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Adult Mental Health Module An Organized Approach to Mental Health Issues in Realistic Time www.pspbc.ca www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources Faculty/Presenter Disclosure Speaker’s Name: Speaker’s Name Relationships with commercial interests: - Grants/Research Support: PharmaCorp ABC - Speakers Bureau/Honoraria: XYZ Biopharmaceuticals Ltd - Consulting Fees: MedX Group Inc. - Other: Employee of XYZ Hospital Group 2 Disclosure of Commercial Support This program has received financial support from [organization name] in the form of [describe support here – e.g. educational grant]. This program has received in-kind support from [organization name] in the form of [describe the support here – e.g. logistical support]. Potential for conflict(s) of interest: - [Speaker/Faculty name] has received [payment/funding, etc.] from [organization supporting this program AND/OR organization whose product(s) are being discussed in this program]. - [Supporting organization name] [developed/licenses/distributes/benefits from the sale of, etc.] a product that will be discussed in this program: [enter generic and brand name here]. 3 Mitigating Potential Bias [Explain how potential sources of bias identified in slides 1 and 2 have been mitigated]. Refer to “Quick Tips” document 4 Support Team Advisor Roles Psychiatrists and Mental Health Clinicians Learn/understand module Share resources Comment/advise Tell colleagues/Root for the PCPs www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources 5 Support Team Advisor Roles Office Assistants: Understand module Take course on Mental Health First Aid Organize office scheduling, materials Flag patient issues www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources 6 Support Team Advisor Roles Nurses Absorb these tools through your own lens. Think about your own scope of practice Present your ideas during the action period planning and strategize with your doc how you will implement today’s training www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources 7 Adult Mental Health Module Team GP Champ, OA, nurse Psychiatrist Mental Health Clinicians PSP Coordinators Data Analyst PSP Tech Group Bounce Back Coaches 8 Request your Permission Anyone NOT wishing their name and EMR information shared with our PSP Technology Partners please let ___ know. 9 Housekeeping www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources 10 Welcome 1. 2. 3. 4. Roles Survey feedback CME credits What are we trying to accomplish Context, aims, goals, module pathway, CBT, QI, Results 5. Physician, patient advocate testimonial 6. Break 7. Algorithm scavenger hunt 8. Tools intro, tips, PL, RL, PLAP Separate: MOAs billing and scheduling 9. BB 10. Billing 11. Action planning, Evaluations 11 Where You are Now Where You Would Like to Be Thank you for your responses to the following questions. 1. What are your challenges or frustrations supporting patients with mental health concerns? 2. How do you currently support these patients & how is this working? 3. What are you hoping to get out of the PSP Mental Health module? 4. Are you familiar with the PHQ 9 screening tool 5. Are you paper based or do you have an EMR? 6. Are you with a group practice or alone? www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources 12 Results of pre-course assessment survey N=36 What are your challenges and frustrations? www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources 13 How do you currently support MH patients? www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources 14 What do you hope to get from PSP training? www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources 15 Familiarity with the PHQ9 screening tool? www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources 16 Paper or EMR? www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources 17 What did we learn about you? Want to provide the best care for your patients with MH problems Concerned about time efficiency in your practices Doing a lot of MH care already Some don’t feel confident in MH care they provide and some feel emotionally drained by it Would like clearer and more timely access to mental health specialists for your patients Here