Behavioral Health - Resources for Integrated Care · Behavioral Health § Behavioral health (BH) is...

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Wednesday March 15th, 2017

Behavioral Health

DCC Pillars Webinar Series

https://www.ResourcesForIntegratedCare.com2

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Introductions

§ Andrew Jorgensen, MD− Credentialed in Internal Medicine

and Pediatrics− Associate Med. Dir., Outer Cape

Health Services

§ Dikke Hansen, LICSW− Director of Behavioral Health

§ Christopher Duff− Disability Practice and Policy

Consultant

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Disability-Competent Care Webinar Series Overview

The Lewin Group, under contract with the CMS Medicare-Medicaid Coordination Office, partnered with Christopher Duff and other disability practice experts to create the “Disability-Competent Care Webinar Series”. § This is the sixth session of the seven-part series.

§ Each session will be interactive, with 40 minutes of presenter-led discussion, followed by a 20 minute presenter/participant question and answer session

§ Video replay and slide presentation are available after each session at:

https://www.ResourcesForIntegratedCare.com/

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https://www.resourcesforintegratedcare.com/


DCC Pillars – Webinar Series

1. Understanding the DCC Model

2. Participant Engagement

3. Access

4. Primary Care

5. Care Coordination

6. Behavioral Health

7. Long Term Services and Supports

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Agenda

1. Behavioral health within Disability-Competent Care

2. Mental health

3. Behavioral challenges

4. Substance use

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BEHAVIORAL HEALTH WITHIN DISABILITY-COMPETENT

CARE

Behavioral health is an integral component of health, and needs to be closely integrated with primary care and the Interdisciplinary

Team (IDT)

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Behavioral Health

§ Behavioral health (BH) is a term encompassing what has traditionally been referred to as mental health, substance abuse and chemical dependency.

§ The term, “behavioral health” encompasses all aspects of mental health, including chemical imbalance, behavior challenges and substance use.

§ As with other DCC pillars, the focus is on the functional limitations or barriers experienced by persons with behavioral health issues. − DCC organizations have learned that behavioral health care should

be integrated with primary care to ensure continuity with the interdisciplinary team (IDT), the participant’s Individualized Care Plan (ICP) and the delivery of services and supports.

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Health Disparities

People with disabilities are more likely to:

§ Experience difficulties or delays in accessing both physical and behavioral health care.

§ Experience worse outcomes and are less likely to receive the recommended care.1

§ Experience depression and chronic conditions.2

§ Experience disabling illnesses such as heart disease, high blood pressure, respiratory disease, diabetes and stroke and to develop these problems at an earlier age.3

§ Not receive comprehensive preventive care, such as medication adherence, BMI assessment and metrics due to providers difficulty interfacing with some individuals with BH issues.

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Sources: 1) Office of the Assistant Secretary for Planning and Evaluation. (2016). Report to Congress: Social Risk Factors and Performance under Medicare’s Value Based Purchasing Programs

2) Canadian Institute for Health Information, 20083) Honey A, Emerson E, Llewellyn G, Kariuki M. 2010. Mental Health and Disability. In: JH Stone, M Blouin, editors.

International Encyclopedia of Rehabilitation


Social Factors

§ Disability status and health disparities are often associated with poorer performance on measures that are linked to payment in value-based purchasing programs.4

§ On many measures of focus (e.g., cancer screenings, vaccinations, diabetes management), the clinical interventions are straightforward but communications and service delivery for people with disabilities stretch the disability competence of most providers.

§ Persons with disabilities have over twice the incidence of mental health problems due to the interface with their other disabilities, and socioeconomic factors.5

§ Addressing the health disparities and social factors can significantly improve outcomes for people with disabilities, having a direct impact on revenue for many providers and plans.

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Sources: 4) National Academies of Sciences, Engineering, and Medicine. (2017). Accounting for social risk factors in Medicare Payment, Washington, DC: The National Academies Press. doi: 10.1722

5) Honey A, Emerson E, Llewellyn G, Kariuki M. 2010. Mental Health and Disability. In: JH Stone, M Blouin, editors. International Encyclopedia of Rehabilitation


Behavioral Health and Primary Care

§ Behavioral health and primary care services are typically delivered by different providers in separate settings, often with little coordination or integration.

§ This fragmented delivery of care can be particularly problematic for individuals requiring a wide variety of services to address physical, emotional, and behavioral challenges.

