2020 Workshops

Summary

Summary

The American healthcare system has failed to address the needs of vulnerable patients with multiple, chronic, co-morbid conditions. We focus our attention on the opioid epidemic as it kills Americans by the tens of thousands and is currently the greatest threat to health. Decreased cost and improvements in treatment outcomes for complex patients demand that providers learn a new set of clinical skills. These skills are not given enough focus in current medical school curricula or post-graduate psychology training programs. This has never been more important than now, a time where the iatrogenic opioid epidemic has occurred along with the widening illicit use of fentanyl and fentanyl opioid derivatives. We have published a textbook on this subject entitled, Integrative Medicine for Vulnerable Populations: A Clinical Guide to Working with Chronic and Comorbid Medical Disease, Mental Illness, and Addiction. Our model of Integrative Medicine provides a methodology and a skill set that has been successful at treating individuals with co-existing chronic physical and mental health conditions including substance use, severe mental illness, chronic pain, trauma, infectious disease, and other chronic conditions that are comorbid and syndemic, difficult or impossible to treat in isolation and occur more commonly in impoverished communities and people of color. We are currently focusing our attention in Kensington and North Philadelphia, areas of Philadelphia that have been most hard hit by the syndemic with high rates of overdose death, new HIV infection, and epidemic Hepatitis A. Our model focuses on comprehensive evaluation, an integrated formulation that adequately addresses all of the problems, and a rehabilitative holistic treatment plan that targets both physical and mental health conditions provided by a highly coordinated interdisciplinary team of providers. This practice requires that the team understands each discipline’s role and that team communication is built into practice. At a time when “burnout”threatens the integrity of our field, this model improves outcomes, decreases costs, and improves staff and patient retention. We will describe the kind of patients who require this high intensity service, the essential elements of the method, empiric outcomes data, barriers and facilitators to effectiveness, the implications of the structure of the team, and the financial model that we have developed for our work. Finally, we will focus on an extended case study of a patient our team has treated for more than 10 years.

Summary

Traumatic childhood events have the potential to shape later life experiences and choices (Layne et al., 2014). Felitti et al. (1998) found that higher numbers of adverse childhood experiences (ACEs) correlate to an increase in health risks and risky behaviors in adulthood. There is currently a lack of research regarding ACEs scores among graduate students in the helping profession. Thomas (2016) noted that graduate students in the helping profession have been overlooked in ACEs research although they tend to have higher rates of adverse childhood experiences than peers in comparable graduate programs. The current study sought to discover the rate of ACEs and if, among graduate students in the helping profession, self-compassion and psychological flexibility ameliorate the impact of ACEs on professional quality of life. Ninety-two participants were sampled from doctoral and master’s programs at George Fox University. Data analysis shed light on how ACEs scores, level of Self-Compassion, and level of Psychological Flexibility predicted self-reported Professional Quality of Life. A strong positive relationship was found between the abilities of self-compassion and psychological flexibility. In this sample, 25.8% endorsed 4 or more ACEs. Overall, they reported significantly more ACEs than the Felitti et al. (1998) sample and were more likely to report emotional abuse, emotional neglect, parental separation or divorce, having a household member incarcerated, and a household member struggling with mental health concerns. These adversities should become a strong consideration in program development, student support systems, and early career guidance. The present findings suggest that psychological flexibility and self-compassion may be important antidotes to the adverse impact of childhood suffering. Level of psychological inflexibility was shown to predict burnout; a concerning element of professional work. These data point to the importance of strengthening responses characterized by psychological flexibility and self-compassion during the educational stage of early career. The results of this study have implications for individuals, organizations, and the populations served by helping professionals. Often, the focus of trauma-informed policies is on the consumer. These data indicate the need for increased awareness of the trauma histories of providers and the development of self-compassion and psychological flexibility skills.

Summary

Have you ever wanted to talk about race in health and behavioral healthcare, but find it challenging for you or your organization to make real progress in this area? You are not alone. While most professional training programs and organizations emphasize the importance of cultural humility in practice, there are few opportunities to sustain conversations on race in healthcare. This session provides a “101”on race equity in healthcare and provides cultural humility and culturally responsive care frameworks for achieving race equity in this sector. We will provide clarification on major concepts such as race, racism, prejudice, internalized oppression, implicit bias, and equality versus equity. We will use an interactive, case-based, and discussion-based approach to ensure attendees leave the session with concrete steps they can take to begin or continue conversations on race equity at their home institutions.

Summary

Delaware Valley Community Health is a Philadelphia-based FQHC. In 2018, medical providers from our largest and busiest center brought to leadership some significant concerns around burnout. Looking at the issue from all angles, we decided to pilot a group for medical providers, over lunch, to discuss patient care and the challenges faced daily that contributed to burnout. Based on the principles of a Balint group, the Circle of Trust was created. The monthly group is led by the Director of Integrated Behavioral Health with significant support from the center’s Medical Director. These discussions of patient care guided by both a licensed clinical social worker and a medical doctor, began to bring new perspectives to shared frustrations, as well as opening doors for organizational change. Starting with only a few attendees, the Circle of Trust now regularly has 100% attendance and participation. Together, we have structured a an opportunity to speak with and listen to one another, impart strategies for mitigating burnout, build skills around effective patient communication, boundary setting, and problem solving. In this session, we will share the foundation and structure of Circle of Trust, some of the topics covered, and the changes it has effected over the course of two years. We will provide tools and strategies to form this group in your organization.

Summary

45% of people who have died by suicide attended a primary care appointment in the month preceding (SAMHSHA-HRSA, 2019). As such, primary Care is the front line for assessment of patients presenting with SI. When a patient demonstrates that they are a threat to their own safety, the standard of care is to send the patient to the ED for evaluation. For systems following this standard protocol, ED providers are often called upon to be the “first responders”to mental health concerns in emergency care settings (Suicide Prevention Resource Center [SPRC], 2016). Unfortunately, what was particularly concerning is there has been a relationship between visits to the ED (for suicide ideation) and subsequent suicide deaths (within two months post ED visit) (Knesper, 2011). In order to provide effective and seamless care for this nuanced issue, the gap between primary care and ED systems must be bridged and providers trained accordingly. We plan to share clinical examples of 6 patients who presented to primary care with SI and were escorted to the ED for further evaluation and treatment. These examples highlight the complex systemic barriers both providers and patients face. We plan to share how these barriers have been addressed in two primary care clinic through interdisciplinary collaboration and systemic understanding.

Summary

Mental Health America of Greater Houston’s (MHAGH) Integrated Health Care Initiative works with over 50 organizational collaborators to expand and enhance integrated health care in greater Houston and Texas. A recent focus has been the expansion of integrated care to private practice, particularly private pediatric practices. Private pediatric practices that accept CHIP and Medicaid form a de facto part of the safety net, yet they have been largely left out of the movement towards greater integration of behavioral health in primary care. In 2018, in partnership with the Texas Children’s Hospital system, MHAGH funded a pilot project to bring integrated behavioral health to two private pediatric practices and evaluate the financial sustainability of offering integrated behavioral health care in such settings. Since then, Texas Children’s Hospital has expanded this pilot to several additional private pediatric practices. In response to barriers encountered during the pilot, MHAGH has developed capacity-building trainings such as How to Pay for Integrated Health Care in a Fee-for-Service Environment and Credentialing for Behavioral Health Providers in Integrated Health Care. To enhance provider skills, MHAGH is also partnering with The REACH Institute to provide mini-fellowships for private practice pediatricians to expand their knowledge and ability to address mental health conditions seen in their practices. Expansion to private practice strengthens integrated care to help meet complex needs in a greater variety of settings. To promote such expansion, this presentation will include original, empirical data from the pilot project, including data regarding financial sustainability. The presenters will also discuss the process of moving the private pediatric practices towards integrated behavioral health care, including training provided for the practices, as well as actions now being implemented in response to workforce- and payment-related barriers encountered.

Summary

Substance use among pregnant women has seen recent growth because of the opioid epidemic (Patrick & Schiff, 2017). The Healthy Families Program (HFP), funded by SAMHSA, provides gender-focused, family-centered comprehensive and collaborative residential prevention, treatment and recovery support services to pregnant and postpartum women (PPW) who have opioid use disorders (OUD) and other substance use disorders (SUD), and their children, and families. The program utilizes a multidisciplinary team including substance use treatment center staff from two states, and a primary care clinic that provides comprehensive maternity care for PPW who are dependent on opioids and other substances. The goal of the HFP is to expand service provider capacity for PPW treatment services, and enhance services for PPW, their children, and family members. All clients are asked to complete evaluation interviews at intake, 6 months after intake, and discharge. Assessments include substance use, employment and housing status, mental health, and family functioning. Thus far 107 women have enrolled, with 6-month data collected from N=55. Most describe themselves as African American (40%) or White (49%), ages between 18 and 34 (79%). Preliminary outcomes indicate increased abstinence from substance use after six months, reduced substance use consequences, increased employment/education and stable housing. Statistically significant, positive outcomes are also observed for depression and trauma-related symptoms and family functioning. This presentation will begin by describing the HFP, key components and strategies for implementation and evaluation, evaluation findings and data limitations (20 minutes). The audience will then apply program implementation and evaluation strategies using a logic model worksheet (30 minutes). The presentation will conclude with a group discussion on the strengths and barriers of programming for PPW with SUDs and Q&A (10 minutes).

Summary

Substance use among pregnant women has seen recent growth because of the opioid epidemic (Patrick & Schiff, 2017). The Healthy Families Program (HFP), funded by SAMHSA, provides gender-focused, family-centered comprehensive and collaborative residential prevention, treatment and recovery support services to pregnant and postpartum women (PPW) who have opioid use disorders (OUD) and other substance use disorders (SUD), and their children, and families. The program utilizes a multidisciplinary team including substance use treatment center staff from two states, and a primary care clinic that provides comprehensive maternity care for PPW who are dependent on opioids and other substances. The goal of the HFP is to expand service provider capacity for PPW treatment services, and enhance services for PPW, their children, and family members. All clients are asked to complete evaluation interviews at intake, 6 months after intake, and discharge. Assessments include substance use, employment and housing status, mental health, and family functioning. Thus far 107 women have enrolled, with 6-month data collected from N=55. Most describe themselves as African American (40%) or White (49%), ages between 18 and 34 (79%). Preliminary outcomes indicate increased abstinence from substance use after six months, reduced substance use consequences, increased employment/education and stable housing. Statistically significant, positive outcomes are also observed for depression and trauma-related symptoms and family functioning. This presentation will begin by describing the HFP, key components and strategies for implementation and evaluation, evaluation findings and data limitations (20 minutes). The audience will then apply program implementation and evaluation strategies using a logic model worksheet (30 minutes). The presentation will conclude with a group discussion on the strengths and barriers of programming for PPW with SUDs and Q&A (10 minutes).

Summary

Medication assisted treatment (also known as medication assisted recovery or MAT) for opioid use disorder (OUD) is an excellent example of a treatment plan that can involve bidirectional warm handoffs between medical providers and integrated behavior health (IBH) providers. In practices that have integrated MAT services within primary care, medical primary care providers (PCPs) can prescribe buprenorphine for their patients with OUD and potentially involve an IBH provider to help solidify the treatment plan, either through a warm handoff or a formal referral. In our practice, our IBH provider routinely screens for substance use disorder at initial intakes. If a client screens positive, it may be appropriate for the IBH provider to initiate a warm handoff with the medical provider to consider MAT treatment with buprenorphine. This workshop will introduce the concept of bidirectional handoffs/referrals, and attendees will have an opportunity to practice these handoffs in real-time using a standardized patient model. We will then have an opportunity to debrief how the experiences went, and discuss lessons learned. Basic Outline: 1. Introduction of MAT and discussion of methods of incorporating medical and behavioral health components (10 minutes) 2. Live simulation of bidirectional handoffs using our providers and standardized patient (20 minutes) 3. Breakout sessions where participants can practice the skills observed (15 minutes) 4. Debrief and discussion of lessons learned and any additional applications (15 minutes)

Summary

Guided by 2 position papers prepared by the Canadian Psychiatric Association and College of Family Physicians of Canada in 1997 and 2011, these two organizations have spearheaded the movement in Canada towards collaborative (integrated) care and have outlined a framework within which collaboration has evolved. The last 10 years have seen significant progress across the country, including a wide range of innovative projects and models of practice and increased collaboration between planners and funders, and it is now a greater expectation of patients as well as providers. To build on these successes the two organizations decided to produce a new position paper with the goal of setting the stage for the next 10 years of collaboration in Canada. The strategy outlined is based upon 3 core values – 1) Improve access and equity, 2) Enhancing the experience of care in a patient and family-centred approach and 3) sustainable high quality services and programs through innovation, adaptability and enhancing the provider experience. The paper discusses the principles that should guide collaboration between services and between providers, and the potential goals of any project. It outlines the key components of effective projects, the roles of all team members – including patients – and changes required to support these initiatives. It also addresses medical care for people with mental illnesses, the potential uses of newer technologies, competencies required by providers, a training strategy for learners and an approach to evaluation using a quality framework. It also looks at changes any mental health service can make in their relationship with local primary care providers to improve access, communication and care co-ordination and increase system capacity, Finally it looks at how better collaboration can address wider challenges facing any health care system

Summary

While the Latinx community continues to grow in the US (including workforce, small businesses, and college students), disparities in access and quality of healthcare have remained stable over the last two decades (Vega, et al., 2009). Research highlights low access to healthcare, low cultural sensitivity in health providers, and language differences as the main barriers to address health disparities (Velasco-Mondragon, et al., 2016). In East TN, Cherokee Health Systems (FQHC and CHC) provides services to the Latinx community across 11 counties. In the counties with the highest concentration of Latinx patients, CHS services 17.29 to 36.42% of the Latinx population. This study aims to address the role of cultural brokers, Spanish-speaking behavioral providers, and in-person interpreters in engagement of healthcare. The sample will consist of at least 150 individuals (including foreign- and US-born nationals) whose primary language is Spanish and receive services by CHS’s interdisciplinary team. The study will compare two samples (those with cultural brokers as part of their care team and those without) using an independent-samples t-test. It is hypothesized that having access to Spanish-speaking providers and cultural brokers increases patients’ engagement in care (as measured by attendance to scheduled appointments) and helps discover needs that can be addressed by a culturally-sensitive integrated team (as measured by collaboration from multi-disciplinary team members).

Summary

A warm handoff (WHO) in integrated care setting typically occurs when the primary care provider introduces the patient to the behavioral health provider in response to a mental or behavioral health concern identified as part of routine care. Anecdotally, WHOs are considered a beneficial, if not essential, component of integrated care models, including Primary Care Behavioral Health and Collaborative Care Management. However, like many other components of integrated care, there are varied descriptions of what constitutes a WHO and relatively limited empirical evidence to support the impact of WHOs on patient or system outcomes. This symposium will address the conference theme related to implementation of evidence-based practices by exploring the nature of WHOs and the extent to which they have empirical support across integrated primary care platforms. The target audience for this presentation is clinicians, administrators, and researchers who want to know more about the potential value and limitations of WHOs. A panel representing integrated care experts in research, implementation and clinical practice will discuss the nature of a WHO as a concept and process of care, research evidence regarding to date regarding WHOs, operational and clinical perspectives on why WHOs may be important and could benefit from future study. Through panel discussion and audience feedback, we will develop a tentative research agenda on this topic, including priorities for operationalizing WHOs and identifying appropriate methods for advancing the state of the science.

Summary

Background: Launched in 2017, Certified Community Behavioral Health Organizations (CCBHO) are required to provide evidence-based, integrated care for patients with complex health and behavioral health problems. Unlike FQHCs, CCBHOs have not been well understood by the larger national integrated care community. As such, our presentation will describe, from the perspective of Compass Health Network, the nation’s largest CCBHO as well as a multi-site FQHC: (1) CCBHO integration-related certification requirements, (2) evidence-based screening and treatment practices within the CCBHO/FQHC, (3) organization-wide CCBHO quality improvement metrics impacted by integrating care; and (4) improvements in quality measures and outcomes of patients receiving integrated care compared to those receiving exclusively primary care (PC) health services. Population sampled, procedure, measures, and design: Our data are pulled from two existing EHR systems, for a one-year window, and comprise the entirety of the patient population in the two programs (CCBHO/FQHC) that receive a single (PC) service (n=7,200) compared to the patients in both programs that receive PC and at least one additional integrated service (n=3,400; behavioral health, whether therapy, psychiatry, rehabilitation, and/or SUD treatment, is counted as one service). Our evaluation of CCBHO performance is based on required quality metrics, including SUD treatment engagement, medication adherence, hospitalization follow-up rates, and suicide risk assessment. Our FQHC analysis compares the standard UDS clinical measures defined by HRSA (e.g., BMI screening, tobacco screening and cessation, A1c, screening and follow up for depression, use of appropriate asthma medications). Patient ages for this analysis range from five to 65+, and include somewhat more females (55%) than males. The study design is an organization-wide quality improvement evaluation, assessing changes in a number of metrics longitudinally, corresponding to the implementation and ramp up period for CCBHO activities. Key results & conclusions: A comparison of the two groups on a set of 13 HRSA clinical metrics reveals that performance was significantly better for those patients receiving an additional service integrated with PC, according to a z-test for proportions (p<.05). Among that group five of 13 measures exceeded targets, whereas only one of 13 did so in the PC-only group. Additionally, each of the six CCBHO quality metrics exceeded targets by a statistically significant margin according to a series of z-tests (p<.05). Our conclusions are: (1) CCBHO standards are helping drive greater integration of services, (2) the organization is exceeding quality standards across the board, (3) a concerted focus on integration across CCBHO and FQHC appears to consistently lead to better outcomes, and (4) patients who engage in only PC are less likely to improve than those involved in more than one service line.