to learn skills and tools to help with diagnosis and in-office management as well as learn about helpful resources www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources 18 Mainpro+ Credits for Primary Care Physicians 21 Mainpro+ Certified credits based on completion of: › All 3 Learning Sessions › At least one Action Period › The post-reflective questionnaire (requested 2 months after LS3) 19 MOC for Psychiatrists “This event is an Accredited Group Learning Activity eligible for up to 10.5 (3.5 per session) Section 1 credits as defined by the Maintenance of Certification Program of the Royal College of Physicians and Surgeons of Canada. This program has been reviewed and approved by the UBC Division of Continuing Professional Development.” 20 Who sees MH patients in Canada? Pan Canadian Survey 2011 21 Hypothesis Family docs need: time efficient skills to increase their comfort and confidence in treating their mental health patients fee codes that fit this mental health work www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources 22 Developed Training tools CBIS manual – cognitive behavioral interpersonal skills manual. This formed the core of the BC provincial practice support program adult mental health module Weinerman R et al, Improving Mental Healthcare by Primary Care physicians In British Columbia. Healthcare Quarterly, 2011. 14:1, 36-38 MacCarthy,D;Weinerman,R:Kallstrom,L;Kadlec,H;Hollander,M;Patten,S;Mental Health Practice and Attitudes Can be Changed. The Permanente Journal, 2013, Summe; 17(3);14-17. www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources 23 Key Components of the Adult Mental Health (AMH) Module 1. Screening scales: ie PHQ9 2. CBIS Screening Assessment tools: ie Diagnostic Assessment Interview (DAI) 3. Three Supported Self-Management Cognitive Behavioural Therapy (CBT) skills options CBIS Manual Bounce Back Antidepressant Skills Workbook www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources 24 Results n=525 physicians 100 90 80 70 60 50 40 30 20 10 0 Training improved pt care Enhanced skills Improved MD confidence Improved MD job satisfaction Further Results 100 90 80 70 60 50 40 30 20 10 0 Help pts return to work Help pts stay at work Increased pts sense Reduced reliance of partnership on meds alone Hope/Aim/Goals Provide PCPs with effective tools to screen, diagnose, engage, partner with, manage their MH patients Improve PCPs’ comfort, confidence and satisfaction Improve patient experience and outcomes Reduced healthcare provider stigma www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources 27 Depression used as Lens (Anxiety too) High prevalence in isolation/comorbid and comorbid with chronic disease Lifetime prevalence of Ranked by frequency ** Major Depressive Episode: 12.2% Major depressive disorder Past-year episodes: 4.8% Specific Phobia Past-month episodes: 1.3% * * Descriptive Epidemiology of Major Depression in Canada. Patten, SB; Wang, JL; Williams, JVA et al. Canadian Journal of Psychiatry; Feb 2006; 51, 2; 84. Social phobia PTSD GAD Separation anxiety ** Twelve-month and lifetime prevalence and lifetime morbid risk of anxiety and mood disorders in the US. Kessler, RC, Petukhova, M, Sampson, NA, Zalavsky, AM, Wittchen, H-U. Int J Methods Psychiatr Res. 2012 Sep:21(3) 169-184 Panic Bipolar Agoraphobia OCD 28 Focus of this module Patients that present with: 1.fatigue, depression, anxiety, panic, insomnia, psychosomatic symptoms 2. chronic pain, headache, chronic illness, 3. depressed demeanor, worrier a thick chart and trigger you to generate a mental health screening. 29 Bike ride Improvement Ramp Plan: Ride my bike to work Attempt #3 Attempt # 2 • • • • Attempt # 1 Get up Get ready Get bike Go • • • • • • • • I was late I was sweaty Bike was rusty I was stiff Fix bike Stretch Leave early Take clothes/shower at work • • • • Rain/wind Forgot soap Still late Too many hills • • • • • Done!! Check google for bike time Got poncho/glasses Brought shampoo Find straighter route Leave earlier • On time!! • Felt good!! • I Can do this! Always go back to why is this important! Get exercise Save on gas & wear/tear on car Contribute to carbon footprint Promote exercise/wellness in community 30 Lessen traffic flow by one car……… Module Pathway •Ongoing Support •CME •Post Module Reflective Questionnaire (mid-March) •Survey-barriers, desires •Orientation to Algorithm, •Review use of MH Log Sheet •Location of tools on algorithm • Confirm use of EMR •Confirm patient population •Locate tools on algorithm •Begin trying out tools •Review use of MH Log Sheet •Confirm MOA role •Billing questions/tech assistance Pre-visit •Review Log Sheet progress •Use of DAI •Use of other resources •Discuss optimal office flow (include MOA) AP1 AP2 Month 0 Sustain Month 7-8 •Overview of aims, CBIS, ASW Bounceback and practice finding the tools (Scavenger Hunt) •Log sheet/AP requirements •Billing and EMR optimization •Develop an action plan •Share experiences (good & bad) w peers • Use of tools •DAI role play •Log sheet/AP requirements •Update action plan •Share experiences •Community Resource Cafe •Troubleshoot issues for sustainability & improvement •Sustainability Plan Cognitive Behavioural Therapy (CBT): Setting the Stage www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources 32 What is a Cognitive Behavioral Approach? Level 1 Evidence based. CBT prevention endures beyond tx cessation. If both CBT and meds stopped after successful acute treatment, patients who received CBT have lower rates of relapse ** Behavior/Activation oriented Helps patients learn to change thought patterns/behaviors that negatively affect mood Gives patients a sense of power and control Retrains the brain! You are the coach not the therapist **CANMAT Clinical Guidleines for the management of major depressive disorder in adults: Kennedy SH, Lam RW, Prikh SV, Patten SB, Ravindran AV www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources 33 How does CBT and CBT skills work? Use this to introduce CBT skills Situation Situation www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources 34 How does CBT and CBT skills work? Use this to introduce CBT skills Problem Solving Behavioural Activation ACTIONS SITUATIONS • Loss • Conflict • Isolation Withdrawal Reduced activity Poor self-care PHYSIOLOGY Altered sleep Low energy Δ brain chemistry 3 5 35 Realistic Thinking THOUGHTS • Harsh selfcriticism • Over-pessimistic • Catastrophic about future EMOTIONS Sadness Despair Numbness 35 The benefits of using CBT skills? Helps on its own Mild or moderate depression, mild and moderate anxiety disorders such as GAD, social anxiety, panic, stress, anger, self esteem, some personality disorders As an adjunct with medications in primary care or collaborating with secondary care Severe depression, anxiety disorders, obsessive compulsive disorder, bulimia, posttraumatic stress disorder, personality disorders, stable bipolar disorder and stable psychosis Engages, empowers patients to work towards their recovery Provides patients with coping skills & a sense of control A non-pharmaceutical option/adjunct for treatment that is enduring and prevents relapse www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources 36 An alternate approach….consider saying to your patient…. “Before just jumping into pharmaceuticals you can start with other things like re-training your brain, I have some strategies involving some homework to help you, what do you think about trying this?” Dr. Howard Bright, Chilliwack www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources 37 Results n=525 physicians 100 90 80 70 60 50 40 30 20 10 0 Training improved pt care Enhanced skills Improved MD confidence Improved MD job satisfaction New Hypothesis Giving practitioners and patients more coping tools reduced healthcare provider stigma against AIDS ** Family docs feel unequipped to deal with mental health issues *** Novel hypothesis Providing tools for practitioners, patients to use will reduce healthcare provider stigma against mental health issues ** Brown, L. Trujillo, L., Macintyre, K.; (2001)Interventions to Reducde HIV/AID Stigma: What have we learned?, Horizons Program/Tulane School of Public Health and Tropical Medicine, New Orleans, Louisiana, *** Clatney, L., MacDonald, H., & Shah, S.M. (2008). Mental health care in the primary care setting: Family physicians’ perspectives. Canadian Family Physician, 54, www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources 39 OMS-HC Total average scores: Both groups 40 *Wilcoxen rank sum test was used to measure between group change from pre-test to followup, p<.001 **Wilcoxen sign rank test was used to measure within group change. Intervention group pretest to post-test change, p=.002; post-test to follow-up change, p=.017. Control group, not significant. 