Behavioral Health Integrated Care Curriculum

What is Behavioral Health Integrated Care?

“A practice team of primary care and behavioral health clinicians working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population. This care may address mental health and substance use disorders, health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stress-related physical symptoms, and ineffective patterns of health care utilization.”

Source: Peek CJ. The National Integration Academy Council. Lexicon for Behavioral Health and Primary Care Integration: Concepts and Definitions Developed by Expert Consensus [AHRQ Publication No. 13-IP001-EF] Rockville, MD: Agency for Healthcare Research and Quality; 2013.

Click Here to Review the Standard Framework for Levels of Integrated Care.

What are the goals of Behavioral Health Integrated Care?

To enhance the primary care team through:

  • Expanding identification / screening for individuals with behavioral health disorders.
  • Improving outcomes for both physical and behavioral health diagnosis.
  • Avoiding hospital admissions and readmission.
  • Reducing emergency room utilization for patients of the primary care practice.
  • Preparing the practice for value-based payment models, case rate and episode-based reimbursement.

What are the Levels of Behavioral Health Integrated Care?

The levels of integrated care are threefold – Coordinated, Co-Located, and Integrated, and range from level 1, minimum collaboration, to level 6, full collaboration. Select the following hyperlink for a more detailed layout of each level.

Why choose Behavioral Health Integrated Care?

  • As many as 40 percent of all patients seen in primary care settings have a mental illness.
  • 27 percent of Americans will suffer from a substance use disorder during their lifetime.
  • 80 percent of patients with behavioral health concerns present in ED or primary care clinics.
  • Approximately 67 percent of patients with behavioral health disorders do not receive the care they need.
  • 68 percent of adults with mental disorders have comorbid chronic health disorders, and 29 percent of adults with chronic health disorders have mental health disorders.
Videos to gain more information: Sources:

The Quadruple Aim:

The Quadruple Aim refers to the four benefits related to Behavioral Health Integration.

Click each item below for more information.

Improved Population Health

  • Improves health outcomes for patients with mental illness and/or substance use disorders. This study examined outcomes across 5 integrated primary care practices and found that 50% of patients had a ≥5-point reduction in PHQ-9 score and 32% had a ≥50 reduction.
  • Improves health behaviors such as compliance with treatment recommendations, exercise, and diet.
  • Early identification of trauma, social and emotional disturbance in children, can lead to better quality of life and better health outcomes.
  • Outcomes of Integrated Behavioral Health with Primary Care - PubMed (nih.gov)

Improved Experience of Care

  • Increases access to behavioral health care. About 40 percent of all patients seen in primary care settings have a behavioral health disorder and approximately 67 percent of patients with behavioral health disorders do not receive the care they need.

Bending the Cost Curve

Improved Provider Satisfaction

Sources:

  • Balasubramanian BA, Cohen DJ, Jetelina KK, Dickinson LM, Davis M, Gunn R, Gowen K, deGruy FV 3rd, Miller BF, Green LA. Outcomes of Integrated Behavioral Health with Primary Care. J Am Board Fam Med. 2017 Mar-Apr;30(2):130-139. doi: 10.3122/jabfm.2017.02.160234. PMID: 28379819.
  • Zubatsky M, Pettinelli D, Salas J, Davis D. Associations Between Integrated Care Practice and Burnout Factors of Primary Care Physicians. Fam Med. 2018 Nov;50(10):770-774. doi: 10.22454/FamMed.2018.655711. PMID: 30428106.

Are you ready for Behavioral Health Integration?

Taking the leap to integrate behavioral health and primary care requires energy, leadership, provider and staff buy-in, and human and financial resources. The payoff is worth it as we’ve already discussed, but how do you decide where, when and how to start integration?

Below are some tools to help you assess your organization’s readiness for integration and to take those first steps toward integration:

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Screeners for Mental Heath and Substance Use Disorders

 

Mental Health Disorders

Click below to expand and read more.

Depression

What are the Depression Screening Tools?

The two recommended screening tools for depression are the PHQ-4 and PHQ-9. They are instruments for screening, monitoring and measuring the severity of depression.