Summary

People with Opioid Use Disorder (OUD) have complex healthcare needs that are best addressed by integrated care teams. Although the number of new HIV diagnoses in the United States decreased by 9% between 2010 and 2017, the rate of new infection among people with OUD is increasing. This is due not only to the sharing of needles, but because people with OUD being more likely to engage in high risk sexual behaviors. Additionally, these individuals face increased discrimination, have poor access to appropriate substance abuse treatment, and experience higher rates of incarceration, homelessness, and other socioeconomic factors that adversely impact their health. All of this places them at an increased risk for acquiring HIV. Although pre-exposure prophylaxis (PrEP) has been available to the public since 2012, the use of the medication has not been widely adopted, even among medical providers treating members of high risk groups. The Centers for Disease Control and Prevention estimates that PrEP is 99% effective at preventing the transmission of HIV, when used correctly. Therefore, we believe that the inclusion of PrEP navigation should be standard in primary care-based opioid use disorder treatment. Providing comprehensive care within an integrated healthcare team that includes mental health, medical, dental, nutrition, and social service providers is the most effective way to accomplish these goals. Attendees will be educated about the clinical utility of PrEP navigation as part of OUD treatment, as well as how to discuss sexual health and PrEP with patients in an open, thoughtful, non-judgmental manner. Using the results of a patient survey about attitudes toward PrEP along with clinic experiences providing integrated care to this population, the presenters will discuss the challenges and successes that we have faced in our own organization while implementing this as best practice. Data from the patient survey will also inform recommendations for overcoming barriers and best practices.

Summary

As biomedical and behavioral providers (alongside public health professionals, hospital/clinic administrators, and others), we know that attention to our own self-care and (inter)personal well-being is essential to maintaining balance and biopsychosocial/spiritual health. But we also know that doing this is easier-said than it is done vis-à-vis the time-demands that our jobs require, the political impasses that we must often navigate, and the intensity (and at times, heartbreaking nature) of the clinical presentations that we see. Drawing from on-the-ground efforts advanced by trauma-response teams (e.g., MRC, ICISF, RCF, FEMA), the presenters will introduce empirically-supported strategies in self-care that harness our resources across individual, family, social, and spiritual systems continua. Bridging these strategies to the everyday contexts of our “day jobs”in primary, secondary, and tertiary care will be outlined. Tangible resources / tools used in fieldwork and everyday practice(s) will be shared.

Summary

This presentation directly addresses the conference theme regarding the needs of patients with complex care needs. It defines and describes a way to engage family members/support persons through the electronic medical record (EMR). The intention of this engagement strategy is to assist with meeting treatment plan goals, reduce medical and human communication error, and increase collaboration between patients, support persons/family members, and their healthcare team. To date, studies done have looked solely at patterns of utilization related to health outcomes of patients (e.g., Burke, Rossi, Wilner, et al., 2010; Goldzweig, Orshansky, Paige et al., 2013). Additionally, little to no research has been done including family/support persons and/or use of the proxy function in EMRs for improving patient engagement, family engagement, and comprehensive health outcomes. Findings from two qualitative studies conducted by the presenters address how use of the EMR patient portal system may improve the flow of communication between the treatment provider, patient, and patients’ support system. Improved communication between patients, family members/support persons, and members of the healthcare teams may help to reduce hospital readmission rates. Over 20 participants representing patients, families, and providers contributed to these studies. Findings include themes that help understand high readmission rates for patients in DKA and strategies for increasing knowledge among family members/support persons to help improve patient health outcomes. Attendees who may benefit from this presentation include administrators and providers who utilize an EMR system. Attendees will learn how to: (a) create the infrastructure for piloting a similar EMR project in their settings, (b) expand inclusion of family members/support persons through the patient portals available in their EMR systems, and (c) track outcomes of its impact.

Summary

The Blueprint for Complex Care provides some key points to consider related to the ongoing development of complex care practices. Complex care is defined as “the care for people with complex health and social needs.”One key issue the Blueprint targets is the need for training and professional development programs that support implementation of evidenced based models and solutions. The Blueprint recognizes there is not an adequate supply of professionals, namely primary care & behavioral health clinicians, to provide direct services on the front lines of complex care. The Blueprint also acknowledges that the existing professional workforce is not well prepared for addressing complex care needs. Complex care requires new skills and competencies, workflows, and knowledge of how to navigate systems and formulate sequenced responses to complex comorbid needs within a team. This panel presentation aims to discuss the challenges of training BHCs, vital members of integrated care teams, in a context that requires attention to multiple, complex healthcare needs and system variables. The PCBH model is a person centered approach which focuses on increasing access to whole-person care. When the care a person receives aims to target behaviors that are responsive and indicative of health, personality, situational state, context, culture, and social determinants of health, complexity is inherent in the decision making. Using SAMHSA’s competencies for integrated care workforce, the panel will discuss the implications, challenges and frame some possible solutions, frameworks (i.e., the Four Point method; Jonsen, Siegler, and Winslade, 2010) and training tools that can help improve individual readiness for team-based integrated complex care.

Summary

The opioid epidemic has impacted a viral hepatitis epidemic, HIV outbreak, and an increased prevalence of sexually transmitted infections increase among people who inject drugs. In order to move forward with integrated care strategies in a financially sustainable way, especially in an increasingly Value-based payment world, behavioral health providers need to look toward innovative reimbursement models and collaborations with payers. In this hour-long workshop, leaders in substance use disorder treatment, infectious disease care, and managed care organizations will present a unique partnership that has enabled a novel payment structure to support integrated care within a methadone maintenance clinic. This presentation will walk attendees through the current Medicaid carve-out payment structure in Pennsylvania; the goal for the physical health integration of a Methadone clinic in urban Philadelphia; and the development of organizational partnerships among the physical and behavioral health MCOs;. The current status and accomplishments resulting from this collaboration will be reviewed (e.g., metrics, access to data, novel reimbursement models, improved collaboration of care for individuals served). The target population for this program is program leaders and administrators who desire to move toward integrated service delivery models or policy makers who are interested in learning more about innovative approaches to reimbursement models.

Summary

Narrative medicine is a powerful tool for reflection, wellness, team-building, and improved clinical services. A strong narrative practice assists faculty and supervisors in the teaching and clinical settings. During this session we will engage in a narrative medicine activity of reading, writing, and sharing, then explore model narrative medicine curricula that have been applied in clinical settings. Regarding clinical practice, the text “The Principles and Practices of Narrative Medicine”observes that: “Narrative Medicine began as a rigorous intellectual and clinical discipline to fortify healthcare with the capacity to skillfully receive the accounts persons give of themselves–to recognize, absorb, interpret, and be moved to action by the stories of others. It emerged to challenge a reductionistic, fragmented medicine that holds little regard for the singular aspects of a patient’s life and to protest the social injustice of a global healthcare system that countenances tremendous health disparities and discriminatory policies and practices.”(p. 1) In support of wellness, narrative medicine offers a format for reflection and professional development, and is at the heart of wellness for team-based education. As many supervisors and faculty lack formal education in close reading and group facilitation, the need for new skill and knowledge can present obstacles to implementing narrative medicine as a tool in a clinic or training program. This program will present a first exposure to narrative medicine and provide guidance and templates on how to implement this practice in personal, clinical, and teaching settings. Timeline: :00 – :05 Introductions and Overview :05 – :10 Small group outloud reading of either a poem or short story :10 – :25 Small group discussion of the poem or short story :25 – :35 5-minute prompted writing of a reflection (with intro) :35 – :45 Sharing of writing in small groups :45 – :60 Discussion of application to clinical and teaching settings / QA

Summary

Recognizing and addressing adverse childhood experiences, exposure to lifetime trauma, posttraumatic stress, and posttraumatic stress disorder have increasingly been prioritized in primary care. While few would argue against expanding education and training medical providers on this topic, it is equally critical to understand the individual, relational, and system-level challenges practicing PCPs face in integrating trauma-informed principles and PTSD screening and management into routine patient care. This presentation will review qualitative survey data from a Department of Family Medicine and Community Health listserv of practicing primary care providers. PCPs were asked to consider the following question, “Think about your day-to-day practice as a primary care provider. Identify three specific challenges (individual or system level) you’ve encountered trying to integrate trauma-informed care into your routine patient care.”Nearly 100 qualitative responses were collected and reveal nuanced and complex challenges that make it difficult for practicing PCPs to address this important component of their patients’ health. The presenters will focus on examining themes across reported challenges, exploring individual and system-level root causes of challenges, and providing recommendations for acknowledging and addressing these challenges in training and practice.

Summary

The integrated primary care team is increasingly called upon to manage patients with a wide spectrum of psychiatric presentations often with co-occurring complex social needs. Psychopharmacology Review for Integrated Primary Care will provide an overview of drug classes, approach to common clinical presentations, and management of adverse effects. Psychopharmacology challenges related to social determinants of health, medication options for substance use disorders, and the role of non-prescriber integrated team members will be discussed. Case examples, clinical pearls and links to clinical drug resources will facilitate learning. Our target audience will be prescribers wishing to enhance their knowledge and non-prescribers wishing to add to their knowledge base. All disciplines are welcome.

Summary

Eating disorders (ED) can have a devastating impact on an individual’s physical and mental health as well as on the larger healthcare system. EDs are associated with increased healthcare utilization, long-term health complications, and mortality. Detecting EDs early is vital, and research suggests that most individuals with EDs or subclinical ED symptoms present to primary care first. Behavioral health consultants (BHCs) within integrated primary care are uniquely qualified to assist primary care physicians (PCPs) and support staff in assessing and treating EDs in primary care and can be an integral part in the prevention of EDs more broadly. The purpose of this presentation is to synthesize the most up to date literature on preventing, assessing, and treating EDs in primary care, while also providing practical recommendations for translating research into clinical practice. First, a comprehensive literature review on preventing, assessing, and treating EDs will be presented. Time will be dedicated to discussing the intersection of EDs and social determinants of health (SDoH) with specific focus on challenging assumptions of ‘typical’ ED presentations. Next, recommendations for brief assessment and intervention of EDs in primary care will be provided (handouts will be used to summarize recommendations). These recommendations will also address how to assess for EDs while considering SDoH. Lastly, a deidentified case study will be presented on how these recommendations can be implemented within a Family Medicine Residency Clinic located within an underserved community. This case study will be based on a 40-year-old, African American patient who presented to primary care with angina, asthma, and insulin-dependent diabetes and was later diagnosed with binge eating disorder (BED). The BHC, PCP, and patient’s perspective on the integrated care treatment approach to managing BED will be provided.

Summary

Improving dissemination and implementation of evidence-based practices (EBP) in integrated behavioral health (IBH) is inextricably linked to the need to improve quadruple aim outcomes to compete in an ever-changing health care landscape. In our integrated health system, since 2011 we have expanded from 3 to 11 pediatric IBH sites since 2011 and from 0 to 8 adult IBH sites using a variation of the PCBH model to address local needs in access to high-quality behavioral health care. In 2017, we added embedded research to increase capacity for applied research and in 2019 we engaged in organizational restructuring to facilitate continued growth and collaboration between adult and pediatric IBH. In this presentation, we will briefly describe the evolution of our PCBH model related to improving EBP and illustrate aspects of our progress, challenges, and opportunities in improving population behavioral health. The model is based on integrating complementary frameworks, including a) conceptualization of health care as a co-created service between patients, providers, and transdisciplinary researchers; b) extending the learning health care system approach to behavioral health; and c) leveraging contextual behavioral science principles to enable dissemination and implementation of innovations. Together, our framework supports both transformation and continuous improvement towards high value behavioral health care. We will also illustrate applications of this model by highlighting three projects: 1) A mixed methods project engaging patients and providers to develop and conduct preliminary user testing of a behavioral intervention technology platform to empower parents to take charge of their child’s behavioral healthcare; 2) implementation of interdisciplinary primary care resident training in behavioral health; and 3) incorporation of a precision health youth advisory council into stakeholder feedback for quality improvement of youth suicide prevention efforts.

Summary

A practice-based research study to investigate integration of mental health in primary care was conducted generating a cohort of 2495 cases obtained from an FQHC in Montana during primary care visits. The results from electronic self-report administration of the PHQ-9 with a QPD in-depth psychological assessment administered randomly before or after the PHQ-9, are analyzed from multiple perspectives and used for training. First, using CJ Peek’s three world view, the effectiveness and cost-effectiveness of the clinical depth, breadth, accuracy and automation used in the study are analyzed demonstrating the need for dynamic administration of latent trait measures. Second, the study dataset is analyzed to produce the evidence-based AI network weights used for probabilistic, higher accuracy, item-by-item scoring, enabling more effective dynamic administration. The evidence-based AI network weights are also generated between latent traits making the comorbid relationships in the dataset explicit and available to drive the AI interview process. Finally we will use the study dataset to analyze effective use of a data warehouse integrated with an EMR and how to automatically support practice-based research. Based on the information learned, attendees will then design a screening solution for their practice that covers detection, in-depth assessment, actionable results and potential research, outcomes and QI initiatives.

Summary

A practice-based research study to investigate integration of mental health in primary care was conducted generating a cohort of 2495 cases obtained from an FQHC in Montana during primary care visits. The results from electronic self-report administration of the PHQ-9 with a QPD in-depth psychological assessment administered randomly before or after the PHQ-9, are analyzed from multiple perspectives and used for training. First, using CJ Peek’s three world view, the effectiveness and cost-effectiveness of the clinical depth, breadth, accuracy and automation used in the study are analyzed demonstrating the need for dynamic administration of latent trait measures. Second, the study dataset is analyzed to produce the evidence-based AI network weights used for probabilistic, higher accuracy, item-by-item scoring, enabling more effective dynamic administration. The evidence-based AI network weights are also generated between latent traits making the comorbid relationships in the dataset explicit and available to drive the AI interview process. Finally we will use the study dataset to analyze effective use of a data warehouse integrated with an EMR and how to automatically support practice-based research. Based on the information learned, attendees will then design a screening solution for their practice that covers detection, in-depth assessment, actionable results and potential research, outcomes and QI initiatives.

Summary

Behavioral health integration has many moving parts: collaboration across departments and with outside providers (ex: referral to BH specialist), documentation, billing, and patient and provider buy-in. Technology can be used to alleviate the most burdensome paint points (administering/scoring questionnaires), remotely monitor patients, provide 24/7 resources, and collaborate between care team members. Through the use of technology you can proactively identify urgent/at-risk patients with the resources they need in a timely manner and provide measurement-based care for patients. We have implemented this solution with a variety of clinics (primary care, OBGYN, Behavioral Health, Psychiatry, etc.) geographically (Pennsylvania, New Jersey) and have seen patients see symptom improvement for depression (82%; PHQ-9) and (77%; GAD-7). In this interactive session, we will provide a case study of implementation of a behavioral health app, NeuroFlow, in a large primary care health system. We will discuss incorporation into workflows, provider and patient uptake, and its return on investment. Audience members will then participate in an app “show and tell.”We will walk participants through the app’s provider features, including automatically scored questionnaires, automatic documentation for billing, remote monitoring patients, alerting providers of those in need, and billing documentation. It will also demonstrate highlights of the patient app, including its use of behavioral economics to facilitate behavior change and improved patient outcomes. The final portion of the session will be an audience brainstorm about barriers and facilitators to app integration in their practice settings. Participants will leave with resources and strategies for behavioral health app implementation.

Summary

Burnout is a national health crisis (Noseworthy et al., 2017), with PCP burnout rates ranging from 13.5-60% (Abraham, Zheng, & Poghosyan, 2019). Provider burnout is adversely associated with patient care, provider wellbeing, and organizational outcomes (West et al., 2018). In 2018, the National Academy of Medicine launched an Action Collaborative to advance initiatives to improve clinician wellbeing. Additionally, wellness is an increasing area of emphasis in medical education (AMA, 2018). Practice environment is the most common predictor of PCP burnout (Abraham et al., 2019). Modifiable environmental factors associated with lower burnout include defined team structures, goal-directed solution seeking, mutual support, and consistent, straightforward communication (Abraham et al., 2019; Salas, 2018). Simply put, teamwork is a foundation for building and sustaining resilient and effective primary care practice environments (Salas, 2018). As featured in Dr. Belinda Fu’s CFHA conference plenary (2019), medical improv is “an emerging field in which the principles and training techniques of improvisational theatre are used to improve cognition, communication, and teamwork in the field of medicineâ€

Summary

As the integrated behavioral health workforce continues to expand, with inherent complexities of care, additional supervisors and trainers will be needed to develop the core competencies of the PCBH role, such as GATHER (Reiter et al, 2018). Formal preparation training to become a clinical educator or supervisor of integrated behavioral health providers is not well-defined. The focus of this moderated clinical round table presentation is to share expert strategies in orienting, training, and developing new primary care behavioral health providers from a panel of experienced integrated supervisors and consultants. The session will include discussion of supervisory-level competencies on: –Onboarding: setting a training schedule, orienting to the model, training competencies and setting up shadowing experiences for the new clinicians. –Note-writing: helping shape primary care-specific, efficient integrated practice notes –Staff development: using supervision and reverse-shadowing to provide feedback and enhance competency skill-development –Ongoing support: growth identification, scaffolding development, chart audits, supervision, utilizing a lens of multiculturality and understanding complexity within the PCBH role, training, and continued shadowing. The presentation will include discussion of core competencies, provision of resources to the audience (e.g., BHC Core Competency Shadowing Rating Scale), case examples, and question/answer period. Discussion on managing up/down and advocating for supervisees with site leadership will also be addressed. Pilot data will also be shared on the use of a competency tool in BHC shadowing.

Summary

Depression is one of most common mental health conditions and the leading cause of disability worldwide, affecting about one in 10 adults in the US. Depression treatment is vital for underserved primary care patients who often experience multiple chronic medical conditions along with higher rates of health disparities. These challenges are very complex. Emerging evidence suggests mobile app technology can aid in the self-management of depression. Yet, there is limited research exploring the use of mobile health apps in this population with specific gaps concerning the feasibility of integrating these tools. Filling this gap is needed to inform evidence-based training, clinician tools, and educational material to facilitate the implementation of mobile apps with clinical care. Attendees, who could be at any stage in their education or careers, will learn about the process and results from a study that explored the feasibility of integrating depression self-management smartphone apps into primary care for an underserved patient population with depression. Adult patients with an active or previous depression diagnosis were eligible to participate. Participants were asked to complete measures which explored self-efficacy, and patient activation, along with questions pertaining to smartphone ownership, type of data plan, and willingness to use apps for self-management. Patient and provider/staff focus groups were conducted at clinic sites to explore the feasibility of using smartphone apps for depression management. Initial findings suggest that patients are likely to attempt app use for self-management when physicians make this suggestion. Results also suggest that giving patients an array of smartphone apps to choose from increases their likelihood of app use. The presentation will also include descriptive statistics, survey results, provider and patient perspectives of app integration into standard of care, and future directions.

Summary

Primary Care Behavioral Health (PCBH) is a popular service delivery model of integrated care; however, a key limitation to its growth in practice and research is the lack of understanding for how to define PCBH and ensure fidelity. To date, a majority of research and clinical work has focused on defining PCBH primarily as the presence of an embedded behavioral health consultant (BHC)and characteristics of the appointments conducted by the BHC (e.g., appointment length and number of appointments). However, this approach ignores other elements thought to be essential to PCBH practice and allows for wide variation in PCBH implementation. Such practice variability significantly limits the ability to identify PCBH outcomes. This presentation will describe the importance of assessing PCBH fidelity and shares a logic model developed and subsequently refined using expert consensus methods. This logic model elaborates and defines the structural components, activities, outputs, and outcomes of PCBH across the clinic, primary care team, primary care provider, behavioral health consultant, and patient levels. The discussion will focus on how this comprehensive set of relevant fidelity indicators of PCBH can be utilized by administrators and clinicians to improve practice as well as allow researchers to add rigor to any investigation of PCBH impact on outcomes.

Summary

As the demands on primary care providers (PCPs) are increasing, addressing the stress levels of PCPs, specifically daily stressors, is crucial (Bodenheimer & Sinsky, 2014). These stressors lead to burnout and are affecting PCPs at alarming levels. Bodenheimer and Sinsky (2014) report “…46% of US physicians experience symptoms of burnout…68% of family physicians would not choose the same specialty if they could start their careers anew” (p.574). While much of this frustration is associated with administrative work, this has had a ripple effect in leaving little time and energy for engaging with more difficult complex patients who present as some of the most draining of patient encounters (Babbott et al., 2014). Physicians report this is primarily because they see little improvement in many of these patients and realize that their medical school training did not prepare them for dealing with this (Linzer et al., 2002).  They are specifically referring to additional skills and ways to interact with these patients, understand them, and enhance their motivation to change.  In the attempt to assist with this, leveraging additional benefits of integrated care, the following intervention carried out by the behavioral health consultant (BHC) was developed.  This intervention combines the basic skills of motivational interviewing and training on the diagnosis and treatment of medically unexplained symptoms (MUS) or, as it presents more commonly in primary care, stress illness.

The intervention in this study is focused on 1) teaching PCPs the spirit of motivational interviewing (MI) and basic MI skills and 2) educating PCPs on MUS/ stress illness including skills for diagnosis, discussion, screening, and treatment of these patients many of whom have experienced childhood stressors (Anda & Felitti, 1998). The participants in this study are patients, PCPs, Nurse Care Managers (RNs), a Pharmacist, and BHCs of a large integrated primary care practice following the primary care behavioral health model. This study involves a two-part training comprised of 4 forty-five minute didactic, interactive and experiential group training along with optional individual BHC-PCP shadows involving real-time training. All components of training will be designed as achievable within the fast pace of primary care. The goal of the study is to lower physician daily stress levels (DSLs) and improve treatment outcomes for MUS/ complex patients. With this intervention, the expected results will transform the frustration associated with the treatment of these patients into a collaborative relationship, employing joint decision-making processes, increasing patient adherence, and improving treatment outcomes while additionally reducing the PCP’s stress affiliated with these visits and improving daily stress levels (Rollick et. al, 2008). The study is currently in progress and as a result of COVID-19 is not complete.  We are encouraged to use this as an opportunity to explore the impact of COVID on integrated primary care, specifically on the effects of this study, and to delve deeper into the particular teaching components of this intervention providing practical “take-homes”.  We will be detailing the core components of our training program/ intervention in the hopes of adding value to programs and ideas that may be implemented in settings nationwide. Additional time will also be allotted for role play, feedback, questions to accomplish this goal.

Summary

Transgender individuals experience significant health disparities associated with barriers to care, including lack of provider training, discrimination, system barriers, and financial barriers (Safer et al., 2016). Comfort with primary care services impacts health outcomes for transgender individuals (Clark et al., 2018). For example, affirming, integrated services for transgender youth that include early identification and family support improve psychological outcomes (Janicka & Forcier, 2016). Moreover, primary care services may offer connections to affirming medical interventions, such as puberty blockers and hormone replacement therapies; Turban et al. (2020) found that access to pubertal suppression during adolescence was associated with lower risk of lifetime suicidal ideation. Consistent with previous studies (Kano et al., 2016), this project used qualitative methods to develop gender-affirming programming based on input from patient stakeholders. This presentation describes the development of an intervention program for gender creative patients, including identification of patient population, needs assessment, patient-guided iterations, and the current state of the program. Study sample included youth aged 8-18 years and their families from two integrated primary care clinics located in central and northeastern Pennsylvania. Needs assessment procedures and data will be reviewed. Presentation will share details of the intervention and procedures, and patient experiences and outcomes will be captured in qualitative data. Quantitative data will include demographic data, diagnostic categories, and average length of care. Preliminary data suggests that patients report a high degree of satisfaction with the current program. Families identify the gender program as their “child’s tribe” and “the best day of the month.” Families also comment on the layers of support, mentoring, and education offered by the intervention.

Summary

Individuals with a severe and persistent mental illness (SPMI) have over twice the risk of mortality than those without SPMI, which is partially attributed to a greater burden of chronic conditions. Individuals with SPMI are more likely to have diabetes, and suffer more severe consequences from diabetes than those with diabetes alone. Chronic disease self-management programs have been tested and used primarily within the general population. Individuals with co-occurring SPMI and diabetes, however, encounter additional barriers to managing diabetes that are not addressed in traditional programs. Self-management programs designed specifically for this population are critical in addressing health and health disparities among individuals with SPMI and diabetes. In this session the presenter will guide the audience through the elements of developing, implementing, and evaluating an innovative pilot intervention in an integrated healthcare setting, using our diabetes self-management pilot as a teaching tool. Session participants will learn, practice, and receive tools for successful pilot implementation and rigorous process and intervention evaluation, to enable them to successfully implement a pilot in an integrated healthcare context. During the session participants will brainstorm potential challenges they might encounter in the implementation and evaluation process. Then, utilizing a logic model to guide planning, participants will identify process measures and outcomes that would be critical in successful evaluation of an example pilot project. Lastly, participants will explore mixed methods analysis in the evaluation stage of their pilot project, and how evaluation methods guide reporting and communications. At the conclusion of the session participants will receive resources to supplement the information presented, including: logic model template, quick primer on mixed methods analysis tools, and additional links to resources on process evaluation and mixed methods analysis. Anticipated Session Outline 1. Overview of Cascadia Behavioral Healthcare and integrated diabetes care to develop context for the session and activities (3 min) 2. The basics on how to develop a pilot program, using Cascadia’s work as an example to guide instruction and discussion (6 min) a. Using evidence and research b. Planning c. Implementation d. Evaluation 3. The logic model as a tool to guide steps a-d a. Didactic instruction (5 min) b. Exercise using a logic model to plan implementation and evaluation – Barriers and supports brainstorm and logic model development (15 min) 4. Evaluation of pilot program using mixed methods research a. Didactic instruction (7 min) b. Exercise developing measures/outcomes based on program goals, and guided by logic model (15 min) 5. You’ve evaluated your program, so now what? (7 min) a. Quick activity around creative approaches to reporting and communicating results 6. Questions/final remarks

Summary

Individuals with a severe and persistent mental illness (SPMI) have over twice the risk of mortality than those without SPMI, which is partially attributed to a greater burden of chronic conditions. Individuals with SPMI are more likely to have diabetes, and suffer more severe consequences from diabetes than those with diabetes alone. Chronic disease self-management programs have been tested and used primarily within the general population. Individuals with co-occurring SPMI and diabetes, however, encounter additional barriers to managing diabetes that are not addressed in traditional programs. Self-management programs designed specifically for this population are critical in addressing health and health disparities among individuals with SPMI and diabetes. In this session the presenter will guide the audience through the elements of developing, implementing, and evaluating an innovative pilot intervention in an integrated healthcare setting, using our diabetes self-management pilot as a teaching tool. Session participants will learn, practice, and receive tools for successful pilot implementation and rigorous process and intervention evaluation, to enable them to successfully implement a pilot in an integrated healthcare context. During the session participants will brainstorm potential challenges they might encounter in the implementation and evaluation process. Then, utilizing a logic model to guide planning, participants will identify process measures and outcomes that would be critical in successful evaluation of an example pilot project. Lastly, participants will explore mixed methods analysis in the evaluation stage of their pilot project, and how evaluation methods guide reporting and communications. At the conclusion of the session participants will receive resources to supplement the information presented, including: logic model template, quick primer on mixed methods analysis tools, and additional links to resources on process evaluation and mixed methods analysis. Anticipated Session Outline 1. Overview of Cascadia Behavioral Healthcare and integrated diabetes care to develop context for the session and activities (3 min) 2. The basics on how to develop a pilot program, using Cascadia’s work as an example to guide instruction and discussion (6 min) a. Using evidence and research b. Planning c. Implementation d. Evaluation 3. The logic model as a tool to guide steps a-d a. Didactic instruction (5 min) b. Exercise using a logic model to plan implementation and evaluation – Barriers and supports brainstorm and logic model development (15 min) 4. Evaluation of pilot program using mixed methods research a. Didactic instruction (7 min) b. Exercise developing measures/outcomes based on program goals, and guided by logic model (15 min) 5. You’ve evaluated your program, so now what? (7 min) a. Quick activity around creative approaches to reporting and communicating results 6. Questions/final remarks

Summary

As the field of integrated care continues to grow, the demand for well-trained, well-prepared behavioral health providers ready to work in complex health systems has also increased. There has been significant effort to identify core competencies for behavioral health providers working in integrated care models in recent years which can help shape training programs. However, the perspective of the student has not been included. While clinical skills, communication skills, consultant skills are typically emphasized by training programs, students are often looking for other factors when searching for training opportunities at various levels. These can include geography, diversity of patient population, diversity of faculty/staff, opportunities for research, opportunities for program development, understanding the complexities of the health care system and more. The goal of this session is to briefly review core competencies utilized in training programs, and then gather feedback from students in the audience. Presenters represent 3 training program sites across the country. Small group discussions will provide an opportunity for students to share with each other what factors they value in training programs. Groups will be asked to report out their findings, and audience members will be asked to rank their findings through an interactive poll. The results can be utilized by students to organize their thinking and decision making as they progress through graduate training, and by training directors to understand how students select training sites.

Summary

One of the benefits of integrated primary care settings is the wealth of bi-directional learning that can occur through consultation and collaboration. In VA Connecticut’s Center of Education (COE) in Interprofessional Primary Care, residents from clinical health psychology (CHP), medicine, nursing, and pharmacy work together to provide fully integrated and comprehensive care. In the precepting room, physician (MD) and nurse practitioner (NP) residents meet with an attending provider to review patient care and develop a treatment plan. During interprofessional precepting, CHP residents provide mental and behavioral health consultation, and in turn, are exposed to professional practices in primary care. This project is an extension of previous work done examining active and passive learning in the precepting room. The sample consisted of 2 CHP residents, 14 physician (MD) residents, and 6 nurse practitioner residents (NP) over a 12-month period. During precepting, CHP residents tracked the type of consultation provided, if a CHP referral was discussed, and if a “warm introduction”was performed. CHP residents qualitatively indicated what they learned from precepting and themes were identified by two CHP providers not participating in precepting. Of the 122 patient visits precepted (60 by MD residents, and 62 by NP residents), consultation was provided 90% of the time. Consultation included health behavior change (70%), patient-provider communication (30%), understanding psychiatric presentations (22%), cultural considerations (11%), providing patient education handouts (10%), and mental health resources outside of the clinic (9%). Warm introductions were positively associated with health behavior change consultation (χ2= 6.81, p = .009). CHP referrals were discussed 30% of the time and were inversely associated with consultation on psychiatric presentations (χ2= 5.53, p=.019). Learning among CHP residents occurred 76% of the time and consisted of clinical/biomedical information (74%), profession-specific practices in primary care (19%), facility-related content (10%). MD and NP faculty identified coaching from CHP residents on communication techniques (e.g. motivational interviewing) as being particularly beneficial in MD/NP resident development. Other benefits of consultation included a greater appreciation for how mental health disorders impact care, alternative perspectives on clinical conceptualizations, and encouragement after multiple unsuccessful prior attempts to engage patients in changing health behaviors. Future directions include obtaining and examining qualitative data from MD and NP residents related to the impact of consultation with CHP residents on developing advanced competences in integrated care.

Summary

African American men are more likely to be diagnosed with and die from prostate cancer (American Cancer Society, 2016; Kreps, 2006). For those who survive, prostate cancer side effects, such as erectile dysfunction, impact the patient’s quality of life and their romantic relationship. Sexual satisfaction seems to impact the perceived quality of life and overall health for African American men (Kinlock et al., 2017). When compared to white men with prostate cancer African American men are less likely to trust their physicians, this may be related to medical mistrust (Boulware, Cooper, Ratner, LaVeist, & Powe, 2016). The purpose of this study was to understand the association between trust and confidence in medical care, quality of life, sexual satisfaction, and couple’s satisfaction for African American prostate cancer survivors. This study looked at African American men (n=24) who were in or had completed treatment and were in romantic relationships. A one-time, self-report survey was conducted. Surveys were web-based or in-person depending on the participants’ preference. Participants were recruited nationally through prostate cancer support groups, medical and mental health listservs, social media (e.g. Facebook, Twitter, etc.), urology clinics and primary care clinics. Due to the difficulty of accessing the African American population for research, this study used non-random sampling such as convenience (i.e., quota or accidental) sampling (Etikan et al., 2015; Kumar, 2011) and snowball sampling (Kumar, 2011). Participants filled out questions from the following measures Functional Assessment of Chronic Illness Therapy-Treatment Satisfaction-Patient Satisfaction (FACIT-TS-PS), Functional Assessment of Cancer Therapy-Prostate Cancer (FACT-P), Couples Satisfaction Inventory (CSI-4), PROMIS SexFS. Due to the small sample size (n = 24), non-parametric correlations were conducted to test hypotheses. Positive associations were found between physician communication and quality of life, couples satisfaction, sex life satisfaction, and orgasm pleasure as expected. As well as confidence and trust in medical care, quality of life, couples satisfaction, sex life satisfaction, and orgasm pleasure. Recruitment of African American men for this study was difficult and the response rate was low. In healthcare research, one study found that older African American men who witnessed the Tuskegee disclosure were less likely to engage in healthcare (Alsan & Wanamaker, 2017). Health disparities researchers face a conundrum, to change health disparities we must study a population that is hesitant to engage in research. To make an impact on health care disparities, researchers should understand barriers to engaging in research and how to gain trust in minority communities. This workshop will focus on the experiences that African American men with prostate cancer face. As well as how to engage African American men in health disparities research.

Summary

Though significant attention has been paid to burnout in healthcare workers, the predominant focus has been on the physician experience with lesser attention to other members of the team. This is particularly concerning in long-term care (LTC), where thirty-seven percent of nursing staff report experiencing burnout, compared to just 22 percent of nurses working in other settings. Burnout has been linked to elevated turnover, absenteeism, and poorer mental and physical health outcomes for health care workers, but also poorer safety and quality for patients, and increased costs to employers. LTC staff report that one of the greatest contributing factors to burnout is challenging patient behaviors. This is particularly salient given that over the past ten years, adults ages 31 to 64 have been the fastest growing population in nursing homes, and they are more likely to have experienced additional social determinants of health–leading to more complex care needs–including developmental disabilities, trauma, psychiatric diagnoses, and inpatient stays in psychiatric facilities. At our facility, behavioral health specialists have long served as physician educators and delivered brief interventions to patients. Yet no supports to increase nursing knowledge or comfort working with behavioral challenges existed. As a result, a needs assessment was conducted with nursing staff in one multi-unit LTC to identify potential benefits of providing interdisciplinary teaching on these topics to support patient care and reduce rates of staff burnout. Nurses identified a need for additional training focused on addressing challenging patient behaviors and family interactions. In response, a twelve-month training program was created by a team which included medical family therapy, behavioral, and geriatric expertise and was delivered to all nursing staff of a 40-resident LTC unit. Pre-training, mid-point, and end-of-training-year measures were collected to determine training impacts on clinical and operational outcomes for patients, staff, and the facility, including staff burnout. The interdisciplinary healthcare team that designed and supported the program will describe the needs assessment design, development and implementation of the program, and evaluation methodology and results.