41 41 Dr. Fiza video Why this module will change everything! 42 Perspective www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources Break 44 Let’s Do it! www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources Today: Start with Algorithm and 4 Basic tools PHQ9/ GAD7 Bounce Back Coaching/ DVD AntiDepressant Skills Workbook CBIS Manual Updated Algorithm Available Scroll to this: ‘Google’ this: www.gpsc bc.ca Click PSP • • • • • Scroll down Click Adult Mental Health Select Algorithm for Mental Health (pdf) Right click select "Save target" to download to your desktop Algorithm Scavenger Hunt (locating the tools quickly) MH Tools Scavenger Hunt Form groups of 2-3, each with at least one laptop with downloaded MH Algorithm OR Google www.gpscbc.ca click PSP, scroll down click Adult Mental Health Module, select Algorithm, right click save target 49 Format Each Pair: Will review 2 Case Studies (Anxiety, Depression) Must complete each task to receive next task One person to bring completed task to Coordinator Each Group Member: Will receive an Action Period log to fill in (keep at your table until the end of the Scavenger Hunt) Bonus Tasks = Prizes Coordinators will be circulating to provide assistance 50 Algorithm Scavenger Hunt Discussion and “Treasures” MOA Tasks to discuss Reschedule MH patients in blocks Organize relevant resources – forms, booklets, other materials Provide patient follow-up calls Identify how Action Period logs will be completed and faxed Complete the CMHA Mental Health First Aid course Contact the Practice Support Team for support Ensure Algorithm is loaded on each computer 52 Today: Start with 4 Basic tools PHQ9/ GAD7 Bounce Back Coaching/ DVD AntiDepressant Skills Workbook CBIS Manual PHQ-2 & PHQ-9 www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources 54 Need one or both questions endorsed as “2” or “3” (“More than half the days” or “Nearly every day”) 55 PHQ-9 Scoring Major Depressive Disorder: Need 5 or more questions endorsed as “More than half the days” or “Nearly every day” (i.e. in shaded areas) 8 1 9 18 56 PHQ-9 Scoring Is functional impairment endorsed as “Somewhat difficult” or greater? 8 1 9 18 www.gpscbc.ca/psp-learning/ adult-mental-health/toolsresources 57 DSM 5 Confirming Diagnosis of Major Depressive Episode Criteria A: reflected in PHQ9 nine questions 1 symptom is either depressed mood or loss of interest or pleasure (PHQ9 1st 2 questions) 5/more symptoms present in same 2 week Criteria B: Reflected in PHQ9 function question Criteria C: episode is not due to a substance or other medical condition period/change of function 58 Bereavement May resemble a major depressive episode Use your clinical judgment depending on your knowledge of the individual and their cultural norms 59 Manual Overview Assessment DAI Problem List Action Plan Resource List SAQ Anxiety Dx Flow Skills Activation Cognition Relaxation Lifestyle Anxiety 60 61 Flexibility of Use - Key Strategy Tools – use according to your needs Be selective Use all, some, now, later Be strategic www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources 62 Shift in How we Work Shift to shared patient responsibility Chronic problems No quick fix All tools to engage Build partnership 63 General Breathe, relax No right or wrong PDSA Can’t hurt Negotiate, demonstrate and soft sell Validate, encourage and praise 64 Skills • Activation - first • Cognition – prepare • Relaxation/Anxiety – demonstrate • Lifestyle – always good • Anxiety disorders - Organizing Tips Handouts available One at a time Small goals Chart homework given Regular follow-up Practice 66 Problem List 67 Resource List (Reslience) About the patient Shift to strength Challenging Help Internal and external Wellspring 68 Problem List Action Plan All known Patterns, not solutions Chaos organized Being heard Validated Prepares for action 69 Small Group Activity – Problem List Action Plan 10 min Ask patient: What action do you think would be helpful