§ Increasingly BH is integrated into primary care settings. Alternatively, some health systems and plans are now embedding primary care into BH clinics.

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Behavioral Health Concerns among Medicare-Medicaid Enrollees

§ Forty percent of Medicare-Medicaid Eligible enrollees who are under 65 have a mental health diagnosis.

§ Medicare-Medicaid spending is twice as high for individuals with Serious Mental Illness (SMI).

§ Health care utilization and costs are twice as high in diabetes and heart disease patients with depression.

§ Nationwide, approximately 217 million days of work are lost annually to related mental illness and substance use disorders (costing employers $17 billion/year).

§ Effective depression treatment in primary care lowered total health care costs by $3,300 per patient over 48 months.

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Source: 6) Ensslin B, Soper MH. (2014). State Approaches to Integrating Physical and Behavioral Health Services for Medicare-Medicaid Beneficiaries: Early Insights. Available at: http://www.chcs.org/media/State_Approaches_to_Integrating_Physical_and_Behavioral_Health.pdf


MENTAL HEALTH

DCC defines mental health from a functional perspective, where it is viewed as a state of well-being in which participants realize their

own potential, can cope with the stresses of life, can work productively and fruitfully, and are able to make contributions to

their community.

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Screening for Depression and Anxiety

§ The incidence of depression and anxiety are higher among adults living with functional limitations or disabilities.

§ Depression and anxiety can be a primary disability or secondary as the direct result of life as a disabled individual.

§ It is imperative that the IDT assess each participant for depression and anxiety, discuss the results with the participant and develop plans accordingly.

§ There are a range of tools that have been developed and validated. The following tools are brief and easy to complete independently by the participants: − PHQ-9: for assessment of depression7

− GAD-7: for assessment of anxiety8

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Sources: 7) Pfizer Inc. Patient Health Questionnaire. 1999. http://www.integration.samhsa.gov/images/res/PHQ%20-%20Questions.pdf8) Spitzer RL, Kroenke K, Williams JBW, Lowe B. A brief measure for assessing generalized anxiety

disorder. Arch Inern Med. 2006;166:1092-1097. http://www.integration.samhsa.gov/clinical-practice/GAD708.19.08Cartwright.pdf


Including Mental Health Professionals in the IDT

§ A key value of the DCC model is an interdisciplinary team’s (IDT) approach to care. − Each participant with a mental health concern needs the input and

involvement of a mental health professional or specialist.

§ Not all persons with disabilities present a mental health concern.

§ Over time, a mental health concern may present itself or become apparent. − It is important to include a mental health professional on the IDT or to

have a mental health professional readily accessible to the participant or IDT.

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Specialists in the Behavioral Health Network

§ Anxiety and depression can commonly be addressed by the IDT with input from the team’s mental health professional. − To address additional mental health concerns, it is best to refer to a

specialist experienced with the specific concern.

§ Keeping the IDT coordinated with external providers can be challenging when referring participants for ongoing treatment. − A designated communication agent from the IDT, with permission of

the participant, will help ensure two-way communication.

§ The IDT should keep external specialists up-to-date with their observations of the impact of the BH intervention, and progress towards the identified goals.

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Nancy’s Story

§ Nancy, in her early 60’s, lives with her partner in a small town in the Midwest.

§ She recently moved to a new rural community in the Northeast.

§ Prior to moving, her doctor wanted to stop her hormone replacement medication, and she wanted to reduce her anti-depressant medication.

§ During her move from the Midwest to the Northeast she experienced diarrhea and panic attacks. Her panic attacks are linked her fear of leaving her home.

§ After she moved, a new primary care relationship was established in her community and, she agreed to see a social worker at the clinic.

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Nancy’s Story

§ Nancy, her social worker and doctor have been in close communication, and she has consulted the clinic’s psychiatrist for medication consultation.

§ Nancy’s anti-depressant medication was discontinued, and a new anti-anxiety medication was prescribed.

§ Nancy returned to the hormone replacement medication at a fairly lower dosage.

§ Nancy reports that she is doing well and, she continues to see the social worker weekly and her PCP every 2-3 months. The physiatrist is consulted if issues arise.

§ Nancy’s wife is helping her make new friends and she has set up a studio in her house so that she can return to her artwork.