Where can I access the Depression Screening Tools?

You can access the screening tools here: PHQ-4 and PHQ-9.

How should I use these tools and who should administer them?

The two depression screening tools are self-reported measures, however a clinician should follow-up on responses that indicate depressive symptoms to assess the patient’s understanding of the question and to learn the context behind their responses. A PHQ alone should not be used for diagnosis of depression. It must be accompanied with a clinical conversation. For example, if someone’s pet just died last week or if someone is newly pregnant and experiencing nausea/sleepiness/mood changes, their PHQ score might be high but it may not indicate depression.

How to interpret results?

Interpretation of Total Score:
1-4 = Minimal depression
5-9 = Mild depression
10-14 = Moderate depression
15-19 = Moderately severe depression
20-27 = Severe depression

What do I do with the results?

If results are 0-4
There’s no to minimal depression and you should monitor symptoms (may not require treatment).
If results are 5-9
There’s mild depression and you should repeat the PHQ-9 and the follow-up visit.
If results are 10-14
There’s moderate depression and you should use clinical judgement (symptom duration, functional impairment) to determine necessity of treatment. Consider counseling, follow-up, and/or prescription medication.
If results are 15-19
There’s moderate to severe depression and warrants active treatment with psychotherapy, medications, or combination. Prescribe prescription medications. If there are poor responses to treatment, immediately refer the patient to a mental health specialist for counseling.
If results are 20-27
There’s severe depression and warrants active treatment with psychotherapy, medications, or combination. Prescribe prescription medications. If there are poor responses to treatment, immediately refer the patient to a mental health specialist for counseling.
Sources:

Postnatal Depression

What is the Edinburgh Postnatal Depression Scale?

The EPDS is a screening tool to identify individuals at-risk for perinatal depression.

Where can I access the Postnatal Depression Screening Tools?

You can access the screening tools here: edinburghscale.pdf (ucsf.edu)

How should I use these tools and who should administer them?

The EPDS is a self-report measure. However, the EPDS score should not override clinical judgment. A careful clinical assessment should be carried out to confirm the diagnosis. The scale indicates how the mother has felt during the previous week. In doubtful cases it may be useful to repeat the tool after 2 weeks. Notably, the scale will not detect mothers with anxiety neuroses, phobias or personality disorders.

Instructions for using the Edinburgh Postnatal Depression Scale:
  1. The mother is asked to check the response that comes closest to how she has been feeling in the previous 7 days.
  2. All the items must be completed.
  3. Care should be taken to avoid the possibility of the mother discussing her answers with others. (Answers come from the mother or pregnant woman.)
  4. The mother should complete the scale herself, unless she has limited English or has difficulty with reading.
  5. The EPDS may be used at six to eight weeks to screen postnatal women or during pregnancy.

How to interpret results?

Scoring questions 1, 2, and 4 → 0 points (top box, first choice option), to 3 points (bottom box, last choice option)

Scoring questions 3, 5-10 → 3 points (top box, first choice option), to 0 points (bottom box, last choice option)

Add scores for each question – the maximum score is 30 points.
If the patients score is 10+, they could possibly have postnatal depression.
Pay specific attention to question 10 – if they have any suicidal thoughts, be sure to address right away.

What do I do with results?

Women who score above 13 are likely to be suffering from a depressive illness of varying severity. Women who score 10 or greater should be assessed further for depression and referred for treatment (medications and/or psychotherapy) as needed.

Sources:
  • Cox, J.L., Holden, J.M., and Sagovsky, R. 1987. Detection of postnatal depression: Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry 150:782-786.
  • K. L. Wisner, B. L. Parry, C. M. Piontek, Postpartum Depression N Engl J Med vol. 347, No 3, July 18, 2002, 194-199

Anxiety

What is the Anxiety Screening Tool?

The GAD-7 is a valid and efficient tool for screening for Generalized Anxiety Disorder and assessing its severity in clinical practice and research.

Where can I access the Anxiety Screening Tool?