Summary

Although anxiety is highly prevalent in primary care and a top reason for referral to Primary Care Behavioral Health (PCBH), understanding of anxiety interventions used in routine PCBH practice is limited. The objective of this study was to examine patient-level and provider-level correlates of delivering evidence-based anxiety interventions to inform research and practice on the implementation of evidence-based treatment in integrated primary care. In a cross-sectional survey, 209 PCBH providers recruited from national email listservs reported on use (yes/no) of various interventions in their most recent session with an adult patient referred for non-PTSD anxiety (e.g., generalized anxiety, social anxiety, panic, phobias). We used multivariate logistic regression to examine whether provider discipline and theoretical orientation, session type, likelihood of follow-up, and patient age, anxiety severity, depressive severity, comorbid concerns, treatment priority, and anxiety medication were associated with intervention delivery. Providers reported using an average of 5.77 (2.05) intervention techniques. Relaxation training was more likely to be used during initial (vs. follow-up) sessions, whereas cognitive therapy was less likely. Cognitive therapy and behavioral activation were less likely to be used for patients who prioritized treating anxiety (vs. other concerns), whereas relaxation training was more likely. Exposure and Acceptance and Commitment Therapy-based interventions were more likely to be delivered by psychologists (vs. other providers). Overall, PCBH providers seemed to consider the patient’s priorities and likely course of treatment in selecting interventions, but their own training background may also factor in. The presenters and audience will discuss clinical, research, and training implications of the results as well as potential implementation strategies to increase the delivery of evidence-based anxiety interventions in integrated primary care.

Summary

Quality improvement is an area in which healthcare organizations strive to achieve; however, the realities of being in a fast-paced, safety-net primary care clinic often preclude the ability to efficiently evaluate the clinical utility of implemented quality improvement interventions beyond objective statistical measures. Although statistical measures may show significant improvements in outcomes, such as HbA1c scores, these measures may not accurately reflect the amount of labor that was required to affect change, thus calling into question the effectiveness of the intervention and opportunities for improvement. The Plan-Do-Study-Act (PDSA) Model for Improvement is a tool that was developed by the Associates in Process Improvement in order to track a test of change, and is used by numerous healthcare organizations. Although there are several PDSA worksheets available, these worksheets can be confusing to healthcare employees who have not received specific training in this area or lack experience with this process. Furthermore, lacking an advance plan to evaluate a test of change, such as tracking outcome measurements, can significantly increase the amount of time required to determine if the test of change was effective, thereby obfuscating the process of the PDSA in of itself. This presentation aims to provide a brief overview of the PDSA process, while taking a look at innovative methods that were utilized in an integrated family medicine residency primary care clinic to ensure the completion of PDSAs in a time-efficient manner. This presentation will provide PDSA examples ranging from implementation of new behavioral health services to the development of a new job position. Audience members will be encouraged to identify an intervention at their clinic for which they would like to complete and PDSA, recognize potential barriers to the PDSA, and develop solutions for overcoming these barriers.

Summary

Research on Adverse Childhood Experiences (ACE) has demonstrated a significant association between childhood maltreatment and later life health and well-being. Other research has linked the impact of parental trauma and intergenerational trauma. Adults who experienced trauma as children are at higher risk incidence of parenting poorly. Additionally, mothers and fathers who experience postpartum depression are at greater risk for abusing or neglecting their children. The aim of this pilot study was to implement a screening process and intervention to address trauma, anxiety, and postpartum depression in parents with the intent of improving parental well-being. We conducted a brief pilot study implementing ACE, depression, anxiety, child quality of life and social determinants of health screening in our integrated behavioral health and primary care pediatric-focused health home, Jefferson Plaza Family Health Home (JPFHH) in Lakewood, Colorado. Medicaid was the predominant payer at this clinic and almost 50% of the population were of Latinx heritage. This health home is unique in that it is a bidirectional model providing a full range of both mental health services and medical services. The establishment of the health home was made possible by support and funding from the Colorado State Innovation Model (SIM), with the overarching goal of increasing access to integrated physical and behavioral healthcare services. Starting in January 2018, we implemented ACE Questionnaire, PHQ-9 depression screen, Edinburgh Postnatal Depression Scale (EPDS), Generalized Anxiety Disorder Screen 7 (GAD-7), and a self-scaled questionnaire on the Substance Abuse Mental Health Administration’s (SAMHSA) 8 Dimensions of Wellness for the caregivers of infants as part of our intake process. Additionally, the child’s quality of life was tracked using the age appropriate KINDL measure. Parents who screened positive on these tools were offered a variety of services from Jefferson Center, including, but not limited to, behavioral health assessment and education, individual therapy, navigation services, wellness services (health coaching), and family services . Patients received an average of 12 services. Of note, is that fathers who were screened appreciated being asked about their depression and trauma history and welcomed the opportunity to receive supportive services. Assessing and treating parental behavioral health may positively impact child well-being.

Summary

Existing literature has indicated utilizing current care teams marked an improvement in readmission and reduction in emergency department visits. Reducing Emergency Department visits is a system initiative within Geisinger Health System. Being integrated into the primary care setting, data was collected to determine if utilization could be decreased in those utilizing the emergency room for psychiatric related chief complaints (anxiety, depression, psych eval). Motivational Interviewing techniques were used by mental health professionals making the phone calls to patients. Reason for their visit, other options for care, and appointments were offered with the embedded behavioral health professional and/or their PCP. Data has been collected for 1 year to determine the impact of a mental health professional reaching out to those going to the emergency department with a mental health chief complaint. One year post intervention there was a 80% decrease in repeat ER utilization and a 14% decrease in overall ER utilization. There was shown to be a decrease in repeat patients and those using the emergency room and not being admitted for inpatient stays. Pre and post comparison will be included in the final presentation.

Summary

The EHDI is an innovative program that was created through the collaborative efforts of behavioral- and biomedical- healthcare professionals with local leaders (patients, families) in Minnesota’s American Indian community. This workshop will describe the initiative’s interactive, community-based, and educational efforts to engage Native people in addressing contemporary struggles with addition (opiods, ETOH), mental illness (depression, anxiety), obesity and diabetes, and social isolation. These efforts advance a multifaceted approach to reclaiming health-related activities that reflect traditional Indigenous culture(s), food/diet, and family members’ (elders, men, women, youth) roles. Evaluative longitudinal data (quantitative) and qualitative accounts about participants’ experience(s) in EHDI programming will be put forth.

Summary

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Summary

Background/Rationale: Traditional models of psychiatric care delivery have failed to keep up with patient demand. Psychiatrists offer expertise in several needed areas for population health including psychiatric diagnosis, psychopharmacology, access to specialty programming, and in helping to deal with complex medical and psychiatric patients. In primary care settings, behavioral health providers have had to adapt their approaches to the challenges and opportunities in those settings however in adding a psychiatric provider to a primary care team, there may not be awareness of the evidence based options available. We hope to introduce the audience to direct and indirect ways to leverage psychiatric care based on the literature and our own experience. We will include information on involving all psychiatric providers (not just MDs), use of telemedicine tools, the collaborative care model, project ECHO, measurement based care, and how to address financial barriers. Each of us has chosen this work at least in part because we appreciate working with a team involving behavioral health providers and primary care and as such we will highlight ways to make psychiatric providers a part of an integrated team. Our presentation will include the following components: 1. Introduction and overview 5 min Williams 2. Seeing patients – opportunities and challenges 20 min Salter 3. Indirect patient care 15 min Gibson 4. Providing education and decision support 15 min Williams 5. Plan for Suicide prevention a case example 15 min Le 6. Financial realities and recruiting 20 min Raney 7. Questions and answers 30 min Our goal is to describe models that have been tested, are being tested, and practical realities from those doing this work. This presentation is a part of organizing a Special Interest Group for psychiatric providers doing integrated care.

Summary

The fields of family medicine and behavioral health are stepping up to meet the growing demand for providers trained in the provision of team-based, integrated and interdisciplinary, healthcare. Each field has created competencies to guide their respective training programs and help ensure that trainees acquire the necessary skills to function in this collaborative environment. However, much of that training occurs separately, with the behavioral health and medical providers coming together only during the application of those skills to actual patient care. Because of this, each brings their own boxed recipe for patient care that they then must figure out how to mix together. Although some of this is necessary, given the unique value each field has to offer, at times it can lead to half-baked outcomes. When it come to the shared ingredients, what if we started from scratch when the providers are in their required training programs and integrated pieces of their training? Central Washington Family Medicine houses a family medicine residency, a predoctoral psychology internship, and a psychology postdoctoral fellowship. Since the inception of the psychology internship, we set out to integrate as many facets of the training programs that have shared relevance as possible, starting from day one with a robust orientation and community medicine month. In this presentation the psychology internship training director, the chief medical resident, and former psychology intern/current postdoc will review details of the orientation, as well as the other integrated training experiences, and the impact of those experiences. Strategies for implementing or enhancing integrated medical and behavioral health training as well as added benefits, lessons learned, and ethical considerations will be identified.

Summary

As many as 30% of primary care patients suffer from symptoms of depression, and many receive a diagnosis and an antidepressant medication as first-line treatment. People challenged by more social determinants of health are more vulnerable to development of depression symptoms, and they may experience harm from unnecessary use of antidepressant medications. In this presentation, participants will learn alternatives to using a depression symptom screening and prescribing broadly. The first alternative, informed by Focused Acceptance and Commitment Therapy (FACT), has a primary care provider or behavioral health consultant completing a brief functional assessment (love-work-play-health) and developing a behavioral health experiment to improve their quality of life in a first visit for depression. In a small randomized controlled trial, half of the patients that received this intervention were improved at a one-week follow-up. A second alternative is use of the Coping Strategy Use Scale (CSUS), a 6-item measure designed to rapidly identify the patient’s needs for coaching on skills associated with mood improvement. A post hoc analysis of a randomized controlled trial found that patients seen by a behavioral health consultant recommending the skills demonstrated higher rates of use one month after diagnosis, as well as fewer symptoms of depression.

Summary

Research has clearly demonstrated that, irrespective of other risk factors, the presence of a firearm in the home greatly increases the risk of suicide. There is also solid empirical support for deploying means restriction as one of the most effective approaches to prevention of suicide among those who are actively suicidal or in a mental health crisis. Furthermore, we know from research and clinical experience that physicians, nurses, psychologists, psychiatrists, and other providers are very often uncomfortable and ill-equipped to have effective firearm safety and means restriction discussions with at-risk patients. This presentation is aimed at briefly reviewing the research, and then proposing multiple methods for healthcare providers to effectively screen for, discuss, and competently and ethically handle any information related to individuals’ with both suicidal ideation or intent and access to firearms. Interactive activities and role-play will assist providers in practicing the language and interventions to increase confidence and allow attendees to leave with an actionable skill. We will discuss the initial implementation response and data of these recommendations in a multi-center health care network.

Due to the pandemic, the clinic we intended to utilize for gathering pilot data went all virtual, causing significant delays in data gathering. We still have a great deal of information and expertise regarding and discussing this topic, and the l/o’s won’t change. We are hoping to start data collection as restrictions are lifted over the next few months or we may need some way to utilize an online format.

Summary

Professional and family identities are often at odds when physical and behavioral health clinicians become family caregivers for their own ill or aging family members. Those clinicians have special knowledge about their loved ones’ conditions and personalities but feel constrained in expressing their clinical opinions to the treating professionals who may regard them as a welcome resource or potential challenge to their authority. Or, conversely, clinician-caregivers may feel compelled to speak up to advocate for their loved ones and thereby risk multidisciplinary team members’ resentment and avoidance. In this workshop, a family physician, nurse practitioner and clinical psychologist who have recently had experiences as family caregivers for parents with neurodegenerative diseases will share their own and others’ personal experiences and stepwise advice for establishing trust and collaboration with primary care, specialty care and hospital teams.

Summary

The U.S. healthcare system has experienced a paradigm shift in the way it delivers care since the implementation of the Affordable Care Act. Its emphasis on improving the health of the population, enhancing the experience and outcomes of the patient, and reducing per capita cost of care for the benefit of communities (the Triple Aim for populations)1 has created opportunities and challenges for numerous health care entities, especially for those that have not implemented an integrated behavioral health component. Providers have also faced challenges in fulfilling the Triple Aim, leading to calls for a Quadruple Aim that includes a focus on provider well-being.2 The benefits of integrating a behavioral health consultant in the primary care setting are well established. Sixty (60) Jefferson Health primary care practices were accepted into the Center for Medicare and Medicaid’s (CMS) 5-year Comprehensive Primary Care Plus (CPC+) demonstration program (2017-2021). CPC+ selects practices that have demonstrated a solid track record of practice transformation and have demonstrated advanced capacity and readiness for enhanced care delivery. Through CPC+, Jefferson has had the opportunity to rapidly scale up system-wide primary care integrated behavioral health (PCIBH) model.3 This included the hiring and embedding over 25 Behavioral Health Consultants across four regional areas throughout Pennsylvania and New Jersey. Initial outcome metrics have reflected a fundamental transformation in how primary care providers at Jefferson understand and deliver integrated, team-based care within the practices, improved patient outcomes for depression and anxiety as measured by the PHQ9-and GAD7; improved physician well-being and expanded options for long-term program financial sustainability. This approach has fundamentally transformed how team-based care is delivered at Jefferson and could offer valuable lessons to other organizations looking to implement a similar model.

Summary

This session is intended for new and aspiring behavioral health providers working in a primary care medical setting (although we heartily welcome interested colleagues and collaborators across all disciplines). Our panel of behavioral health consultants (BHCs) will provide an overview of 1) the Primary Care Behavioral Health (PCBH; Reiter, Dobmeyer, & Hunter, 2018) model and 2) BHC competencies as defined by Robinson and Reiter (2016), including 3) brief assessment and intervention approaches most useful to a BHC working in primary care. The above will provide some structure to the session, but our primary aim is to allow significant time for Q & A. Our panel includes BHCs with experience working in family practice, pediatrics, and geriatrics, in MAT programs, in both federally-qualified health centers as well as a large private non-profit healthcare organization, and with early experiences implementing a new integrated behavioral health program into a healthcare organization.

Summary

Opioid Use Disorder (OUD) has impacted New Hampshire (NH); in 2016, the overdose death rate was 35.8 per 100,000, almost three times higher than the national rate. The presentation will describe how the Institute for Health Policy and Practice, NH Citizens Health Initiative and the University of New Hampshire’s (UNH) Department of Nursing furthered the work of the NH Behavioral Health (BH) Integration Collaborative with the development of the Partnership for Academic Clinical Telepractice – Medications for Addiction Treatment (PACT-MAT). Eighteen community health care practices throughout NH and 64 students participated in the learning community; PACT-MAT demonstrated a 50% increase in patients’ treatment for OUD and increased provider knowledge and confidence. The presentation will describe “how”to use the project ECHO® model, to link interdisciplinary teams and students developing a reflective and adaptive learning community guided by a continuous improvement approach to identify both clinical practice and policy issues. The presentation will include a community practice site provider who will discuss how they utilized the knowledge and confidence gained through participation to increase access to treatment at their community health center. Building on the integrated care approach, PACT-MAT was the first in the world to incorporate nursing students into an ECHO. The presentation will discuss best practices for onboarding students into this type of teaching modality as well as discussing augmentations to the ECHO format. An integral component of the program was the use of a person-centered approach to care in order to reduce stigma and bias. In addition to didactics specifically addressing stigma and bias, ECHO staff focused on redirecting and modeling language in each part of the ECHO process. Over the course of the sessions, the community developed a culture that understands addiction as a chronic disease and is prepared and capable to address a range of issues, including clinical management, compassion fatigue, stigmatization, and mental health conditions that emerge during the process of treatment. The presentation will share evaluation results and tools used for PACT-MAT to provide a framework for others to build a learning community that advances access to OUD treatment.

Summary

Involving patients and families as partners in their care is an essential component of patient-centered care. However, the lack of evidence-based guidance on how to support patient and family engagement has been a barrier to its widespread adoption. In this presentation, we offer guidance on several best practices for engaging patients and families in their care, emphasizing an interprofessional approach to engagement. This guidance is based on the results of an exhaustive systematic review of 150 collaborative care programs for common mental disorders, as well as a review of recent Canadian and international clinical practice guidelines. The presentation will address the current state of involvement of patients and families in mental health care, describe practical team-based approaches to patient and family engagement, and include an interactive discussion of implementation issues.

Summary

Primary care opioid prescribing for patients with chronic non-cancer pain has increased over the last 20 years, even with a lack of evidence for effectiveness and concerns about long-term safety. High dose opioid prescribing may be more likely in high deprivation areas and long term use of prescription opioids is associated with dependence, addiction, and opioid-related deaths. Primary care patients with chronic non-cancer pain have responded favorably to low intensity interventions promoting non-medication treatment (Kanzler, Robinson, McGeary, Mintz, Potter, et al., 2018; Kesten, Thomas, Scott, Bache, Hickman, et al., 2020). This presentation introduces participants to a low intensity intervention from Acceptance and Commitment Therapy, The Quality of Life Matrix. This approach encourages sustained support of non-medication treatment for patients with chronic pain and continuity among members of the inter-professional team.

