Behavioral Medicine Clinical Pathways in Primary Care Making

Behavioral Medicine Clinical Pathways in Primary Care: Making Them Work Christopher L. Hunter, Ph. D. , ABPP Department of Defense Program Manager for Behavioral Health in Primary Care The opinions and statements in this presentation are the responsibility of the author, and such opinions and statements do not necessarily represent the policies of the U. S. Department of Defense, the U. S. Department of Health and Human Services, or their agencies.

Overview 1. Background/Context Military Health System 2. Model of Integrated Behavioral Health Service Delivery 3. Population Health 4. Clinical Pathway Launch 5. Take Home Message 2

Department of Defense Primary Care Population 3. 3 Million Enrolled Directly to a Primary Care Provider Age Total % Female 0 -4 5 -14 15 -17 18 -24 25 -34 35 -44 a 45 -64 a 65+ Grand Total 307, 188 478, 689 121, 014 559, 098 723, 752 444, 297 571, 348 145, 792 3, 351, 178 49% 49% 39% 41% 49% 46% 52% a. Total % Active Duty N/A N/A 60% 67% 56% 11% 0% % Retired N/A N/A 0% 0% 6% 45% 49% % Family Members 100% 40% 33% 37% 43% 51% percentage of Active Duty, Retired and Family Members does not equal 100% due to rounding 3

Service Delivery Model • Staffing/Service Delivery Model – Adult PCMH Clinics with 3000 -7499 enrollees – 1 full-time Internal Behavioral Health Consultant (IBHC) – Primary Care Behavioral Health Service Delivery Model 1 – Adult PCMH clinics with 7500+ enrollees – 1 full-time (IBHC) – 1 full-time Behavioral Health Care Facilitator (BHCF) – Blended Model of Service Delivery Model 4

Population Health • Population Health Management Approach – An integrated approach to improve the health of an entire population by targeting the systems and policies that affect health care quality, access, and outcomes 2 • What is the “Population” – The “population” in population health denotes a group of individuals that can be organized into a variety of categories, such as geographic region, sex, ethnicity, age, healthcare system or clinic membership, or various risk factors and medical conditions such as obesity, diabetes, hyperlipidemia, or tobacco use 3 5

Population Health • Peterson, Raj and Lancaster (2014) 4 – Make the argument from a behavioral health perspective, that population health includes interventions and clinical applications focused on the entire patient population not individual patients. – They argue that less intensive interventions, delivered to all beneficiaries who might benefit, have the potential for greater impact on the overall population, than a more effective treatment for a smaller number of patients. – These interventions can be integrated into a set of standard operating procedures for clinical practice that involve administrative, nursing, primary care provider (PCP) and behavioral health consultant (BHC) staff. 6

How are Clinical Practice Guidelines Different from Clinical Pathways? • Clinical Practice Guidelines: “…statements that include recommendations, intended to optimize patient care, that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options” 5 • Clinical Pathways: “A documented sequence of clinical interventions, placed in an appropriate timeframe, written and agreed by a multidisciplinary team. They help a patient with a specific condition or diagnosis move progressively through a clinical experience to a desired outcome. ” 6 “A map of the process involved in managing a common clinical condition or situation. It should detail what to do, when to do it, by whom the action should be undertaken and where the task should be performed. ” 6 7

Clinical Pathways • Method of screening/assessment/intervention for a well-defined group • States the goals and key elements of care • Based on Evidence-Based Medicine guidelines, best practice and patient expectations by facilitating the communication, coordinating roles and sequences of multidisciplinary care team activities • Goal is to improve quality of care, reduce risks, increase pt satisfaction and increase the efficiency in the use of resources 8

Behavioral Medicine Clinical Pathways What Is Your End Game? Design Problems Really Can Slow You Down 9

Clinical Pathways • • Developed by behavioral health and physician PCMH leads Designed to increase use of BHCs as part of standard care Designed to improve outcomes & patient & PCP satisfaction with care 8 Pathways developed o o o o Alcohol Misuse Anxiety Depression Diabetes Obesity Chronic Pain Sleep Problems Tobacco Use 10

Obesity as an Example 1. 2. 3. 4. Identify patients for the pathway Connect the patients to the pathway Intervene in an evidence based way Outcomes…is it working 11

Clinical Pathway Evaluation How do you know if what you are doing is working? 12

Clinical Pathway Evaluation • Program Evaluation Targets – Process Metrics (obesity as an example) – – How many patients seen by primary care providers (PCPs) Of those how many screened (e. g. BMI) Of those how many 30+ on BMI Of those how many received what service – Referral to BHC for behavioral weight intervention – Referral to specialty behavioral medicine service outside the clinic 13

Clinical Pathway Evaluation • Program Evaluation Targets – Outcome Metrics (obesity as an example) – Change in BMI – Change in % of total weight lost – Change on biological measure (e. g. , BP, Lipids, Hb. A 1 c) 14

Clinical Pathway Evaluation Clinical Systems/Processes • Standard Clinical Operating Procedures – Screening/Assessment – Seamlessly woven into clinical care – Can be executed by staff other than the PCP – Valued added clinical data for PCP – Electronic Health Record – Easy documentation and clinical prompts – Data can be efficiently pushed/pulled electronically from the record 15

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Clinical Pathway Evaluation § Population Impact – Are the people who could benefit from care being treated – Are those treated getting better – Does getting better impact healthcare use/overall functioning 17

Clinical Pathways Implementation Facilitators Barriers • Support from management & clinical staff involvement • Allow for flexibility • Staff training • • Lack of outcome expectancy Inertia of previous practice Unconvinced of rationale for pathway implementation Overly prescriptive Active resistance Time constraints Available resources Insufficient staff & lack of training 18

Take Home Message 1. Determine the unmet need in your clinic 2. Engage health care team & leaders in clinical pathway discussion 3. Deliver detailed clinical pathway standard operating procedure -Who, does what, when, for how long? 4. Train all staff on clinical pathway 5. Determine monitoring process and outcome metrics of the pathway 6. Report pathway impact on a set schedule 19

References 1. Robinson, P. & Reiter, J. (2016). Behavioral consultation and primary care: A guide to integrating services (2 nd Edition). Springer International Publishing: Geneva, Switzerland. 2. Meiris, D. C. , & Nash, D. B. (2008). More than just a name. Population Health Management, 11, 181. 3. Kindig, D. A. (2007). Understanding population health terminology. The Milbank Quarterly, 85, 139161. 4. Peterson, A. L. , Raj, J. , & Lancaster, C. L. (2014). Psychology and population health management. In C. M. Hunter, C. L. Hunter, & R. Kessler (Eds. ), Handbook of clinical psychology in medical settings: Evidence-based assessment and intervention (pp. 3 -18). New York: Springer. 5. Consensus Report, Institute of Medicine. Clinical practice guidelines we can trust. March 23, 2011. 6. Hunter, B. & Sergott, S. (2008). Re-mapping client journeys and professional identities: A review of the literature on clinical pathways. International Journal of Nursing Studies (45), p. 608 -625. 20

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