You can access the anxiety screening tool here: GAD-7_Anxiety-updated_0.pdf (adaa.org).

How should I use these tools and who should administer them?

It is typically conducted by the patient via self-report, however it can be administered by a trained clinician.

How to interpret results?

0–4: minimal anxiety
5–9: mild anxiety
10–14: moderate anxiety
15–21: severe anxiety

What do I do with results?

When screening for anxiety disorders, a score of 8 or greater represents a reasonable cut-point for identifying probable cases of generalized anxiety disorder; further diagnostic assessment is warranted to determine the presence and type of anxiety disorder. Using a cut-off of 8, the GAD-7 has a sensitivity of 92% and specificity of 76% for diagnosis of generalized anxiety disorder.

If clinical discussion supports GAD diagnosis, use this resource: GAD+Adult+SORT+Combined.pdf (squarespace.com).

Sources:
  • Plummer F, Manea L, Trepel D, McMillan D. Screening for anxiety disorders with the GAD-7 and GAD-2: a systematic review and diagnostic metaanalysis. Gen Hosp Psychiatry. 2016;39:24-31.
  • Kroenke K, Spitzer RL, Williams JB, Monahan PO, Löwe B. Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Ann Intern Med. 2007;146:317-25.
  • Spitzer RL, Kroenke K, Williams JBW, Löwe B. A Brief Measure for Assessing Generalized Anxiety Disorder: The GAD-7. Arch Intern Med. 2006;166(10):1092–1097. doi:10.1001/archinte.166.10.1092

MDQ

What is the Mood Disorder Questionnaire?

The Mood Disorder Questionnaire (MDQ) is a brief, self-report screening instrument that can be used to identify patients in primary care settings most likely to have bipolar disorder.

Where can I access the MDQ Screening Tool?

You can access the MDQ here MECH (ohsu.edu).

How should I use these tools and who should administer them?

The questionnaire takes less than 5 minutes to complete. Patients check the yes or no boxes in response to the questions. The last question pertains to the patient’s level of functional impairment. The physician, nurse, or medical staff assistant then scores the completed questionnaire.

How to interpret the results?

Further medical assessment for bipolar disorder is warranted if:
  • Patient answers yes to 7 or more of the questions on the screener, AND
  • Answers yes to question 2, AND
  • Answers "moderate problem" or "serious problem" to question 3

What do I do with results?

If you identify that someone has bipolar disorder through further clinical interview, this is a helpful decision-making tool for treatment options.

Source:
  • Hirschfeld R, Williams J, Spitzer RL, et al. Development and validation of a screening instrument for bipolar spectrum disorder: the Mood Disorder Questionnaire. Am J Psychiatry. 2000;157:1873-1875.

Substance Use Disorders

Click below to expand and read more.

AUDIT-C

What is the Substance Abuse Screener?

The Alcohol Use Disorders Identification Test Consumption screening tool (AUDIT-C) is a 3-question screener that can help identify patients with alcohol misuse. The AUDIT-C is a modified version of the 10 question AUDIT screening instrument. The instrument has clinical utility in reliably identifying patients who are hazardous drinkers or who have alcohol use disorders.

Where can I access the Substance Use Screening Tool?

You can access the anxiety screening tool here: AUDIT-C Screening Tool & Overview - SBIRT@IUSM (iusbirt.org).

How should I use these tools and who should administer them?

It is a self-report measure.

How to interpret results?

The AUDIT-C is scored on a scale of 0-12 points (scores of 0 reflect no alcohol use in the past year). In men, a score of 4 points or more is considered positive for alcohol misuse; in women, a score of 3 points or more is considered positive. Generally, the higher the AUDIT-C score, the more likely it is that the patient’s drinking is affecting his/her health and safety.

What do I do with results?

The AUDIT-C is a short screener - a positive screen requires further discussion with the patient to see if they have an alcohol use disorder. If you have a behavioral health specialist on staff, ask them to assess the patient further.

If you’re without a BH specialist, you and the patient can look together at the DSM 5 criteria for Alcohol Use Disorder and see if they meet criteria.