Summary

The Primary Care Behavioral Health (PCBH) model is associated with increased access to and utilization of behavioral health services and improved health outcomes. The benefit of an integrated model with racial/ethnic minorities and underserved populations remains poorly documented. However, an integrated model can meet the needs of this patient population by increasing patient contact and facilitating greater identification of behavioral health needs. Among these underserved populations is the rapidly growing, foreign-born Latinx community that endures adverse social/cultural/political factors which disproportionately affect their health and access to care and increase the complexity of their care in primary care settings. Being aware of these factors is critical in meeting their complex needs. Fortunately, inherent in PCBH is an appreciation for the complexity of patients’ clinical presentations and an understanding that symptoms and behaviors do not occur in a vacuum but are a response to contextual factors. Thus, the contextual interview is essential in addressing the behavioral health needs of Latinx patients. However, with such complex psychosocial histories, inexperienced BHCs or those lacking a guiding cultural framework run the risk of missing relevant cultural information, going down a rabbit hole and deviating from the brevity of the model. This workshop seeks to provide clinicians a cultural framework to guide them in executing a more time-sensitive, culturally informed contextual interview. We will introduce the CAMINO framework (Silva, Paris, & Añez, 2017) which emphasizes pre/post-migration experiences. We will guide participants through the integration of this framework into the contextual interview using case examples. A non-validated tool will be introduced to help BHCs apply this framework with patients. Additionally, participants will have the opportunity to engage in a hands-on activity applying this framework to the contextual interview.

Summary

There is growing emphasis on utilizing novel methodological approaches to evaluate the primary care behavioral health model (PCBH; Hunter et al., 2018). In this project, we used mixed methodology guided by a participatory action research framework (PAR; Baum, MacDougall, & Smith, 2006) to examine patient experiences of PCBH at a Federally Qualified Health Center (FQHC) in an urban community. One hundred eighty-six adult patients (M age = 44.2, 72.6% female, 42.5% black) completed a survey, which included general satisfaction with health care (i.e., the Patient Satisfaction Questionnaire-18, PSQ-18; Marshall & Hays, 1994), satisfaction with integrated services at the clinic, and patient experience of integration. Twelve patients also participated in four separate focus groups which sought to obtain more specific feedback on strengths and weaknesses of the clinic’s model of care. The survey data indicated fairly high levels of satisfaction with the PCBH model, as indicated by the PSQ-18 (M = 65.7, SD = 12.1). Race was the only significant predictor of satisfaction. The focus groups were analyzed via thematic analysis (Braun & Clarke, 2006) and 8 themes emerged related to strengths (convenience, affordability, health improvements, positive provider interactions, available resources, overall satisfaction) and challenges (issues with outside referrals, infrastructure challenges). While the quantitative and qualitative data were fairly consistent, the focus group content highlighted portions of PCBH that are particularly relevant to a lower income and higher needs population. The results can also be reviewed within the context of a PAR framework and the attempt to involve community partners throughout the implementation and evaluation process. This project highlights the use of unique methodology to evaluate PCBH with a diverse and underserved population.

Summary

In this presentation, which was supported by CFHA’s REC Fellowship Program awarded to the first author, we will describe an ongoing research project wherein we aim to adapt Wittink’s (2016) Collaborative Care intervention to VA integrated care teams. For this presentation we specifically focus on our methodology and recruitment strategies used to engage busy primary care teamlets (comprised of PCPs and nurses) in qualitative interviews. Engaging clinical providers in research and evaluation is key to using evidence-based methods to inform practice, including the development and treatment evidence-based treatments. However, care providers are among the most difficult individuals to recruit for research and to assist in data collection for evaluations, with primary care clinicians having some of the poorest recruitment outcomes. Though scant, there is empirical evidence describing some of the strategies known to improve engagement with clinical research and evaluation efforts. These include promoting buy-in and interest, developing front-office rapport, identifying champions, recruiting on-site rather than remotely, and using technology when possible. In this presentation, we will add our own experience with recruiting primary care teamlets (comprised of nurse and PCP), front-line admin staff, and administrative leadership in rural, remote clinics for brief qualitative interviews, and provide evidence-based tips and tricks to increasing provider engagement with research and evaluation projects. We will review the literature on the recruitment of busy healthcare professionals, and then describe our tips, tricks, and lessons learned in attempting to employ evidence-based strategies to optimize our study design and recruitment strategies. Participants will leave with a Provider Recruitment Flowsheet and a better understanding of the efforts we all need to take in order to engage key stakeholders in our research and evaluation efforts. We will first briefly describe the Collaborative Care intervention and our research aimed toward adapting it, in order to give the audience a framework to understand our recruitment efforts. Next, we will review the literature on recruiting healthcare professionals for research as well as to assist in evaluation projects, and will introduce the Provider Recruitment Flowsheet that will be developed for this presentation. We will then discuss the specific strategies that we used to enhance recruitment, including a staggered interview question format, use of instant messaging, oversampling, use of recruitment-enhancing informational materials, and in-person recruitment, and the success or failure rate of these strategies in our work. We will finish with a question-answer period and any audience feedback on their own recruitment strategies.

Summary

Social determinants have a major impact on health outcomes, especially for the most vulnerable populations. Factors such as housing, food, transportation, and other social needs must be considered when providing treatment and care. In its work to improve the health of NH residents and create effective and cost-effective systems of care, the NH Citizens Health Initiative partnered with Connections for Health to provide a year-long practice facilitation opportunity for 8 practices in Seacoast NH. The goal was to expand upon the practice’s knowledge and use of quality improvement science to initiate, improve, or maintain their integration efforts. Practices used the Maine Health Access Foundation’s Site Self-Assessment (SSA) tool to evaluate their level of integration and a facilitated strategy meeting occurred at the practice to develop next steps and opportunities for improvement. Connections for Health used those results to request practice-level proposals to offer 12 months of practice facilitation to help move their goals for integration forward. This presentation will highlight the process of one primary care practice. An interdisciplinary care team comprised of a Primary Care Provider, Medical Assistant, and Integrated Social Work Care Coordinator at a primary care office in Seacoast New Hampshire have been working on addressing the social determinants of health of their patient population. The physician champion will share their confidence in addressing patient complexities and the impact these conversations have on the disease burden of their panel. In addition, this team has collected and utilized data to inform decision making and demonstrate the value of an MSW-level, non-billable clinician. It was apparent to the team that without the crucial role of an engaged and motivated Medical Assistant, implementing a change project would prove difficult. This presentation will highlight the importance of fostering a cohesive team-based approach that emphasizes the critical role each professional has on achieving whole-person care. The team has focused on the “how”to implement a SDOH screening process, build an organizational culture that normalizes SDOH as a standard part of care, and connect with organizations within the community to support patients. This presentation will demonstrate the importance of navigating across three scales to create change for their patients: 1). Micro – Screening patients for SDOH; Warm hand-off to Integrated Social Worker to address patient needs, 2). Meso – Building a culture of whole-person care in the organization; Coordination between Social Work and Nurse Care Coordination; Data collection to support QI efforts, and 3). Macro – Connecting with community based organizations via Community Care Team. The presentation aims to share how taking a measured approach to assessment, planning, implementing, and monitoring over time has been beneficial for a primary care practice at all levels.

Summary

The IBHPC study was an implementation and dissemination project funded by the Patient-Centered Outcomes Research Institute (PCORI), of which the goal was to enhance the integration of behavioral health into the primary care setting. The University of California San Diego Lewis Family Medicine Clinic embarked on an ambitious plan to study how to best approach the care of patients deemed “high-utilizers”

Summary

Child corporal punishment has been a widely debated topic in recent decades. Older research indicated that corporal punishment may or may not harm children, depending on the study. More recent research including meta-analyses, however, indicates a clear relationship between corporal punishment and negative outcomes for children. One negative outcome is increased risk of physical abuse. When caregivers have questions about child behavior and discipline, they tend to seek guidance from pediatricians. Over the years, the American Academy of Pediatrics (AAP) has recommended against corporal punishment. In December 2018, however, the AAP released an emphatic statement plainly recommending against corporal punishment because it harms children. This qualitative study explored how primary care pediatricians address corporal punishment, distinguish it from physical abuse, consider culture throughout the process, and whether they feel well-equipped to do so. Five participants, all primary care pediatricians in Oregon, completed semi-structured, in person interviews during mid-to-late 2018. After coding and interpretive phenomenological analysis of data, results revealed caregivers typically bring up concerns about behavior and discipline, including corporal punishment. Results also revealed participants’ guidance to caregivers on corporal punishment varies from participant to participant and from case to case. Participants’ guidance depended on personal and professional views, factors related to caregivers and children, type of discipline, and participants’ interactions with families. Four out of the five participants did not report considering, following, or sharing with families the AAP’s guidelines regarding corporal punishment. Participants reported that distinctions between corporal punishment and physical abuse tend to be obvious, and if a child’s injuries, or other clinical information, raise suspicion of abuse, they notify authorities. Participants all reported their ability to consider aspects of multiculturalism in these cases but have little need to due to the homogenous patient population. Overall, participants reported feeling well equipped to address discipline and physical abuse, broadly, but received less training on corporal punishment, specifically. Furthermore, participants mentioned interprofessional collaboration with behavioral health consultants when addressing child behavior and discipline. Much like the topic of corporal punishment and associated research this study highlights the complex and evolving nature of primary care pediatricians’ guidance to families. Also highlighted is the use of behavioral health consultants in pediatric primary care to address topics of child behavior and discipline. Results from this study point to a need for standardized corporal punishment screening in pediatric primary care and for pediatricians to receive training on guidance on the topic.

Summary

The electronic health record (EHR) is ubiquitous in integrated behavioral health (IBH). Unbeknownst to many, usable data on many dimensions of IBH are already captured in the EHR as a part of routine care. This represents a largely untapped resource for improving data-based decision making in IBH and demonstrating the value of IBH services. Reasons for this disconnect include lack of additional knowledge and skill required to determine how to leverage EHR data for research and quality improvement purposes in IBH. This presentation will illustrate actionable strategies for the practicing clinician to conceptualize electronic phenotypes for EHR data and collaborate with Health Information Technology analysts and researchers at your institution. We will present for 5 minutes on foundational information in a didactic lecture to orient the participant to key concepts in secondary data analysis and electronic phenotypes. We will use 15 minutes to reinforce key concepts using a case example of a retrospective cohort study of a crisis evaluation service in a pediatric IBH setting compared with consults obtained in an emergency department within the same health system. By combining IBH program evaluation data on identified crisis cases with existing EHR data, we learned about key outcomes, including: a) a higher proportion of youth were hospitalized from the IBH service; b) the IBH service demonstrated shorter latency to the next behavioral health appointment; and c) there was higher proportion of IBH patients who engaged with any follow-up treatment in the year after the evaluation. Next, participants will engage in 20 minutes of exercises using a project conceptualization worksheet to develop operational, clinical, and financial indicators available in the EHR, from data that easily captured manually by practitioners, or both. Ample time will remain for questions and illustration, and electronic handouts of these resource and a reading list will be provided.

Summary

The electronic health record (EHR) is ubiquitous in integrated behavioral health (IBH). Unbeknownst to many, usable data on many dimensions of IBH are already captured in the EHR as a part of routine care. This represents a largely untapped resource for improving data-based decision making in IBH and demonstrating the value of IBH services. Reasons for this disconnect include lack of additional knowledge and skill required to determine how to leverage EHR data for research and quality improvement purposes in IBH. This presentation will illustrate actionable strategies for the practicing clinician to conceptualize electronic phenotypes for EHR data and collaborate with Health Information Technology analysts and researchers at your institution. We will present for 5 minutes on foundational information in a didactic lecture to orient the participant to key concepts in secondary data analysis and electronic phenotypes. We will use 15 minutes to reinforce key concepts using a case example of a retrospective cohort study of a crisis evaluation service in a pediatric IBH setting compared with consults obtained in an emergency department within the same health system. By combining IBH program evaluation data on identified crisis cases with existing EHR data, we learned about key outcomes, including: a) a higher proportion of youth were hospitalized from the IBH service; b) the IBH service demonstrated shorter latency to the next behavioral health appointment; and c) there was higher proportion of IBH patients who engaged with any follow-up treatment in the year after the evaluation. Next, participants will engage in 20 minutes of exercises using a project conceptualization worksheet to develop operational, clinical, and financial indicators available in the EHR, from data that easily captured manually by practitioners, or both. Ample time will remain for questions and illustration, and electronic handouts of these resource and a reading list will be provided.

Summary

Sexual health is a complex and often overlooked aspect of overall health. As the entry point to the healthcare system, primary care is an ideal setting for identifying sexual health concerns, and integrated behavioral health providers (BHPs) can assist the primary care team with assessment and treatment. The objective of this study was to assess the prevalence and correlates of sexual dysfunction and examine preferences for discussing sexual problems in primary care. We conducted a cross-sectional survey of a random sample of Veteran primary care patients from 3 VA medical centers across Central and Western New York. Of 1500 surveys mailed, 313 were returned (21% response rate) and 248 had complete data for this analysis. Participants (M age=49 years, SD=13, range: 25-85) were mostly White (87%), female (61%), and married (79%). They completed a brief measure of sexual functioning (Arizona Sexual Experiences Scale) and items on preferences for discussing sexual health concerns. Half of the sample, 32% of men and 62% of women, screened positive on the ASEX for sexual dysfunction, with low sex drive being the most common issue. The odds of sexual dysfunction increased with age. Participants were more likely to agree that, if they were having sexual problems, they would want the primary care team to ask about it (66%) rather than wait until they brought the topic up on their won (33%). Most participants were willing (59% agreed and 27% were neutral) to meet with a BHP to discuss sexual dysfunction if their primary care team recommended it. The preferred format for help with sexual health concerns was a face-to-face meeting with the PCP (33%), followed by a face-to-face meeting with the BHP (17%). Findings suggest sexual dysfunction is common among Veteran primary care patients, especially women and older adults, and patients are receptive to being asked about and discussing sexual health concerns with their primary care team, including BHPs.

Summary

This presentation will detail the development, execution, and evaluation of a collaborative exercise between nursing and counseling students in a small state university. The students used SBIRT and Motivational Interviewing to work collaboratively with simulated patients. Students and faculty were surprised at the different approaches used to achieve the same objectives. The exercise fostered a new understanding of collaboration between students in two different health professions.

Summary

Research has shown the effects of social determinant of health (SDoH) in pregnancy for both the patient and the child; however, the ability to adequately assess for the areas can be difficult. Often in residency, residents struggle to adequately address all the medical and psychosocial needs that can arise during pregnancy; however, family medicine residents are in a unique position to provide integrated prenatal care in a primary care setting. In this presentation, participants will learn how the Alaska Family Medicine Residency (AKFMR) successfully implemented strategies to helped patients receive access to integrated prenatal care in a primary care setting through a biopsychosocial framework. An overview is provided of how AKFMR expanded their OB curriculum to provide prenatal care utilizing a biopsychosocial framework delivered by an interdisciplinary team. Based on the 2016 recommended AAFP guidelines for maternity care, AKFMR used an SBIRT model to implement a maternal psychosocial intake and needs assessment to improve provider awareness of SDoH variables impacting women during their pregnancy and gather baseline mood screening using the EPDS. Based on the information gathered, pregnant patients are offered brief interventions and referrals to appropriate interdisciplinary resources. In addition, an interdisciplinary chart review led by family medicine residents was implemented for all patients between 28-32 weeks gestation to assure prenatal care and increase team communication around patient care and needs. An evaluation of the overall OB curriculum expansion process will include data that has been gathered since August 2016 from maternal psychosocial intakes which includes: demographics, social support system, maternal health risk factors, psychiatric and substance use history, SDoH concerns, lifestyle practices, and an initial perinatal mood disorder screening using the EPDS. Additionally, explanation of how the interdisciplinary OB chart review is conducted and tracked will be reviewed.

Summary

Families are the most powerful and proximal determinant of health prevention, promotion, and disruption across the life course (Haskins et al., 2014). Indeed, the economic value that families provide in caring for their individual members far exceeds that of the medical care system (Leiter et al., 2004). Primary care has been identified as an ideal setting to deliver preventative, family-based interventions (Leslie, et al. 2016). Experts define family health as “a resource at the level of the family unit that develops from the intersection of the health of each family member, their interactions and capacities, as well as the family’s physical, social, emotional, economic, and medical resources”(Weiss-Laxer et al., 2020). However, a standard instrument to assess family health in clinical settings does not exist. To fill this gap, our interdisciplinary team composed of public health researchers, family scientists, mental health providers and a primary care physician developed and validated a Family Health Scale (FHS), based on responses from N=2050 U.S. adults, representing a range of family structures (Crandall et al., under review). In this presentation, we describe the potential clinical application of a 10-item version of the FHS and its four subscales, which include: 1) Family social and emotional processes, 2) Family healthy lifestyle, 3) Family health resources and 4) Family external social capital. An example item includes: “In my family, we help each other in seeking health care services when needed (such as making doctor’s appointments).”A screening instrument assessing family health could be highly valuable in clinical settings where many health outcomes are driven by social determinants. In addition, integrated care providers may benefit from such a scale when developing treatment plans and delivering their holistic care (Berg et al., 2017). Recommendations for applications of the FHS in clinical settings, including opportunities and challenges, will be discussed. Examples will be drawn from the fields of primary care pediatrics, family medicine, and obstetrics.

