EXPANDING INTEGRATED CARE ACROSS THE LIFESPAN: KNOWLEDGE AND SKILLS FOR PEDIATRIC AND GERIATRIC PRACTICE

Colleen Fischer, 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

Christopher Sheldon, Ph.D., Psychologist, Denver Health Medical Center

Collaborative Family Healthcare Association 17th Annual ConferenceOctober 15-17, 2015 Portland, Oregon U.S.A.

Session #C2cOctober 16, 2015

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.

Faculty Disclosure

The presenters of this session:

Have NOT had any relevant financial relationships during the past 12 months.

Learning Objectives

At 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

Learning Assessment

A learning assessment is required for CE credit.

A question and answer period will be conducted at the end of this presentation.

Denver Health Snapshot

Acute Care

Hospital

FQHCs

School

Based

Clinics

Detox

Center

Ambulatory

Specialty Center

Public Healt

h Dept.

• 127,000 patients: Medicare, Medicaid or uninsured.

• The CMMI target population is almost entirely low income (over 90% are below 150% FPL)

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

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)S

ub

. A

bu

se

An

xie

ty

Dem

en

tia

Dep

ressio

n

Geriatric Primary Care Clinic

Mental Health in Pediatric Primary Care

Integrated approaches reduce barriers to treatment of pediatric mental health concerns

Up to 70% of primary care appointments are for issues related to psychosocial concerns

Assessment and treatment of a wide range of pediatric emotional and behavioral concerns (birth to age 18)

Complexity of the biopsychosocial assessment in the pediatric population

Ob

esit

y/

Pre

dia

bete

s

Develo

pm

en

tal

Issu

es

AD

HD

/D

isru

pti

ve

Beh

avio

rs

Trau

ma/

An

xie

ty

/Dep

ressio

n

Pediatric Primary Care Clinic

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)

Assessment

Diagnostic evaluation Screening measures Risk assessment Referrals for testing/long term

therapy/outside agencies Collaborative consultation

Interventions

Intro to behavioral health/warm hand off Brief therapy Crisis management Curbside consultation Telephone care coordination Health behavior interventions/change

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

Case conceptualization/interventions Collaboration with PCP

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, not sleeping 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

BHC Impact ScaleHow helpful have the psychologists or psychology resident been in

addressing the following clinical areas?

Clinical Areas Assessed

• Depression/Anxiety4.83• Identification/Tx of

Substance Abuse4.67• Severe mental illness4.40• Psychiatric medications3.20• Chronic medical conditions4.40• Chronic Pain4.50• Family/Parenting issues4.67

Likert scale: 1 (Very Poor) 5 (Very Good)

BHC Impact Scale How helpful have the psychologists or psychology resident been in

addressing the following clinical areas?

• Warm Handoffs4.83• BHC

Collaboration/Provider Satisfaction

5.00

• BHC Utilization33% daily, 67% several times a

week • BHC/Provider Communication5.00

• BHC Service Quality4.83

• Helpful aspects of grant?Calming

influence, very helpful

• Problematic Aspects of grant?

Spanish, > therapy time,

in-home

BHC Functioning within the Clinic

Likert scale: 1 (Very Poor) 5 (Very Good)

Lessons learned one year in

Timing of grant funding Buy in from clinics, teaching and marketing Provider variability Logistical challenges Need for modification/adaptation of interventions

specific to the population Underestimation of substance use disorders Importance of baseline screening measures to

identify changes in cognitive functioning and mood

Opportunities

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

providers

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.

Session Evaluation

Please complete and return theevaluation form to the classroom monitor

before leaving this session.

Thank you!