If they do, use this resource: 201215+Alcohol+Use+Disorder.pdf (squarespace.com).

Sources:

DAST-10

What is the Substance Abuse Screener?

The Drug Abuse Screening Test (DAST) assesses drug use (not alcohol or tobacco) in the past 12 months.

Where can I access the DAST-10 Screening Tool?

You can access the DAST-10 screening tool here: DAST-10 (drugabuse.gov).

How should I use these tools and who should administer them?

It can be administered by a clinician or via self-report, though it was designed to be a brief, self-report measure and it is most commonly used in this manner.

How to interpret results?

Score 1 points for each “yes”, except question #3, it gets a point if answered "no".

Score Degree of problems related to drug abuse Suggested action
0 No problems reported None at this time
1-2 Low level Monitor, reassess at a later date
3-5 Moderate level Further investigation
6-8 Substantial level Intensive assessment
9-10 Severe level Intensive assessment

What do I do with results?

Here are a few resources for you to use upon interpreting results: Substance Use Disorders – The Waco Guide

Sources:
  • Source: Skinner HA (1982). The Drug Abuse Screening Test. Addictive Behavior. 7(4):363-371./

Trauma

Click below to expand and read more.

Averse Childhood Experience (ACEs)

What is the ACEs Screener?

The Adverse Childhood Experiences (ACEs) Screener assesses ......?????

Where can I access the ACEs Screening Tool?

You can access the ACEs Screening Tool here - Screening Tools | ACEs Aware – Take action. Save lives.

How should I use these tools and who should administer them?

It should be self-administered by the patient. There is debate about the risks/benefits around universal screening for ACEs. Some experts believe that it is potentially retraumatizing to ask these sensitive questions about trauma in a medical setting. Others believe that it can be very helpful if you are thoughtful about the way you implement ACEs screening. Avoidance of rescreening must be prioritized. A comprehensive child trauma-informed care delivery system must be adopted by the clinic (see details below on what this looks like).

How to interpret results?

A higher score indicates a greater or more complex trauma history. A higher score is associated with a greater number and complexity of physical health problems in adulthood.

What do I do with results?

Answering yes to 1 or more questions indicates a history of adversity in childhood. This does not mean that someone is destined to have negative outcomes as an adult as many protective factors can intervene. To respond to positive ACEs score, the clinic can adopt a comprehensive child trauma-informed care delivery system. Here is a description of what that can look like: Child trauma-informed integrated healthcare is the prevention, recognition, and response to trauma-related difficulties through collaboration of physical and mental health professionals with the child and family. This can be achieved by co-location of medical treatment, mental health care, and social services in health care settings; stream-lined communications between providers, and full partnerships regarding treatment decisions among providers, the child, and caregivers. Healthcare systems can infuse and sustain trauma awareness, knowledge, and skills in their organizational cultures, practices, and policies and use the best available science to facilitate and support the recovery and resilience of the child and family. Such systems can then support staff awareness and procedures that help them respond to the impact of trauma and address the social determinants of health. They also can recognize the potentially traumatic aspects of medical experiences and work to mitigate the effects on children and families. The trauma-informed integrated care approach is intended to be a cost-effective method of providing improved coordination of care that is also more responsive to the specific needs of patients and their families.

Important strengths and weaknesses of the ACEs score is located on page 4 of the PDF.

To learn more: Videos: Sources:

Primary Care Post Traumatic Stress Disorder

What is the PC-PTSD screener?

Primary Care Post Traumatic Stress Disorder (PC-PTSD) for DSM-5 is a 5-item screener that was designed to identify individuals with probable PTSD in primary care settings.

Where can I access the PC-PTSD Screening Tool?

You can access the PC-PTSD screener here: Primary Care PTSD Screen for DSM-5 (PC-PTSD-5) – PTSD: National Center for PTSD (va.gov)

How should I use these tools and who should administer them?

The PC-PTSD is designed to be administered by the patient via self-report. Those who screen positive require further assessment, preferably with a structured interview such as the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5). If a clinical interview is not possible, it is recommended that additional assessment is conducted using a validated self-report measure such as the PTSD Checklist for DSM-5 (PCL-5).