Summary

BACKGROUND: Effective patient-provider communication is critical to optimizing patient health and well-being [1]. Clinician coaching directly targets these skills [e.g., 2,3]. The current project builds on an established coaching approach used with MD/NP residents in an integrated VA primary care setting. Coaching is delivered by clinical health psychology (CHP) staff and targets: Motivational Interviewing (MI), Shared Decision Making (SDM), and Trauma-Informed Care (TIC). Based on the New World Kirkpatrick training evaluation model [4], the project used previous learner/coaching data [5] and current literature to revise this approach to promote behavioral transfer of skills. METHOD: Population included 24 residents (NP=6, MD=18) who received clinician coaching and feedback from CHP staff during the 2018-2019 academic year. Residents completed a pre-planning session, observation, and coaching in MI, SDM, and TIC. Skills were evaluated on empirically supported checklists. Forms were reviewed by another CHP staff for trends and inconsistencies in ratings and use. Resident satisfaction data were examined. RESULTS: Items observed 100% of the time were removed from the checklists. Low frequency items were starred and coaches are now encouraged to highlight them with residents pre-observation. Residents are now asked to identify an observation appointment where MI is likely to be paramount (e.g., smoking cessation) and one where SDM is likely to be emphasized (e.g., medication changes); TIC continues to be evaluated at all appointments. A self-reflection component was added, prompting learners to rate the extent to which they were guided by MI, SDM, or TIC-based principles during the appointment. The new approach has now been implemented. Formal evaluations will be completed at the end of the academic year. CONCLUSIONS: The updated form/coaching approach, promotion of MI and SDM-specific case selections by residents, and addition of a self-reflection component all serve to support the behavioral transfer of patient-centered communication skills. The presentation will highlight data, present changes, and elicit feedback from conference participants.

Summary

The Primary Care Behavioral Health (PCBH) model continues to garner support and acclaim, and has demonstrated vast potential for not only mental health but also physical health related outcomes. Contemporary focus on PCBH has begun to shift toward the identification of operational efficiencies and the testing of best practice applications in a variety of settings. The purpose of this presentation is to explicate such elements from a unique PCBH model positioned in the context of a medical education setting, linked to HEIDS quality health outcomes, and which is using a continuous quality improvement (CQI) format to provide further innovation. This presentation will specifically explore core components of the project including the inception of an integrated primary care taskforce using Kotter’s 8-Step Change Model, strategies for service evaluation that have linked behavioral interventions to physical health metrics, and examination of new directions in the context of value and time driven activity based costing methods (TDABC). To begin, the presentation will set the context for how PCBH was developed in the novel environment of an internal medicine residency clinic via use of an IPC taskforce. This taskforce utilized models from the business world to expand the work of existing health system’s IPC efforts. Briefly, we will delineate the Kotter’s 8-Step Change Model and discuss how this successfully impacted the framework of our PCBH services. Second, the focus of the presentation will turn to the specific CQI principles employed and the aim of linking health outcomes and IPC interventions. The project included a standard screening process, and provided a number of opportunities to compare pre and post intervention data. Metrics of interest in the presentation will explore readiness to change scores, the iterative effects of PCBH related to successive visits, and comparisons of top physical health outcomes as connected to HEIDs quality metrics and IPC. Concluding, this presentation will highlight developing initiatives for the CQI project including the value stream components of IPC in the education setting. Highlights of this section will explore efforts to utilized contemporary costing strategies such as TDABC, examining value associated with prospective revenue capture, and map both upstream and downstream costs savings.

Summary

Burnout, usually defined as a personal stress reaction of individuals resulting from their perceptions of the workplace, is associated with impaired clinical care, increased attrition and turnover of professional staff, and increased costs for health care systems. For physicians, professional burnout can contribute to broken relationships, alcoholism, and suicide. A high level of burnout is one reason that accounts for high physician turnover and decreased productivity. This presentation will depict an origin story-telling initiative targeted at promoting understanding, collegiality, and a culture of well-being for physicians.

Summary

In 2018, Boulder Community Health (BCH) started a Collaborative Care Management pilot in primary care to better serve patients facing barriers of timely access to behavioral health and psychiatry. Collaborative Care is a population health model addressing barriers of psychiatry shortage by bringing psychiatric consultation into enhanced primary care paired with robust care management. This delivery model leverages existing provider-patient relationships, and people receive services within their familiar and convenient primary care medical home setting at a lower cost than specialty psychiatry. It amplifies scarce resources by allowing providers to consult on a panel of 40 or more patients weekly rather than dedicating 1 hour/patient.

In the first 12 months of implementation, BCH found increases in primary care provider satisfaction and capacity as well as encouraging treatment outcomes for patients. Pre/post staff surveys showed pilot clinics had statistically significant increases in provider and staff ratings of comfort treating behavioral health conditions and increased satisfaction with resources, outreach, and follow up when Collaborative Care was offered.

At the same time, implementation presented many challenges. Provider turnover and a system-wide priority of transitioning electronic medical record systems limited resources and capacity.

During this interactive presentation, social workers will have an opportunity to review patient case studies and dialogue around lessons learned from implementing innovative behavioral health programs within a complex and fragmented health care system.

Summary

In October, 2019, Community Health of Central Washington (CHCW) embarked on a health care journey to improve access to medical and behavioral health care to the students at Davis high school in Yakima, Washington. Yakima is a rural, medically underserved, low income county with 85% of the 2,400 students at Davis high on Apple Health Care. The clinic was opened knowing that funding would continually be a struggle, but that it was the right thing to do, we needed to address the disparity of medical and behavioral health care to the adolescent community. The Davis Health Clinic is a fully functioning medical clinic located inside Davis high school that offers integrated behavior health care to work with patients with multiple adverse childhood experiences (ACE’s) and social determinants of health (SDoH). While our model of care is proving successful within the school setting, we continue to search for ways to expand with limited to no external funding. In this presentation, we will discuss our successes and struggles in opening an integrated health clinic in a rural, central Washington town.

Explaining challenges related to telehealth with adolescents and navigating the challenges of COVID-19 and the school district

Summary

This presentation will use a PDSA framework to illustrate the implementation of an early intervention and secondary prevention initiative for women with postpartum depression and anxiety in rural Nova Scotia. This community based initiative directly fills a gap identified by mothers with postpartum mental health needs, family physicians and public health nurses, and complements office-based primary care and outreach distance interventions. By listening to the women, accessing early treatment protocols and resources from the IWK Reproductive Mental Health Care program, and establishing a stable workforce and specialist collaboration, we have created primary care treatment and secondary prevention that is sustainable and will serve rural women with postpartum mental health needs either sufficiently or until they can access specialized mental health services. This project has provided key learning about the potential spread of postpartum mental health care for rural women across Nova Scotia provided by primary care networks of teams and partners. Now in its fourth year of implementation as part of Primary Health Care services in the Annapolis Valley, the focus is on continued evaluation and patient advice for improvement. The evaluation component is strengthened in 2020 through our partnership with the family medicine residency program as one resident’s community project. The presentation will highlight continued improvement such as our current virtual care option, enhanced emphasis on self-management and the spread of peer support within communities by the women who have attended the program.

Summary

Alaska Family Medicine Residency’s (AKFMR) continuity care clinic, Providence Family Medicine Center (PFMC), is a patient centered medical home located in Anchorage, AK. Identified as one of two safety-net clinics in Anchorage, PFMC primarily serves underserved populations with significant social determinants of health needs and the substantial majority of PFMC’s patients are enrolled in Medicaid, Medicare, or are uninsured. Due to insurer and billing challenges in Alaska, patients often experience barriers in their ability to access mental health and/or behavioral health (MH/BH) services. Multiple surveys of PFMC’s providers and clinic staff identified a gap in terms of their patients’ ability to expediently access MH/BH services, despite the integration of BH providers at PFMC. Prior to this study, PFMC offered MH/BH services through BH consultation — where patients are able to meet with a BH provider during their medical visit — and psychotherapy for 8-12 sessions. However, regardless of these services, PFMC was experiencing similar wait-times, with patients waiting 9-12 months to establish services. Given that research has shown a mode of 1 for MH/BH sessions attended by patients, the authors looked into the single-session models as an evidence-based practice to address this gap, and implemented a single-session/brief intervention (SBI) pilot in addition to the current BH services offered. Based on the success of the pilot, the SBI clinic was implemented in full. This presentation will focus on the implementation process as well as a program evaluation of this clinic. The current sample size is n = 97 and will continue to increase over time. The mean and mode sessions attended was 2, and a 77.14% reduction in the number of patients on the waitlist was demonstrated. Preliminary data analysis is being conducted and paired sample t tests will be utilized to analyze scores on screening measures, such as the PHQ-9 and GAD-7, as well as descriptive statistics analysis for the Session Rating Scale and Outcome Rating Scale.

Summary

Physical symptoms, including chronic pain, that are not linked to organ disease or structural abnormality are the reason for 30-40% of visits to primary care. These medically unexplained symptoms and chronic functional syndromes, collectively known as Psychophysiologic Disorders, have led to development of several new (and related) psychotherapeutic techniques in recent years. These include Pain Reprocessing Therapy, Emotional Awareness & Expression Therapy and Intensive Short-Term Dynamic Psychotherapy. The goal for these is relief of physical symptoms rather than merely helping the patient manage or cope with their condition. A developing evidence base documents the success of these overlapping approaches. These concepts will be introduced with emphasis on PRT and EAET, the evidence base will be presented and the benefits to the quadruple aim of teaching these concepts to behavioral and medical staff will be reviewed. This presentation is a concise, practical version of courses taught in two doctoral programs and many primary care practices since 2013.

Summary

Mazzoni’s “Drop-in clinic” for patients ages 14-24 began as a resource for patients with complex care needs; LGBTQ HIV positive youth who had a difficult time maintaining scheduled appointments and were prone to falling through the cracks and often lost to care. From humble roots we have grown into an interdisciplinary team consisting of medical providers, social workers, psychiatry fellows, lawyers, insurance coordinators and educators. Patients may access medical care, housing supports, legal resources, behavioral health, education re: sexual health and relationships, insurance navigation, food, travel passes and gender affirming services and surgery navigation. Come join us for a panel discussion where we will explore our successes and failures and demonstrate through case examples and data gathered from the past year how this flexible and extensive model creates access to services for underserved LGBTQ youth who might not otherwise engage with medical care and social support services. How does changing the model and working creatively and collaboratively shift who accesses medical care and social support services?

Summary

As Behavioral Health (BH) Integration in primary care settings steadily becomes the standard of care it has never been more important to build up the BH workforce with skilled new professionals ready and able to work such settings. Despite an increasing number of trainees who are interested in receiving training primary care settings, there is a dearth of competent clinical supervisors to execute this task. Therefore, it is imperative to support clinical supervisors in order to mitigate this imbalance. The purpose of this presentation is to provide a clinical supervision primer for those who currently serve as clinical supervisors or who plan to provide clinical supervision to BH trainees in the primary care setting. This presentation will review evidence-based clinical supervision approaches, the differences between clinical supervision in mental health settings versus primary care settings, the infusion of evidenced-based teaching practices from medical education into clinical supervision for behavioral health trainees, and the importance of understanding macro versus microsystem issues that occur within clinical supervision in primary care settings. Qualitative examples from a current HRSA Behavioral Health Workforce Education Training Grant will be discussed as well as recommendations for supporting community-based clinical supervisors as well as faculty members who serve as clinical supervisors from training programs.

Summary

As applications and accomplishments of the Primary Care Behavioral Health (PCBH) model proliferate (Reiter, Dobmeyer & Hunter, 2018), possible contributions of a family systems perspective in this arena seem conspicuously absent. Understandably, population health priorities such as accessibility, high productivity, and brief, team-based episodic care may leave little time for systemic formulations of problem maintenance or interventions that target social units and processes beyond the patient. Here we describe an adaptation of strategic-systemic family consultation (FAMCON), originally developed as a specialty approach for change-resistant health and behavior problems (Rohrbaugh & Shoham, 2011, 2017), to primary care. Stepped FAMCON complements the pragmatic, time-efficient PCBH model by reserving family involvement for complaints that do not respond to first-line individual-focused medical or behavioral interventions. This generalist approach addresses behavioral aspects of chronic medical conditions (e.g., non-adherence to diabetes regimen, unexplained physical symptoms) as well as persisting behavioral complaints (e.g., depression, anxiety, SUD). It also (a) formulates problem maintenance, including helper involvement, in a systemic framework not dependent on psychiatric diagnosis; (b) optimizes indirect (non-prescriptive) behavioral intervention framed as assessment; (c) leverages PCP influence to promote patient/family engagement and adherence to behavioral interventions; and (e) enhances response to post-consultation follow-on procedures, including evidence-based individual interventions. FAMCON embodies the systemic themes of circularity (locating problems in current cycles of interaction), context (looking beyond the patient), and pattern interruption (breaking problem-maintaining cycles), with key constructs including ironic processes (when ‘solutions’ maintain problems), symptom-system fit (when problems stabilize relationships), and communal coping (when ‘we-ness’ facilitates change). Procedures include a warm handoff meeting with PCP and systemic BHC followed by 30-60 minutes with BHC; an assessment phase consisting of 1-4 BHC meetings with patient and family members; an opinion/feedback session incorporating observations and recommendations, both medical and behavioral; and a PRN follow-up phase adjusting strategies and tactics to patient/family response. During the assessment phase, with indirect intervention framed as assessment, the BHC remains overtly neutral about behavior change, offering no direct suggestions or advice prior to the opinion/feedback session with the PCP. In addition to highlighting exportable clinical tools (e.g., social network interview; family engagement scripts; communal coping intervention; assessment and opinion planning templates), we discuss promises and pitfalls of stepped FAMCON in light of recent pilot work by first author MR in the rural Virginia primary care practice of third author CM.

Summary

Background. Child health practitioners and managers frequently support recommendations to screen for and provide social determinants of health (SDOH) resources to families. They also report reluctance to implement screening guidelines because they perceive community services to be limited or unavailable. Thus, forging effective partnerships across health care and community service systems is a promising, but still little understood, tool for addressing SDOH. Methods. This paper reports findings from one component of a mixed methods, longitudinal study of nine pediatric health care clinics in five U.S. communities implementing innovations to address SDOH among families of infants. The study reports the results of interviews at two time points with early childhood organizations and health care providers overseeing the innovations. In interviews (n = 60 at t1, n = 18 at t2), participants reported on their partnerships between community service systems and health care; experiences implementing screening, referral, and linkages in pediatric primary care; and key aspects to sustainability. We analyzed qualitative interviews thematically and developed cross-site summaries of emergent findings. Results. Early childhood and health care participants reported that embedding screening in pediatric health care, that includes team-based care, yielded important cross-sector knowledge that did not exist prior to implementing the innovations. Participants also said that the lack of clear financial mandates for the work influenced sustainability, as did a lack of role clarity about which system supported families to support access to community services. Implications. Screening, referral, and linkage for SDOH has promise to increase access to resources for individual families and as well as inform local and state advocacy efforts. However, current funding models, infrastructure, evidence, and will among leadership pose important constraints on scaling innovations to address SDOH.

Summary

This is a 60-minute oral presentation for the research and evaluation track. It reviews the distinct value of the single case research design before delving into various methods of using this research strategy across various real and hypothetical data sets. Because there is such rapid change in our healthcare system, healthcare and community stakeholders need feasible and accessible methods for analyzing the outcomes of programs and treatments including complex patients and those tapering off of opioids. Since there is a scarcity of research on how to influence the social determinants of health, the single case design uniquely offers the most immediate way to demonstrate positive change in an individual or system in a short amount of time. This means that community leaders or various healthcare and nonhealthcare agencies within a system could use these tools to measure their program or intervention. Likewise, the methods can be used by physicians or behavioral health providers at the clinic level. Finally, the author presents data on how this research methodology can be used at the system level to make programmatic decisions about meeting the needs of patient populations. Learners will ascertain information about how to conduct these analyses upon completing the session (e.g., the basics of analyzing trend, level and variability on linear charts; using reversal and withdrawal designs and conducting analyses on the standard celeration chart).

Summary

This is a 60-minute oral presentation for the research and evaluation track. It reviews the distinct value of the single case research design before delving into various methods of using this research strategy across various real and hypothetical data sets. Because there is such rapid change in our healthcare system, healthcare and community stakeholders need feasible and accessible methods for analyzing the outcomes of programs and treatments including complex patients and those tapering off of opioids. Since there is a scarcity of research on how to influence the social determinants of health, the single case design uniquely offers the most immediate way to demonstrate positive change in an individual or system in a short amount of time. This means that community leaders or various healthcare and nonhealthcare agencies within a system could use these tools to measure their program or intervention. Likewise, the methods can be used by physicians or behavioral health providers at the clinic level. Finally, the author presents data on how this research methodology can be used at the system level to make programmatic decisions about meeting the needs of patient populations. Learners will ascertain information about how to conduct these analyses upon completing the session (e.g., the basics of analyzing trend, level and variability on linear charts; using reversal and withdrawal designs and conducting analyses on the standard celeration chart).