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BEHAVIORAL CHALLENGES

In the context of Disability-Competent Care, behavioral challenges are those that impede the participant’s ability to function in their

home and community, their family and peer relationships, and their work.

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Including Behavioral Health in the Assessments

§ As an integral component of DCC, behavioral health challenges need to be incorporated in initial and subsequent assessments.

§ Focus on the participant’s ability to be behaviorally functional in their home, with family and peers, at work and in community activities.

§ If challenges are identified, the initial step is to work with the participant and their care partners to identify behavior and related triggers.

§ From there, a plan can be developed to reduce the stimulation and develop alternative responses.

§ Often IDTs involve a behavior specialist from the community to address these concerns

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Behaviorist in Network

§ Behavior challenges can be complex. They require an understanding of the cause, and the participant’s ability to control and adopt more functional behaviors.

§ Behavior management professionals have varying levels of expertise (e.g., assessing the situation, developing a plan, supporting the participant and others around them to follow through with the plan).

§ While behavioral professionals are needed to support the participant, they are also needed by the IDT, PCP and other providers working with them for consultation.− It is not common to have a behaviorist attend IDT meeting; however

close coordination is recommended

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SUBSTANCE USE

From a DCC perspective, substance use becomes an issue to be addressed if or when it interferes with the participant’s ability to

function in their home and their community, their family and peer relationships, and their work.

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Screening for Substance Use

§ It is highly recommended that screening for substance use be included in all initial and subsequent assessments. This normalizes the issue with participants and gives them an opportunity to discuss it openly.

§ In practice, the participant may not be comfortable divulging their use until they have a higher level of trust with their IDT or a specific IDT member.

§ Additionally, over time, the IDT or their other providers may begin to see signs of use and the IDT may need to address at that time.

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Addressing Substance Abuse Needs

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Screening Findings IDT Action

Not at Risk § Educate about risks, promote healthy norms

At Risk§ Educate about risks§ Decrease risk for consequences or

progression of disease

With Addiction § Refer for specialty addiction treatment



Screening instruments are recommended for all participants.

§ Screening instruments:− NIAAA-1(National Institute on Alcohol Abuse and Alcoholism)− NIDA-1 (National Institute on Drug Abuse) 1-item screen for drug use

If screening indicates concern, the IDT will proceed with an assessment.

§ Assessment instruments:− AUDIT (Alcohol Use Disorders Identification Test) for alcohol use− DAST-10 (Drug Abuse Screening Test) for drug use

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Screening protocol: brief screening

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Brief Screen

NIAAA 1 – item screen NIDA 1 - item screen

Brief Assessments

AUDITDAST-10

Review Results with participant and

recommend intervention

Reinforce healthy behavior

Advise patient of results and plan for

follow-up

Screen indicates minimal concern Screen indicates concern

Screen indicates minimal concern Screen indicates concern


Participant Recognition of Their Substance Abuse

To begin approaching a participant’s substance abuse concerns, the IDT needs to first understand the participant’s perspective, level of acceptance and recognition of their concern(s).

Participant Stage Approach to Care

Pre-Contemplation Establish rapport, raise doubts, increase participant’s perception of risks related to current behavior

Contemplation Elicit reasons for change, risks of not changing, elicit self-motivational statements

Preparation Offer a menu of options for change or treatmentAction Support a realistic view of change through small steps

Maintenance Help the participant identify and use strategies to prevent relapse

Relapse Explore the reality of relapse as a learning opportunity

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Leveraging the ‘Stepped Care Approach’

§ A stepped care approach is useful in working with participants with substance abuse issues. The deeper they are into abuse, the stronger the intervention will likely need to be.

§ At early stages, relatively simply education and discussion is beneficial.

§ If in later stages, they may benefit from self-monitored reductions in their usage and having someone to discuss their ability to self-control.

§ If they are unsuccessful in self control they may benefit from stronger interventions, such as a formal treatment approach.

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The Recovery Model

The recovery model is a process through which individuals improve their health and wellness, live a self-directed life and strive to reach their full potential. The ten guiding principles of the model include:

1. Hope2. Person driven3. Occurs through multiple pathways4. Supported by community

strengths/responsibility5. Supported by peers and allies

6. Supported through relationships and social networks

7. Culturally-based and influenced8. Holistic9. Supported by addressing trauma10. Based on respect

The recovery model is a self-help approach to address behavioral health needs based on four major dimensions: Health, Home, Purpose, and Community.

