboration between Separate Providers Spectrum of Options for Mental Health Services in Primary Care

8. Practice Model 2: Medical-Provided Behavioral Health Care Spectrum of Options for Mental Health Services in Primary Care

9. Practice Model 3: Co-location Spectrum of Options for Mental Health Services in Primary Care

10. Practice Model 4: Disease Management Spectrum of Options for Mental Health Services in Primary Care

11. Practice Model 5: Reverse Co-location Spectrum of Options for Mental Health Services in Primary Care

12. Practice Model 6: Unified Primary Care and Behavioral Health Spectrum of Options for Mental Health Services in Primary Care

13. Practice Model 7: Primary Care Behavioral Health Spectrum of Options for Mental Health Services in Primary Care

14. Practice Model 8: Collaborative System of Care Spectrum of Options for Mental Health Services in Primary Care

15. Spectrum of Options for Mental Health Services in Primary Care Primary Care Behavioral Health Specialty Mental Health population-based client-based; specific requirements for service acceptance often informal client inflow (PCP:BHC ratio is 1:3-4 optimally) formal acceptance process; requires intake assessment, treatment planning treatment usually limited; 1-3 visits 20-30 min. per client often long-term treatment; number variable, related to client condition treatment afforded to persons with mild impairments, those coping with situational stress and sometimes stabilized persons with serious mental disorders treatment restricted to persons experiencing or at risk of serious mental disorders informal counseling session, vulnerable to frequent interruptions (8-12 pts/day) more formal, private interchange

16. Spectrum of Options for Mental Health Services in Primary Care Primary Care Behavioral Health Specialty Mental Health behavioral records often integrated with the medical treatment chart mental health records stand-alone therapist workday often involves jumping from one activity to another therapist can focus on one-to-one client interaction care responsibility returned to medical provider once behavioral treatment is concluded therapist remains contact point if needed frequent consultation with medical provider for clients with co-occurring health and mental health condition often little or no interaction with medical provider regarding medical condition clients often seen, at least briefly, on same day as referral often substantial wait-time for services in non-emergency cases

21. Timeframe http://www.integratedprimarycare.com/Air Force Manual/primary care practice manual.pdf Adapted from: Air Force Manual - Primary Behavioral Health Services Practice Manual

22. Timeframe

23. Timeframe

25. Objectives & Activities 2. The Project Director will conduct 3 staff orientation sessions, offer 2 primary care provider orientation sessions and complete BHCs orientation. The Project Director will present results at the clinic management meeting on ( date) . 2a. Conduct 3 weekly orientation sessions for reception staff and medical assistants, introducing service goals, methods, flow and paperwork/forms to be used 2b. Offer two 30-minute orientation services to PCPs and follow-up with weekly lunch hour Q&A sessions for 4 weeks 2c. Orient and organize Psychiatric Mental Health Nurse Practitioners or BHCs to initially provide services at BHC I level, as measured by the Training Core Competency

26. Objectives & Activities 3. The PCBHCS project will have initiated services to (number) selected patients; with each BHCs providing at least 5 visits each week. This reach will be monitored by the Project Director reviewing the Referral Log of each BHC weekly. The adoption of skills by BHCs will be evaluated by the Project Director using the Training Core Competency Tool Part I by ( date) . 3a. Using vertical integration strategies, select appropriate patients to offer preventive care (weight management and smoking cessation) and mental health brief counseling (depression and anxiety) 3b. BHCs provide basic level skill (above) plus triage and crisis intervention services as needed 3c. Project Director mentors the BHCs and monitors productivity and compliance with skills using the Training Core Competency Tool Part I and the PCBHCS Chart Audit form with each BHC weekly

27. Objectives & Activities 4. PCBHCS project will expand to the full range of services; with BHCs providing at least 15 visits each week. This reach will be monitored by the Project Director reviewing the Referral Log of each BHC weekly. The adoption of skills by BHCs will be evaluated by the Project Director using the Training Core Competency Tool Part II by ( date) . 4a. During the month of (date) , increase Psychiatric Mental Health Nurse Practitioner services to the level of BHC II as measured by the Training Core Competency – Part II 4b. Beginning in (date) , BHCs provide the full range services 4c. Project Director mentors BHCs and monitors productivity and compliance with skills using the Training Core Competency Tool Part II and the PCBHCS Chart Audit form with each BHC weekly

28. Objectives & Activities 5. The Project Director will complete the summative evaluation portion of the formal evaluation to evaluate reach, adoption and maintenance of the PCBHCS. This will be demonstrated in a formal presentation to clinic management and Glide Foundation administrators on ( date) . 5a. Collect all BHC Provider Referral logs and compare utilization to national averages to determine project reach 5b. Evaluate initial to subsequent Behavior Health Questionnaire-36 questionnaires for change in symptoms to determine project efficacy 5c. Summarize findings of the on-going evaluation of PCBHCS Audit Forms to determine final project adherence to project standards and their maintenance 5d. Project Director will administer a PCP Satisfaction Survey Form quarterly for evidence of progress and maintenance of the project implementation. Front desk staff will collect the Patient Satisfaction Survey Form at each visit for the Project Director to use for on-going feedback to BHCs and to evaluate maintenance in the final report

29. Project Evaluation Based the RE-AIM format. See : http://www.re-aim.org/2003/defined2.html Forms referenced are from the Air Force Manual, Appendices: http://www.thenationalcouncil.org/galleries/business-practice%20files/2011%20BHOP%20Appendices,%207.28%20updates.pdf

30. What ’s different with a PMHNP prepared specifically to work in Primary Care? Providers of PCBH Focus & Skills Licensed Clinical Social Worker Case management, community liaison Clinical Psychologist In-depth counseling, specialty connections Psychiatrist psychopharm, specialty connections, medical background Health Psychologist Chronic illness counseling Primary Care Psychologist Risk reduction & behavior change PMHNP Psychopharm, medical bkgrnd, pt. ed., risk reduction

37. Questions?

38. Integrated Behavioral Health Project (California) www.ibhp.org Bureau of Primary Care (HRSA) http://bphc.hrsa.gov California Department of Health Care Services Office of HIPAA Compliance www.dhcs.ca.gov/ formsandpubs/laws/hipaa/Pages/default.aspx CalMEND http://www.calmend.org Collaborative Family Healthcare Association www.cfha.net Hogg Foundation for Mental Health (Texas) www.utexas.edu/programs_ihc.html ICARE Partnership (North Carolina) www.icarenc.org IMPACT Model for Treating Depression in Primary Care www.impact-uw.org Integrated Primary Care www.integratedprimarycare.org MacArthur Initiative on Depression in Primary Care www.depression-primarycare.org Additional Resources Mountainview Consulting Group www.behavioral-health-integration.com National Guideline Clearinghouse www.guideline.gov National Council for Community Behavioral Healthcare www.thenationalcouncil.org Rand Partners in Care Initiative www.rand.org/health/projects/pic Robert Wood Johnson Foundation Depression in Primary Care Initiative www.wpic.edu/dppc The Reach Institute Guidelines for Adolescent Depression in Primary Care www.thereachinstitute.org/guidelines-foradolescent-depression-in-primary-care-gladpc.Html Washtenaw County Health Organization (Michigan) www.ewashtenaw.org/government/departments/wcho/ch_behealthcarepresentation.pdf (Powerpoint of their integrated program)

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