Summary

Background: Integrated primary care for opioid use disorder (OUD) increases access to addiction treatment in rural and urban communities. By reducing stigma, providing medication assisted treatment (MAT), and addressing medical, behavioral and social complexity, primary care contributes to the addiction care continuum. We describe preliminary successes and challenges of a collaborative initiative to support primary care practice implementation of integrated care for patients with OUD. Population: Patients with OUD at participating primary care practices across 7 Pennsylvania counties. From 2015-18, the area saw increasing overdose deaths, driven largely by fentanyl, rising hepatitis C infections, high burden of chronic pain, unintended pregnancies, and limited access to behavioral health and addiction services. Study Design: Combined narrative and case series describes partner engagement to build a coordinated support system for primary care, practice experiences, and patient outcomes. Procedures: Descriptive data about development of the model collected through participatory narrative process. Practices mapped to describe integrated care processes Background: Integrated primary care for opioid use disorder (OUD) increases access to addiction treatment in rural and urban communities. By reducing stigma, providing medication assisted treatment (MAT), and addressing medical, behavioral and social complexity, primary care contributes to the addiction care continuum. We describe preliminary successes and challenges of a collaborative initiative to support primary care practice implementation of integrated care for patients with OUD. Population: Patients with OUD at participating primary care practices across 7 Pennsylvania counties. From 2015-18, the area saw increasing overdose deaths, driven largely by fentanyl, rising hepatitis C infections, high burden of chronic pain, unintended pregnancies, and limited access to behavioral health and addiction services. Study Design: Combined narrative and case series describes partner engagement to build a coordinated support system for primary care, practice experiences, and patient outcomes. Procedures: Descriptive data about development of the model collected through participatory narrative process. Practices mapped to describe integrated care processes and partnerships as they enroll in project. Practice experiences described through team debriefs and training evaluations. Patient data re behavioral/addiction diagnoses, interventions, engagement and effectiveness at each location collected through electronic health records and from structured intake and follow up interviews. Results: Key practice/system parameters, team roles and support measures that facilitate/inhibit change, preliminary patient outcomes.

Summary

In 2015 there were 136.9 million visits to the Emergency Department (ED) in the United States equaling 43.3 visits to the ED per 100 persons for that year. This number represents a substantial increase in ED usage in this country, outpacing population growth. As a result of the increasing number of annual ED visits, the Institute of Medicine described the state of emergency care in the U.S. as “at the breaking point”

Summary

The integration of behavioral health providers (BHPs) in general hospital settings is potentially advantageous because hospitalized patients can have complex care needs and have high rates of psychosocial problems. However, there is a paucity of literature on the topic, including best practices for integrating BHPs and outcomes generated by inpatient BHP treatment. We will describe findings from our scoping review of the literature on BHPs in general hospital settings. Attendees will learn about the results of the scoping review including common collaborative practices and communication strategies. Presenters will describe multiple facilitators and barriers to BHP integration and will discuss the wide varieties of problems treated by BHPs and their extensive array of treatment modalities. The lack of outcome data and patient and providers perspectives reported in the literature will also be highlighted along with ideas about strategies to fill this gap. Using extant literature, presenters will highlight factors that may guide BHPs practicing or interested in practicing in general hospital settings. Hospitalized patients frequently have very complex biopsychosocial-spiritual needs. Thus, the focus of this presentation is directly in line with the conference theme. Presentation content will be applicable to a wide audience; especially providers and administrative professionals whose roles have or will include work in the hospital setting.

Summary

Providing high quality services consistent with the Primary Care Behavioral Health (PCBH) model requires professionals to develop a new professional identity and to master a broad range of skills over a sustained period of time. In order to train others effectively, Behavioral Health Consultant (BHC) trainers need to demonstrate excellent in clinical, consultation, team-based care, and practice management competencies and to learn to be effective teachers. Presenters include three BHC trainers who have worked together in a 3-year project to develop Primary Care Behavioral Health services for a diverse country with a primary concern of achieving health equity. They will introduce a tool for training PCBH trainers and detail lessons learned about training trainers.

Summary

Introduction: Polypharmacy, medication costs, and physician burnout are complex issues at the forefront of American healthcare delivery.1-3 An Ambulatory Pharmacy Program (APP) can help as pharmacists are poised to assist with precisely these issues and remove barriers that providers and patient encounter when navigating the prescription drug market.4-5 This solution can be costly to initiate for already cash-strapped healthcare entities but with value-based, population health movement in full swing, it may not be out of reach. A Medicare demonstration project called CPC+ focuses on evolving primary care teams and encourages pharmacy integration. CPC+ enables infrastructural innovation through grant funding that created the APP.6 Method: The APP was designed to cover nearly 60 practices with three pharmacists. EMR workflows were designed to enable pharmacists to receive referrals directly from providers and nurse care coordinators. Clinical documentation mirrored the Pharmacy Quality Alliance’s (PQA) Medication Therapy Problem Categories Framework to streamline and standardize care delivery. The PQA focuses documentation on medication indication, effectiveness, safety, and adherence. Pharmacists readily use clinical and payer data to evaluate their impact using standardized metrics and payer reports. Initially, program success metrics were process-oriented but have since evolved to evaluate clinical quality outcomes. Results: APP measures include evaluations of process, interventions employed, and clinical outcomes, like Hemoglobin A1c trends in pharmacist-managed diabetics. Discussion: Pharmacists have been able to assist patients and providers through a variety of medication-related issues. Medication expertise, along with the ability to manage chronic disease states, are essential to reduce medication-related costs, and provide the most safe and effective medication therapy management to the patient.

Summary

The objective of this session is to share outcomes from effective team-based practices that particularly benefit older adults with complex combinations of medical, functional, social, and psychiatric factors that often cannot be fully addressed with fast-paced outpatient visits. The help attendees identify ways they can collaborate with other team members as well as patients to address complex issues, particularly in the era of COVID-19.

At Iora Health, the structure of in-office visits and definition of care team member roles allow for deeper relationships with patients and understanding of their needs. Behavioral health staff, nurses, medical providers, team nurses, and health coaches work together via multiple collaborative efforts to identify patients with complex social needs, medical conditions, and behavioral health concerns and then address them in a patient-centered, team-based manner. Using several approaches to risk stratification, team members focus on patients at highest risk of hospitalization or increased morbidity and mortality. At regular intervals, team members develop a care plan to address social determinants of health, and provide the necessary level of medical and behavioral health intervention. Focus on advanced care planning and clarifying patient wishes for medical decision-making and end-of-life care helps care teams honor patient values and wishes, particularly in transitions between outpatient, hospital, and institutional settings.

In the session, presenters will review team-based processes that have been effective, and then work through case vignettes as small groups with discussion as a larger group to learn to apply a patient-centered, team-based lens to stratifying patient subpopulations, identifying social determinants of health, and planning team-based collaborative follow-up.

Summary

Within primary care, children only come through the medical office door one time a year for well child checks or if there is a problem. Although some speciality clinics may see children and teens more than once a year, these visits are often focused on complex symptom management and care among different specialities. The majority of children’s time is spent in the school environment. However, school is a complex system that is often difficult for parents to navigate on their own, which may lead to a disconnect between family and school. This often leads parents to reach out to medical providers first if they are concerned about school difficulty. Sometimes, school staff even request that children see their pediatrician or present proof of a medical diagnosis if there is a concern. Some school concerns that families often share include: learning difficulties, behavioral concerns at school, difficulty concentrating, anxiety and school avoidance, fatigue, and sleep concerns. Often medical providers may feel ill-equipped to manage these concerns and systems (Burka, Van Cleve, Shafer, & Barkin, 2014). With the integration of behavioral health in primary care and speciality clinics it reduces some of the burden on medical providers to help navigate school difficulties and concerns that the family may share and help improve student functioning. Integrated behavioral health providers with school psychology training have an advantage in helping pediatricians and families navigate the complexities of the school system given their experience with multi-disciplinary collaboration and their understanding of academic and behavioral supports. Presenters will discuss important school jargon, legal considerations for care coordination communications, and methods of connecting with school systems as behavioral health providers within integrated settings and a school-based mental health clinic. Successes and barriers to collaboration with school settings will be discussed.

Summary

Publishing work in a peer-reviewed journal disseminates ideas widely and can contribute to the evolution of the field. This interactive workshop, facilitated by the Co-Editors, will engage researchers in co-producing impactful research for publication in Families, Systems, & Health. We will define the opportunity to advance integrated care science through the journal, share exemplars that highlight the journal’s strategic direction, distill themes the editors have encountered in handling submissions from experienced authors, and identify practical strategies for success. Participants will workshop one manuscript that they are working on (which may be at any stage of development) that they might shape for submission to FSH. Finally, they will also have an opportunity to provide the Co-Editors feedback on what would make FSH their journal of choice for disseminating leading edge research on effective integrated care interventions.

Summary

Publishing work in a peer-reviewed journal disseminates ideas widely and can contribute to the evolution of the field. This interactive workshop, facilitated by the Co-Editors, will engage researchers in co-producing impactful research for publication in Families, Systems, & Health. We will define the opportunity to advance integrated care science through the journal, share exemplars that highlight the journal’s strategic direction, distill themes the editors have encountered in handling submissions from experienced authors, and identify practical strategies for success. Participants will workshop one manuscript that they are working on (which may be at any stage of development) that they might shape for submission to FSH. Finally, they will also have an opportunity to provide the Co-Editors feedback on what would make FSH their journal of choice for disseminating leading edge research on effective integrated care interventions.

Summary

As the treatment model for chronic/relapsing substance use disorders in the United States continues to shift from episodic treatment to continuing care, primary care is uniquely positioned to serve those struggling with Opioid Use Disorder, both with Medication Assisted Treatment (MAT) and with the support of Primary Care Behavioral Health (PCBH). The CentraCare Family Health Clinic adopted the PCBH model in the fall of 2015 and began prescribing buprenorphine-naloxone for Opioid Use Disorder in the summer of 2016. As the programs developed and grew concurrently, behavioral health providers have been involved with the MAT program since its beginning. Since 2016, the program has grown from one waivered prescriber to six, along with a group of 11 second- and third-year family medicine residents, increasing the need for structured support. The next phase in our program is to adjust policy, practice, and workflow in our clinic to further integrate behavioral health providers into MAT. This presentation will focus on the current literature around behavioral health support of MAT, the need for a greater base of evidence-based practice, and the progress that one clinic has made in utilizing MAT and PCBH to address the opioid crisis. It will also invite open conversation amongst attendees to promote learning through shared experiences. Special consideration will be given to the implications for rural communities – both through the training of Family Medicine residents, many of whom will further their careers in rural clinics, and the utilization of established tele-IBH services within our organization’s rural clinic settings.

Summary

Pregnancy and childbirth is one of the most biologically, socially, and psychologically complex periods in a woman’s life (Anda, 2010). Carrying an infant in the womb is made even more difficult if a mother has endured her own trauma, potentially transmitting a vulnerability to her child’s development through maternal behavior and emotions (Hudziak, 2018). Additionally, the transition to parenthood is a general life stressor which often activates her attachment system. Symptoms of depression, anxiety, and trauma may also interfere with her ability to bond with her child (Main, 2000). Although the complexity of pregnancy and motherhood can be daunting, a mother’s resilience may mitigate the impact of these risk factors. Resilience involves being able to face challenging circumstances while also maintaining a positive mental health status (Steen, 2015). This study seeks to describe the risk of adverse birth outcomes associated with antenatal trauma and insecure attachment, as well as the impact of resilience through the incorporation of a resiliency-based intervention early in pregnancy. The intervention will target the risk of developing mood symptoms, identify positive coping strategies and highlight meaningful resources. Participants include expectant mothers in their first trimester at a rural obstetric healthcare clinic enrolled in a “New Mom’s”class. While attendance is not required, all newly expecting women enrolling in the clinic for obstetric care are strongly encouraged to attend. Mean age of participants is 28.1 years (SD = 2.03) with 44.4% of participants including first time mothers. Study design: A quasi-experimental design due to the inability to use random assignment. The study looks to assess the feasibility and acceptability of a multidisciplinary group visit to address health behaviors, presence of emotional health concerns, assess for risk of adverse experiences and initiate resiliency development for pregnancy health. Methods: Participants will complete the following measures before the class begins: Adverse Childhood Experience Questionnaire, Revised Adult Attachment Scale, the “New OB: Women’s Health History form including the Edinburg Depression Scale, and the Integrating C.H.A.N.G.E. pre-assessment. Participants will attend a 90min new mom’s class covering medical and emotional concerns associated with pregnancy, and the role adverse childhood experiences can play in coping and emotional wellbeing. Participants will complete a newly developed resiliency-based intervention (My C.H.A.N.G.E. Plan) to identify positive and protective coping strategies that they can use to support biopsychosocial wellbeing both during and after pregnancy. While early in the pilot phase, physician, clinic and patient feedback has been overwhelmingly positive. At the conclusion of the intervention, 100% of participants strongly agreed that they would access behavioral health services to support their perinatal healthcare.

Summary

Some of America’s most important debates were contested in Philadelphia. In that tradition, we present 3 debates at the heart of integrated care. We will strive for robust empiricism, but might settle for strong rhetoric where we lack solid data. Regardless, you will leave informed of the latest science and most relevant policy advances. As participants in an emergent and largely untested healthcare model, our leaders and practitioners face daily quandaries for which we lack data for making an informed decision. By convening the leading researchers and thought leaders of our field, we aim to shed light on some of the most important dilemmas. These will be actual debates using recent research and important policy advances for supporting arguments. They will be adjudicated by the audience and the debater who made the most compelling case will be awarded a signed copy of his or her opponent’s most important literary work. DEBATE 1: IS TRAUMA-INFORMED CARE AN EVIDENCE-BASED PRACTICE? In the years since the publication of the ACEs research, trauma-informed care has brought major re-consideration to our clinical environments and services. While the client-centeredness of these changes is not in dispute, can it be said that the scientific literature endorses these approaches as evidence-based practices? Cara Pozun will debate the affirmative, Stacy Ogbeide the negative. DEBATE 2: ARE THE PHQ AND GAD OVER-UTILIZED? No quality metric has been more widely adopted than universal screening for depression, with screening for anxiety often done concurrently. We rely on the 2/9 AND 2/7 to identify need and assess outcomes. And yet, the United States Preventive Services Task-Force is mixed in support of their utilization. Additionally, as they are so embedded into EMRs, they crowd out other tools that might be more useful. Deepu George will debate their prominence is merited and CR Macchi will counter that they are over-utilized. DEBATE 3: DOES THE EMR INHIBIT OR FACILITATE COLLABORATION? Few innovations have changed healthcare more than the EMR. This revolution has brought many advantages (easy access to records, metrics and data, asynchronous communication), they have also disrupted much of what clinicians value most in their careers (human interaction, efficiency, unimpeded time away from work). What has been the overall impact of the EMR on interprofessional collaboration? Paul Simmons will highlight the benefits of the EMR and Barry Jacobs will convince us of the challenges. Each debate will last approximately 15 minutes, with 4 minutes for each of the opening statements, 2 minutes for each rebuttal, and 1 minute for closing statements TIMELINE: :00 – :05 Welcome and introduction of format :05 – :20 Debate 1 :20 – :35 Debate 2 :35 – :50 Debate 3 :50 – :60 Group discussion of the current status of the integrated care evidence-base and presentation of awards.

Summary

Background: Depression is the most common mental health condition with prevalence rates ranging from 8-14% in primary care (PC) settings [1]. While evidence-based treatments are available, access to these services can be challenging. Moreover, many patients do not attain remission and are vulnerable to a relapsing-remitting course [2]. Consequently, there has been a call for increased services in PC [3]. While collaborative care programs have been shown to help patients achieve and maintain remission over time, they have not yet been employed on a national level [4]. This presentation details an integrated care coordination (ICC) program for depression delivered in PC, focusing on lessons learned over time to improve future implementation and expansion efforts. Methods: Multiple iterations of the ICC program have been employed. Across iterations, nurses serve as the primary liaison between patients and providers to enhance engagement and enhance engagement in evidence-based care. Psychiatrists provide weekly supervision and consultation to a panel of depressed patients. Qualitative information about the program was obtained from multiple stakeholders. Results: In all iterations, there has been a focus on training and supervision to ensure fidelity. The first iteration was a quality improvement process and the second iteration was the Depression Improvement Across Minnesota, Offering a New Direction (DIAMOND) program. Both exemplified the importance of obtaining reimbursement for sustainability. The third, fourth, and fifth iterations included depressed patients diagnosed with anxiety disorders, bipolar disorder, or medical conditions respectively. In these iterations, it was challenging to standardize services, define outcomes, and determine readiness for discharge. Consequently, the DIAMOND program foundations have been re-implemented. Conclusion: The ICC program has been integral to serving the needs of the PC population. Lessons learned include identifying clear measures and workflows, establishing evidence, maintaining fidelity, reporting outcomes, and collaborating with stakeholders for sustainability, which have been echoed in the literature [5]. These lessons have informed efforts to improve and expand the ICC program across a wider region, especially clinics in rural areas.

Summary

Medical and mental health professionals are among the top five professions who are most prone to burnout in the United States. Burnout is characterized by emotional depletion and loss of motivation resulting from prolonged exposure to chronic emotional and interpersonal stress. Burnout among helping professionals is associated with poorer quality of healthcare delivery and reduced patient safety. Efforts to address workplace burnout have been mixed. One challenge often reported is finding effective interventions that fit the needs of a busy clinical setting that has limited time for broad-based staff training. One model that has received increased attention over the past decade is the Community Resiliency Model (CRM). CRM is a 30-hour low dose guided self-help intervention aimed at teaching health workers a set of skills geared toward increasing resiliency and reducing distress both of which are significant components of burnout. Previous use of the CRM model has focused on first responders working in the aftermath of disaster and traumatic situations. However, in this study, the Community Resiliency Model (CRM) training was adapted into a single 3-hour session training session with an additional 1-hour booster session delivered 3 months after the initial training. The training focused on the same six CRM skills that have been found to promote individual resilience and stress reduction. Participants included nurses, social workers, physical therapists, residents, and other care providers. Respondents were ethnically diverse and primarily female, highly educated, and married. An adapted version of the Physician Vitality Measure (PVM) 4-item burnout subscale was used to measure burnout. Paired sample t-tests were conducted to explore differences between the pre and immediate post and the pre and after booster posttest burnout scores. Although there were no significant mean score differences between the pre and after program post-test, there was a significant decrease in burnout and perceived stress scores between the baseline and after the booster session. Our results suggest that a low dose resiliency intervention that teaches wellness skills is a promising and sustainable approach that fits within the demands of clinical settings and can be used to address perceived stress and burnout among helping professionals.

Summary

National figures estimate that over 83% of people who died by suicide saw their primary care provider at least once within the year prior to their suicide death.1. In order to address this most preventable cause of death and with the goal of integrating behavioral and primary care, the Health System has implemented the Zero Suicide model. This evidenced-based approach aims to raise awareness, establish referral processes, and improve care and outcomes for the complex care needs of patients at-risk for suicide.2 As the mandated safety net hospital system for the region and a Level 1 Trauma Center, Bexar County Hospital District, dba University Health System, serves 22 counties through its teaching hospital and ambulatory clinics. University Health System is implementing a comprehensive, multi-setting suicide prevention and intervention approach under the framework of the seven essential elements of the Zero Suicide Model. This workshop will review the Zero Suicide model to include organizational assessments measuring primary care staff competencies related to suicide prevention and care. Additionally, we will review evidenced-based trainings related to screening (Patient Health Questionnaire – PHQ 3/9), assessment (Columbia Suicide Severity Rating Scale – C-SSRS), best practices (Question, Persuade, Refer – QPR3), and treatment interventions (Collaborative Assessment and Management of Suicidality – CAMS4 & Counseling on Access to Lethal Means – CALM5). This innovative approach of the Zero Suicide model is one of the first applications to implementing a comprehensive, universal, suicide prevention program across a regional health system. As a safety net hospital, our primary population encounters complex social needs which can best be addressed by strengthening integrated primary care services. To remain relevant and sustainable, the Health System has incorporated feedback from leadership, community members, leading agencies/organizations in suicide prevention, survivors of suicide, and crisis organizations. We will present findings on barriers to implementation including resistance to change within the system, lack of knowledge and positive attitudes towards suicide prevention, and the efforts made to address these issues.

Summary

More than twenty years of research has confirmed a relationship between Adverse Childhood Experiences (ACEs) and poor health outcomes. Associations of ACEs and future suicide attempts, problematic drug use, sexually transmitted infections, mood and anxiety disorders, and respiratory disease are particularly strong. In response to this finding, primary care stakeholders have proposed screening children and adults for ACEs. Unfortunately, the impact of these screening programs on health outcomes has not been well established. As with all screening programs in primary care it is necessary to establish the expected benefits and potential harms of ACEs screening, prior to establishing policies and workflows for routine screening. This presentation will briefly review the evidence and gaps in evidence associated with universal and targeted screening for ACEs. The evidence for primary care interventions for addressing ACEs will also be reviewed. Small and large group discussions will clarify the expected benefits and potential harms associated with screening for ACEs. The presentation and discussions will explore the relative risks and benefits of screening for ACEs in adult vs. pediatric populations. Additional considerations, for clinicians working in diverse settings with diverse populations. Finally, the presenters will compare and contrast a universal education approach to addressing trauma with a screening approach to identify patients with ACEs.

Summary

This workshop exemplifies ways to maximize the use of the assessments you already collect to inform treatment planning and progress monitoring. Too often, assessments are required by administrators or reporting agencies which are not implemented in ways which help inform individuals at the point of care. When this happens, assessments feel like an unnecessary burden to staff and individuals and the information collected suffers in quality and consistency. The burden is even greater in rural communities where assessments are often captured on paper. It is important to make sure that the individuals who contribute to and collect assessment information find value for use of the information being collected so that they invest in the quality of that information for their own goals. Nobody wins if we use valuable time to fulfill administrative requirements which are not found useful in practice. Many of the assessments we use in the field were developed and validated in research settings. While research implements measures for the sake of research, practice need implement measures for the sake of practice. The measures we found helpful in research must be transformed into tools for practice without changing the validity and reliability of the assessment itself. Research often uses measures to evaluate performance after the program is complete. However, in practice we must consider ways in which we can implement these tools to inform practice during practice. This workshop presents specific examples on different ways in which assessment information you already collect can be meaningfully used within an individual’s period of care in addition to building a knowledge base within and across programs. The workshop will discuss the use of assessments to inform level of care determination, capturing an individual’s story of need and strength, and identifying staff strengths and training needs to increase staff success and retention. The workshop will provide examples of how to test and measure effectiveness of existing level of care algorithms for success in placement. I will demonstrate how assessments can be used to visualize an individual’s story and share information across a multidisciplinary team. The workshop will explore simple approaches and solutions as well as provide an overview of more advanced data visualization and machine learning techniques, as applicable to the task.

Summary

This workshop exemplifies ways to maximize the use of the assessments you already collect to inform treatment planning and progress monitoring. Too often, assessments are required by administrators or reporting agencies which are not implemented in ways which help inform individuals at the point of care. When this happens, assessments feel like an unnecessary burden to staff and individuals and the information collected suffers in quality and consistency. The burden is even greater in rural communities where assessments are often captured on paper. It is important to make sure that the individuals who contribute to and collect assessment information find value for use of the information being collected so that they invest in the quality of that information for their own goals. Nobody wins if we use valuable time to fulfill administrative requirements which are not found useful in practice. Many of the assessments we use in the field were developed and validated in research settings. While research implements measures for the sake of research, practice need implement measures for the sake of practice. The measures we found helpful in research must be transformed into tools for practice without changing the validity and reliability of the assessment itself. Research often uses measures to evaluate performance after the program is complete. However, in practice we must consider ways in which we can implement these tools to inform practice during practice. This workshop presents specific examples on different ways in which assessment information you already collect can be meaningfully used within an individual’s period of care in addition to building a knowledge base within and across programs. The workshop will discuss the use of assessments to inform level of care determination, capturing an individual’s story of need and strength, and identifying staff strengths and training needs to increase staff success and retention. The workshop will provide examples of how to test and measure effectiveness of existing level of care algorithms for success in placement. I will demonstrate how assessments can be used to visualize an individual’s story and share information across a multidisciplinary team. The workshop will explore simple approaches and solutions as well as provide an overview of more advanced data visualization and machine learning techniques, as applicable to the task.

Summary

This seminar will explore and discuss the toxicity in FQHCs, racial enactments and the process of decolonizing practice, agency, and leadership. Through an interactive healing-centered approach, participants will learn about colonialism and critical theory frame works, develop understanding decolonization as a practice tool and philosophy towards liberation practice, and will create a community with one another through storytelling and processing past experiences and struggles with power, subjugation, and the non-profit industrial complex. This seminar will deconstruct concepts like productivity, gatekeeping, organizational gaslighting, exploitation of the other, and the profits over people mindset that has plagued many of our community-based agencies and discuss white supremacy, racism and the internalized colonizer syndrome (Villanueva, 2018). The seminar will end with healing-centered exercises to allow for participants to use developmental frame works, behavioral frameworks and decolonizing theory to find meaning, connection, belonging and action that is aligned with the individual’s true subjectivity. This seminar is meant to be a beginning of an unapologetic conversation about the profession, power dynamics, and liberation in integrated health care.

Summary

As medical organizations continue to adapt to the ever-changing healthcare landscape, quality improvement initiatives are vital for these organizations to meet patient needs, quality metrics, and financial demands. Indeed, one would be hard-pressed to find a health center that does not have a department and/or significant resources related to quality improvement (QI). Integrated behavioral health providers (IBHPs) are in a unique position to support health centers in this realm, as many IBHPs receive extensive training in research and program design, survey development, and statistics. However, there appears to be a lack of acknowledgement regarding an IBHPs vital role in QI projects and even a greater lack of specified training during clinical internships and fellowships for future IBHPs in the QI process. Often, IBHPs may not even consider QI as part of their role. This presentation will give an overview of how a teaching health center (Community Health of Central Washington) incorporates QI into their behavioral health training program. Specifically, the presentation will detail the curriculum for doctoral interns and fellows on the PDSA cycle of QI, how to collaborate and work with medical residents and leadership on QI initiatives, and the completion of a QI project. Additionally, two doctoral fellows who have completed the internship training and subsequent QI projects with the program will share their experience, as well as an overview of their two projects and outcomes. One of the projects is on improving cognitive screening in primary care and the other on the patient experience in the clinic waiting room.

Summary

The transitions of care from hospital to post-acute rehabilitation and then to home are complex, particularly given the biopsychosocial stressors of aging and social determinants of health that are often present for those with numerous underlying chronic conditions. While psychosocial factors are known to impact success with discharge, unmet needs and concerns are frequently voiced by patients and their families during transitions of care. At the same time, limited physician education and training experiences have historically been available in geriatrics, particularly with older adults transitioning between clinical settings. Previously, our facility ran the Hospital to Home Program as a model of geriatric training for internal medicine residents emphasizing the complicating role of psychosocial factors, including social determinants of health, and importance of interdisciplinary collaboration. In 2018, our facility shifted focus to address another high-risk transitional area, hospital to rehabilitation. The post-acute rehabilitation setting offers a unique opportunity to gain feedback around clinical skillsets necessary for collecting psychosocial information to support effective discharge planning, communication between care teams, and shared decision-making with patients to address complex care needs and social determinants of health. This presentation will outline the structure of the Hospital to Rehab program, as part of a university internal medicine residency.. Particular emphasis will be given to the psychosocial interview portion of the rotation, which serves multiple purposes, including (a) collecting baseline information on residents’ communication skills with patients and families; (b) providing modeling and feedback to residents around the psychosocial factors that play an important role in discharge planning; (c) how to facilitate a collaborative conversation around these factors with patients and their families; (d) an opportunity for residents to contribute to successful discharges through documentation that provides a biopsychosocial picture of the patient and their needs. Qualitative data from residents’ reflections on their experiences with the program overall and psychosocial interview in particular will be shared. Recommendations for building interdisciplinary support to facilitate a program such as this will be offered.

Summary

This presentation will explain our fully integrated care model utilizing how we obtained our Behavioral Health Integration Distinction from NCQA. This will include staffing and billing information. Our presentation will showcase how we utilize Masters-level Social Workers in our model to help identify patients who need assistance with creating goals for their chronic conditions, including diabetes and hypertension. We will also discuss how we implemented our MAT program and what techniques and tools we utilize for this. Our presentation will also ensure participants get to practice using tools and techniques, allowing audience members to participate in a problem solving exercise regarding two case studies.

Summary

Primary care patient care models are shifting from lone primary care provider (PCP) decision making to shared responsibility for patient panels, with other team members empowered to provide significant portions of chronic and preventive care across the lifespan (pediatric through geriatric populations). Interprofessional health teams are equipped with a broad range of skills and expertise to address health and wellness needs of patients with complex medical conditions. For example, the interprofessional team can best serve patients with chronic pain and opioid use disorder (OUD), who have an elevated risk of mortality and higher health care costs, compared with the general population. These disparities have been linked to sub-optimal management of co-occurring chronic conditions in primary care, resulting in high costs of care and functional impairment of the patients. In addition, high burnout rates in primary care are rising and can be ameliorated through medical home models that emphasize team-based participatory decision making. One evidence-based strategy to address these issues is the inter-professional team huddle. Another evidence-based approach is Situation, Background, Assessment and Recommendation (SBAR) communication. These strategies can be combined to optimize communication and outcomes. This presentation includes discussion of evidence-based communication techniques and identification of specific roles and responsibilities for each team member to improve coordination of care healthcare team satisfaction and patient outcomes. An interactive interprofessional huddle demonstration will teach how to apply these techniques in a primary care setting. Common comorbid, real world case examples, including a patient with opioid use disorder (OUD), will be discussed by the team during the simulated huddle. Huddle and communication competency guidelines and tools will be applied in the demonstration and shared with participants to encourage application in practice.

Summary

Background: The Legal Clinic for the Disabled, a civil legal aid agency, has four Medical-Legal Partnerships (MLP) across seven diverse sites in low-income communities and developed best practices to implement and sustain MLPs. LCD’s partnership with St. Christopher’s Hospital for Children (SCHC) is a case example of MLP’s effectiveness. SCHC is in an epicenter of poverty where 66% of the children in the surrounding zip code live in poverty. SCHC and LCD established an MLP in 2011. The MLP embeds an attorney in SCHC’s primary care practice to address social determinants of health (SDoH) including housing and habitability, food insecurity, immigration, public benefits, domestic violence, and family law. Attorneys and healthcare personnel combine law and medicine to mitigate negative SDoH. Objective: Systematize screening in an outpatient practice to proactively identify legal issues and connect families with resources or immediate legal intervention to mitigate negative SDoH. Methods: Families received a 14-item SDoH screener during the visit. Providers reviewed the screeners, gave resources and/or referred to an onsite attorney. The attorney regularly trains healthcare staff on screening and substantive legal issues. Screening tools were collected and results compiled. Results: 39833 families were screened for unmet legal needs from August 2011 through December 2019. The number of screens increased each year (year 1=895, year 9=7591). Overall, 40% (10480) self-identified at least one unmet need. From 2011 to 2019, the rate of self-reported unmet need decreased (year 1= 74%, year 9 = 19%) while the service rate (legal assistance and/or resources) increased (year 1 = 27%, year 9 = 63%). Conclusions: The MLP successfully implemented SDoH screening in a busy outpatient practice. With this holistic approach, each team member’s role best utilizes time and capabilities. With efficient screening, triage, and referrals, many families have their issues addressed during the visit.

Summary

Delivering physical and behavioral health services in a single setting is associated with improved quality of care and reduced health care costs. Few health systems implementing integrated care develop conceptual models and targeted measurement strategies a priori with an eye toward adoption, implementation, sustainment, and evaluation. Without this foundation, it is difficult to disentangle why implementation is or is not successful. The purpose of this presentation is to discuss strategic implementation and evaluation planning for a pediatric integrated care initiative in a large health system. A logic model, which defines resources and community characteristics, program components, evaluation activities, short-term activities, and intermediate and long-term patient-, provider-, and practice-related outcomes will be described. The model was designed based on research and stakeholder input to support strategic implementation and evaluation of the integrated primary care program. For each aspect of the logic model, a measurement battery was selected. These measures will be presented to highlight how a logic model can inform targeted measurement selection. Additionally, initial implementation data and intermediate outcomes from a pilot in five practices in a 31-practice pediatric primary care network will be presented to illustrate how the logic model and evaluation plan has been used to guide the iterative process of program development. This model provides a template for future projects integrating behavioral health services in pediatric primary care and can be used broadly to provide structure to implementation activities.

Summary

In the summer of 2017, Cabin Creek Health Systems entered a scope change to support a robust Syringe Service Program. They were able to provide direct, integrative primary care services to participants actively engaged in intravenous drug use. In addition to primary care, relationships with participants were established that worked to motivate participants through the stages of change supporting their transition to Medication Assisted Treatment. social determinants of health were quickly identified as barriers to treatment with an active use population, and successful transition from use to Medication Assisted Treatment was mostly unsuccessful. Since that time Cabin Creek Health System has been in collaboration with Community-Based Organizations to address the social determinants of health. The collaboration includes, a large meal services, multiple shelters, the City of Charleston, WV, and the local Continuity of Care agency. Through collaboration participants are identified and supported as they are transitioned to a person-centered substance use treatment program. Interested participants receive housing support, ancillary items such as identification, and birth certificates, transportation to resources and appointments, meal support, and integrative primary care. Modifications to traditional substance use treatments were required to better meet the needs of the population, this has increased retention, and decreased the negative impacts of other social determinants of health. Adoption of a program involving eight or more agencies has yielded communication difficulties, however having increased connection to resources is improving provider moral and decreasing burnout within Cabin Creek Health System, and for the partners. The target population are individuals who use IV substances, face housing difficulties, homelessness, and struggle with social determinants of health. Initial pilot hopes to track 25 participants of mixed age, race, gender, and sexual orientation. Recruitment continues to be open, and more participants are being induced routinely. Participants will be monitored monthly for continued motivation, attrition, and adherence to program. Providers will be asked to measure their felt work stress and burnout in relation to this participant group. It is expected that participant adherence, attrition, and motivation will be improved in comparison to past referral attempts. A comparison group is unavailable due to poor referrals previously. After collecting this initial data, a more robust research design can be developed for further research. This program aims to establish a community ecosystem of care that activates multiple community agencies into an integrative team to address social determinants of health for an often forgotten, at risk population.

Summary

In Ontario, Canada, rural and under-served regions tend to have higher incidences of mental health disorders, with much of this care being managed within primary care. Challenges exist when primary care providers have limited training, and few local options for psychiatry referrals. Outreach psychiatry is a foundational model, where psychiatrists provide on-site clinical services, education and support to communities across Ontario (usually short term through fly-in/drive-in). While this model has improved access to care, limitations in scope and reach exist, as well as additional costs for adjunct services to create a sustainable, efficient systems-level impact. New technologies and innovations have allowed for the growth of new models that further enhance capacity, collaboration and care in these communities. Specifically, Integrated TeleMental Health models and Project Extension for Community Healthcare Outcomes (ECHO), which provide care and support to patients and providers, and build mental health capacity. This session will discuss the integration of three innovative outreach and capacity building models to improve mental health access, by considering relevant literature and reflecting on experiences with implementation and evaluation. Together these models fit within a stepped-continuum to improve direct care to patients and support for providers in their own communities, thereby building local capacity.