How to interpret the results?

The measure begins with an item designed to assess whether the respondent has had any exposure to traumatic events. If a respondent denies exposure, the PC-PTSD-5 is complete with a score of 0. If a respondent indicates a trauma history – experiencing a traumatic event over the course of their life – the respondent is instructed to answer five additional yes/no questions about how that trauma has affected them over the past month. Preliminary results from validation studies suggest that a cut-point of 3 on the PC-PTSD-5 (e.g., respondent answers "yes" to any 3 of 5 questions about how the traumatic event(s) have affected them over the past month) is optimally sensitive to probable PTSD.

What do I do with results?

If you identify that someone has PTSD, this is a helpful clinical decision-making tool for treatment options.
https://static1.squarespace.com/static/5e14fd98ed4b31566cfea231/t/6140258c1756963564d31620/1631593868576/PTSD+Adult.pdf

Source:
  • Prins, A., Bovin, M. J., Kimerling, R., Kaloupek, D. G., Marx, B. P., Pless Kaiser, A., & Schnurr, P. P. (2015). The Primary Care PTSD Screen for DSM-5 (PC-PTSD-5).

Suicide Risk

Click below to expand and read more.

ASQ

What is the asQ?

The Ask Suicide-Screening Questions (asQ) tool is a brief validated tool for use among both youth and adults. The asQ is a set of four screening questions that takes 20 seconds to administer. In an NIMH study, a “yes” response to one or more of the four questions identified 97% of youth (aged 10 to 21 years) at risk for suicide. Led by the NIMH, a multisite research study has now demonstrated that the ASQ is also a valid screening tool for adult medical patients. By enabling early identification and assessment of medical patients at high risk for suicide, the ASQ toolkit can play a key role in suicide prevention.

Where can I access the ASQ Screening Tool?

You can access the Ask Suicide Screen Question (ASQ) Screener here: asQ NIMH Toolkit.

How should I use these tools and who should administer them?

Recommended age is 8 and up. The survey is typically administered verbally by a nurse or other professional. For screening youth, it is recommended that screening be conducted without the parent/guardian present. Refer to the nursing script for guidance on requesting that the parent/guardian leave the room during screening. If the parent/guardian refuses to leave or the child insists that they stay, conduct the screening with the parent/guardian present. For all patients, any other visitors in the room should be asked to leave the room during screening.

How to interpret the results?

If a patient answers “no” to questions 1-4, the screening is complete and no interventions are necessary
If a patient answers “yes” to ANY of the first four questions, or refuses to give an answer, they are considered positive screens. To determine next steps, ask question #5
If “yes” to question 5
Acute positive screen (intermediate risk identified) Patient requires a STAT safety/full mental health eval Patient cannot leave until evaluated for safety Keep patient in sight and remove all hazardous objects from room. Alert physician or clinician responsible for patient’s care.
If “no” to question 5
Non-acute positive screen (potential risk identified) Patient requires a brief suicide safety assessment to determine if a full mental health eval is required Patient cannot leave until evaluated for safety Alert physician or clinician responsible for patient’s care.

What do I do with results?

What to do with results? Decision tree / logic model for next steps Patients who screen positive for suicide risk on the ASQ should receive a brief suicide safety assessment (BSSA) conducted by a trained clinician (e.g., social worker, nurse practitioner, physician assistant, physician, or other mental health clinicians) to determine if a more comprehensive mental health evaluation is needed. The BSSA should be brief and guides what happens next in each setting. The Columbia Suicide Severity Rating Scale (Columbia SSRS) is a useful tool for more extensive evaluation of suicidality. Any patient that screens positive, regardless of disposition, should be given a Patient Resource List.

Video example of using tool in practice Training video (15 minutes) with more detail on how to use this screener: How to Use the ASQ to Detect Patients at Risk for Suicide

Sources:

Screening Tools Printable Job Aids

Pediatric Screening Tools

Visit the Eastern AHEC website for more information.

Videos/Podcasts

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