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The Recovery Model: Health

§ For everyone in behavioral health recovery, making informed, healthy choices that support physical and emotional well-being is the first step of recovery.

§ The health component of the recovery model focuses on managing or overcoming one’s behavioral health disability, substance abuse or symptoms that interfere with their overall health. − For example, abstaining from the use of alcohol, illicit drugs, and non-

prescribed medications if one has an addiction problem or attending Overeaters Anonymous.

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The Recovery Model: Home

§ In the recovery model, home is viewed as a safe, stable and comfortable place to live.

§ Addressing the home environment includes relationships with others living in the home, and whether these relationship will be conducive to continued recovery.

§ The IDT needs to both assess and address challenges with or in the home environment, such as physical access, ability to pay rent and utilities, and access to adequate food.

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The Recovery Model: Purpose

§ Every individual, regardless of ability, needs purpose in their life.

§ This purpose can encompass a job (paid or volunteer), family caretaking, or creative endeavors.

§ Giving or supporting others is a means of providing purpose. Others can be found through participant-directed groups such as Alcoholics Anonymous or Weight Watchers.

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The Recovery Model: Community

§ Every individual, regardless of ability, needs community in their life – beyond their family.

§ Community represents relationships outside of the participant’s immediate family and care partners.

§ These relationships and social networks provide support, friendship, love, and hope.

§ Being involved in the community requires the capability, income, and resources to participate such as transportation, communication aides and others.

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Kevon’s Story

§ Kevon’s mental illnesses and chemical abuse evolved over decades.

§ Through his 20’s and 30’s, he worked in a variety of jobs where drugs and alcohol were part of the culture.

§ In his early 40’s, he got married and started a family, motivating him to get a professional job to help provide for his family and raise his kids.

§ While his overall life stabilized, he still struggled with depression and was getting high or drunk nearly every day.

§ Over the next decade, he was in and out of rehabilitation, lost a job he loved, and ended up getting divorced. Co-existing with his chemical dependency, he was increasingly depressed and struggled with an anxiety disorder.

§ His PCP kept talking with him about both his depression and his sobriety, but he wasn’t ready to address either. He eventually agreed to see a therapist.

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Kevon’s Story

§ It took trying several therapist for Kevon to settle on one. Once he found a therapist for him we was able to see the impact of his usage. He is now sober.

§ Kevon's path to wellness was difficult. He lived in a halfway house but he kept focused and he is finally living on his own and learning to move forward with addiction and mental illness.

§ Today, he has a steady job, maintains good relationships with his kids and their mother, and is living independently.

§ His self-management strategies include:− Support groups (AA and others)− A gratitude list to help him focus on the positives in his life

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CONCLUSION

The co-incidence of behavioral health issues with physical disabilities is very high, and are mutually impactful. It is important

for the IDT to partner with the participant to develop a comprehensive plan of care.

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Key Takeaways

§ Persons with disabilities experience many health disparities and social barriers to care.

§ While a participant's physical disabilities may be more evident, it is important to not neglect their behavioral health needs.

§ As Kevon showed, it may take years before a participant is ready to address the full range of behavioral health needs they experience.

§ Maintaining the social work / primary care partnership and trust with the participant are key areas of focus that can help ensure success when the participant is ready.

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AUDIENCE QUESTIONS & DISCUSSION

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Send Us Your Feedback

Help us diversify our series content and address current Disability-Competent Care training needs – your input is essential!

Please contact us with your suggestions [email protected]

What We’d Like from You:§ How best to target future Disability-Competent Care webinars to

health care providers and plans involved in all levels of the health care delivery process

§ Feedback on these topics as well as ideas for other topics to explore in webinars and additional resources related to Disability-Competent Care

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mailto:[email protected]


Disability-Competent Care Self-Assessment Tool

Disability-Competent Care Self-Assessment Tool available online at: https://www.ResourcesForIntegratedCare.com/

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Next Webinar

Disability-Competent Care Webinar Series

Disability-Competent Long-Term Services and Supports

Wednesday March 22nd,20172:00-3:00PM ET

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Thank You for Attending!

§ For more information contact:

§ [email protected]

§ Gretchen Nye at [email protected]

§ Christopher Duff at [email protected]

§ Further information, including webinar resources, are available at:

https://www.resourcesforintegratedcare.com

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