for this problem…. ? Activation ? Relaxation ? Thought changing ? lifestyle changes ? medications ? referrals to other resources 70 71 Summary • • • • Just do it! Jump in! Use favorites! Own it! Supported Self Management Cognitive Behavioral Skill Building Mood Improvement Program www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources 73 Accessibility Alternatives Brief ‘Little Booklet’ format with less text Cantonese versions + Coaching also available 74 Additional Information To learn more about Bounce Back in general: Visit our Website: www.bouncebackbc.ca Bounce Back toll-free #s: Phone: 1-866-639-0522 Facsimile: 1-877-688-3270 www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources 75 Advocate Perspective Importance of being heard being asked the questions Short term more time, long term less time/gain Stigma experience Other experience www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources 76 Discussion www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources 77 MSP Compensation CBIS tools • DAI 2 counseling visits 00120 x 2 1 counseling visit finish with MH planning fee 00120, 14043 • Problem List Action Plan Counseling visit 00120 • Skills Office Visit 00100 Tel Fup 14079 78 Impact of using the tools: Dr. Egan’s Renewed Practice Visit 1 PHQ9/GAD & PL/RL Bill 0010 or if >20 minutes, bill 00120 worth 1.5 of a 00100 up to 4 times a year Visit 2 Review PL/RL & create Action Plan, choose Skill sheet Bill 0010 or if >20 minutes, bill 00120 worth 1.5 of a 00100 up to 4 times a year Visit 3 Review and add ASW (pt may choose Bounce Back too) Bill 0010 or if >20 minutes, bill 00120 worth 1.5 of a 00100 up to 4 times a year Visit 4 May need more in depth Diagnostic Assessment Interview 79 More about Visit 4 Visit 4 May need more in depth Diagnostic Assessment Interview Bill 14043 MH planning fee, and after this is billed, this generates 4 more counseling visits giving access to 8 prolonged visits in one calendar year in addition to the planning visit 14043 worth $100 once a year. Plan must include a screening assessment and a planning document to keep on chart. If you take 2 sessions to do this bill 00120 for first and 14043 for second giving you the time to discuss with patient easily. 80 80 Action Period Planning Plan Your Pathway •Ongoing Support •CME •Post Module Reflective Questionnaire (mid-March) •Survey-barriers, desires •Orientation to Algorithm, •Review use of MH Log Sheet •Location of tools on algorithm • Confirm use of EMR •Confirm patient population •Locate tools on algorithm •Begin trying out tools •Review use of MH Log Sheet •Confirm MOA role •Billing questions/tech assistance Pre-visit •Review Log Sheet progress •Use of DAI •Use of other resources •Discuss optimal office flow (include MOA) AP1 AP2 Month 0 Sustain Month 7-8 •Overview of aims, CBIS, ASW Bounceback and practice finding the tools (Scavenger Hunt) •Log sheet/AP requirements •Billing and EMR optimization •Develop an action plan •Share experiences (good & bad) w peers • Use of tools •DAI role play •Log sheet/AP requirements •Update action plan •Share experiences •Community Resource Cafe •Troubleshoot issues for sustainability & improvement •Sustainability Plan PSP Mental Health Log Successful planning for achieving Action Period activities To complete Action Period 1 Replace this box: With your practice ideas • Scheduling options • Create/Review patient registry • Select specific patient criteria…complex care, migraine, others? • Organize relevant resources – forms, booklets, other materials • Follow up with patients (MOA can follow up with patients on homework and goals agreed to in action plans) • Identify changes to work processes and office re-design • Record overall progress on log sheets What is your proof that this stuff works??? My communications with Mental Health and Addictions will improve My MOA will have an enhanced role and a workflow in place Some of my patients may not need to see psychiatry My patients will progress and respond to my approach My income will increase My appointments will be faster My appointments will be proactive How will you know that what you are doing is an improvement??? 86 Thanks for Attending Lunch Info www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources