BEHAVIORAL HEALTH OPERATIONAL RESOURCES TOOLKIT OPERATIONAL RESOURCES TASK FORCE Bryan A. Dovichi, MA, Chair Rachel Broudy, MD Auria Chamberlain, MSW Sheri Gibson, PhD Allison Ilem, PhD, BCBA Katherine Jones Brenda King, PsyD Mary Maina, CTRS Mary Beth Tubbs, BSN, MS BEHAVIORAL HEALTH WORKGROUP MAUREEN NASH, M.D. CHAIR Terry Anderson Sheri Gibson
Victor Lee Nancy Seigal Ashton Andrews Irena Ginsburg Mary Maina Adria Smith Nancy Barkowski Melyssa Harmon Carol McGlone Kristin Springfield
Elisabeth Broderick Carrie Hays McElroy Matthew McNabney Joe Stanley Rachel Broudy Allison Ilem Mary Maxine Mello Laurie Strom Jessica Burt Katherine Jones
Holly Onsager Carmarthen Swift Kelly Cervenka Linda Kasparian Theresa Auria Chamberlain Kendra Kerr Yasiri Perez Mary Beth Tubbs Lynda Davis
Brenda King Sharon Petitjean Lauren Vessella Nicole Desabrais Bill Kirkpatrick Luz Ramos-Bonner Melissa Michael DiBiase Lorelei Landau Arun Rao
Paylor Mary Ann Roberts Misty Taylor-Paladino Weisel Wright CONTENTS Purpose Statement Development Process I. Introduction A. Behavioral Health definition B. Integration of Behavioral Health and Primary
C. D. E. F. G. Care Levels of Integration Behavioral Health Providers Behavioral Health Services Rationale for Integrating Behavioral Health and Primary Care The Need for Behavioral Health in PACE II. Behavioral Health in PACE: Recommendations for Best Practices A. Referrals, Inclusion Criteria, and Confidentiality B. Assessment and Care Planning
i. Clinical Interview ii. Mental Status Examination iii. Cognitive Screening iv. Mood Functioning Measures i. Risk Assessment and Crisis Intervention ii. Psychoeducation iii. Individual Psychotherapy iv. Motivational Interviewing v. Group Psychotherapy vi. Substance Abuse Treatment vii. Psychiatric Pharmacotherapy viii.Psychiatric Admissions A. Special Considerations i. Dementia ii. Severe Mental Illness iii. Elder Abuse iv. Collaborating with Community-Based Behavioral Health Services
B. Outcomes and Measurement-Based Care I. Closing Statement II. References III. Appendix A. Assessment Forms and Policy and Process Examples PURPOSE STATEMENT It was not until recently that Program of All-inclusive Care for the Elderly (PACE) organizations began to recognize the need for Behavioral Health Services and add to their traditional model of care by including various professionals specializing in the discipline. The purpose of this toolkit is to provide a resource and a guide of best practices for PACE organizations looking to achieve a greater level of behavioral health integration. The National PACE Association (NPA) Behavioral Health Operational Resources Toolkit is not intended to be construed or to serve as a standard of care. Standards of care are determined on the basis of an organizations resources. Every PACE organization will differ in its level of integration and implementation of new practices will be successful only if attempted within ones reasonable ability to do so. These recommendations for best practice should be considered guidelines only. Adherence to them will not ensure a successful outcome of implementing Behavioral Health Services, nor should it be interpreted as including all
proper methods of care or excluding of other acceptable methods of care aimed at successful treatment outcomes of PACE participants. DEVELOPMENT PROCESS The NPA Behavioral Health Workgroup was formed in December 2015. Upon formation of the group, the work began by surveying PACE organizations regarding their use of Behavioral Health Services. Based on a thematic analysis of the results, the workgroup was broken down into three taskforces: Education, Operational Resources, and Outcomes. The Operational Resources Taskforce held its first meeting by conference call on June 8, 2016, during which time a work plan and working agenda were developed. It was also during this initial meeting that a call for forms was communicated to taskforce members in order to solicit policies, procedures, and assessment tools being used at members respective PACE organizations. Subsequent monthly meetings were held via conference call (with the exception of November 2016). Each meeting involved members discussing items according to its work plan. The taskforce began by developing and/or selecting definitions for Behavioral Health and levels of integration, providers, and services provided by the discipline. The task force then shifted its focus to developing recommended best practices for the following areas: (1) Referrals and Inclusion Criteria; (2) Assessment and Care Planning; (3) Treatment and Interventions; (4) Special Considerations; and (5) Outcomes and Measurement-Based Care. Time outside of the monthly conference calls included review of the solicited forms and supporting empirical literature and writing, reviewing, and editing this toolkit. INTRODUCTION
Behavioral Health definition Behavioral Health Services offer assistance not just with diagnosable mental illnesses, but also when habits, behaviors, stress, worry, or emotional concerns about physical or other life problems are interfering with a persons daily life and/or overall health. This is achieved by performing a variety of mental health activities within a primary care setting. Integration of Behavioral Health and Primary Care Integrated health care is the systematic coordination of physical and behavioral health care. The idea is that physical and behavioral health problems often occur at the same time. Integrating services to treat both will yield the best results and be the most acceptable and effective approach for those being served. INTRODUCTION INTRODUCTION Behavioral Health Providers Primary (Traditional) Psychologists Psychiatrists
Secondary (Supportive) Primary Care MDs, NPs, and PAs Recreational Therapists/Activities Coordinators Social Workers Physical Therapists/Occupational Therapists Licensed Professional Counselors Chaplain Licensed Marriage and Family Therapists Behavior Analysts INTRODUCTION Behavioral Health Services
Evaluation Assessment Treatment Planning Recommendations Neuropsychological Evals Treatment Short and Long Term Behavioral Medicine Crisis Interventions Individual and Group Education Consultation Didactics Staff Trainings Caregiver / Facility
INTRODUCTION Rationale for Integrating Behavioral Health and Primary Care 1. The burden of mental disorders is great. 2. Mental and physical health problems are interwoven. 3. The treatment gap for mental disorders is enormous. 4. Primary care settings for mental health services enhance access. 5. Delivering mental health services in primary care settings reduces stigma and discrimination. 6. Treating common mental disorders in primary care settings is cost-effective. 7. The majority of people with mental disorders treated in collaborative primary care have good outcomes. (WHO, 2008) INTRODUCTION The Need for Behavioral Health in PACE 59. 7% of participants diagnosed with at least 1 psychiatric disorder with a higher rate of mental illness in the younger age group (53-64: 77.6%) versus the older age groups (65-74: 68.1%; 75+: 53.8%). (PACE Data Analysis Center Report, 2014) 77% of organizations have no formal behavioral health programming in place. Common themes include: (1) Inadequate programing to serve high levels of need; (2) Fragmented communication with external behavioral health providers; (3) Unique challenges
associated with specific populations and diagnoses; (4) Need for staff education on specific topics; and (5) Need for development of policies and procedures. BEHAVIORAL HEALTH IN PACE: RECOMMENDATIONS FOR BEST PRACTICES At the greatest level of integration, Behavioral Health Services in a PACE organization ideally should aim to serve as an essential department integrated within the Interdisciplinary Team (IDT) with a focus on addressing the behavioral, cognitive, and emotional well-being of participants. Implementation should focus on several key areas: Integrated Primary Care Behavioral Health Trauma-Informed Care Culturally Competent Care Preventative Care Data and Information Driven Care BEHAVIORAL HEALTH IN PACE: RECOMMENDATIONS FOR BEST PRACTICES Referrals, Inclusion Criteria, and Confidentiality Identify participants BH needs pre- and post-enrollment (when available, consider inclusion of BH in
the pre-enrollment process). Presenting Issues Methods of referring (EHR vs. paper form) Referral Sources Confidentiality Coordination Limits Documentation; types of notes BEHAVIORAL HEALTH IN PACE: RECOMMENDATIONS FOR BEST PRACTICES Assessment and Care Planning Clinical Interview Mental Status Examination Cognitive Screening Mood Functioning Measures Substance Abuse Measures Other Measures
BEHAVIORAL HEALTH IN PACE: RECOMMENDATIONS FOR BEST PRACTICES Treatment and Interventions Risk Assessment and Crisis Intervention Psychoeducation (with participants, caregivers, and staff) Individual Psychotherapy Motivational Interviewing Group Psychotherapy Substance Abuse Treatment Psychiatric Pharmacotherapy Psychiatric Admissions SPECIAL CONSIDERATIONS Dementia PACE organizations without behavioral health integration have been successful at caring for its participants with dementia for a long time; however, behavioral health may be looked at as a way to help amplify and expand on existing programming. Day Center Programming Monitoring and Tracking Medication Utilization
SPECIAL CONSIDERATIONS Severe Mental Illness Due to the growing number of participants suffering from severe mental illness (e.g., schizophrenia; bipolar disorder), it is important for organizations to develop programming to ensure proper care and treatment for these individuals. There are several areas that often provide difficulties which programs can proactively develop programming to provide effective and quality care: Medication Management Day Center Programming Living Environment and Safety SPECIAL CONSIDERATIONS Elder Abuse There are various forms of elder abuse that PACE professionals should be aware of, including physical abuse, sexual abuse, psychological abuse, neglect, financial exploitation, and abandonment. Abuse occurs in the context of a trusted relationship, and may involve the targeting of older adults specifically because of their age and/or disability status. Another issue that PACE organizations may encounter is that of self-neglect. Who is considered a vulnerable adult?
Not sure whether to report? Consult. Who should report? Person-centered reporting. Reporting responsibility. Other Resources. SPECIAL CONSIDERATIONS Collaborating with Community-Based Behavioral Health Services As the majority of PACE organizations recently surveyed indicated that they have none or are in the very beginning stages of developing and implementing behavioral health programming, effective working relationships with community-based Behavioral Health Services, including counseling and psychiatry, are vital in serving the mental health needs of participants for these organizations. Bringing Behavioral Health Care to the PACE Model When Integration is Limited Psychotherapy Outpatient Psychiatry Specialty Care Settings Non-clinical Resources PACE Behavioral Health Services Outcome Measures
Organization Individual Enrollment Hospitalizations Treatment Outcomes/ Measurement-based Care Participant Satisfaction Hospital Re-admissions Growth/Market Share Avoidable ED Visits Staff Training Psychiatric Admissions
Provider Satisfaction Medication Utilization Placements OUTCOMES AND MEASUREMENT-BASED CARE Frequently referred to as measurement-based care or routine outcome measurement. Use of standardized tools or instruments to obtain objective data to monitor the impact of and inform decisions related to individual plans for care, treatment, or services. Data may also used for organizational performance improvement efforts. Demonstrates the value of services and increases the quality of care provided. CLOSING STATEMENT The PACE model of care and its individual organizations historically have proven to be very effective at caring for older adults since its humble beginnings in 1971 at On Lok in San Francisco, California. It was inevitable that other populations would learn about and gravitate toward this all-inclusive approach to care.
Recently, we have come to see the average PACE participant not only become younger, but also present with more of a need for mental health services. Moreover, as community mental health organizations across the country have demonstrated difficulties in caring for the needs of their patients, it appears that the PACE model of care continues to increasingly grow as an attractive option for many of the individuals served by related agencies. Accordingly, the National PACE Association has recognized the need to adjust and add to its model of care to serve the growing aging population in America. This toolkit seeks to serve as the first step in creating a new department within the existing model the PACE interdisciplinary team and also illustrate the need for PACE organizations to adapt their approach to providing the best care for all participants. As the population continues to evolve, it is the primary goal of the NPA Behavioral Health Workgroup Operational Resources Task Force to continue to provide PACE organizations with a resource to continue to learn, grow, and adapt. Looking to the future, it is recommended that PACE organizations approach the existing model of care with the belief that there is no health without behavioral health. APPENDIX Behavioral Health Referral Paper Form Generalized Anxiety Disorder 7-item (GAD-7) Clinical Interview Schedule
Geriatric Anxiety Scale (GAS) Mental Status Exam Rapid Record Form The Mood Disorder Questionnaire (MDQ) Montreal Cognitive Assessment (MoCA) Administration and Scoring Instructions Alcohol Use Disorders Identification Test (AUDIT) Montreal Cognitive Assessment (MoCA) Version 7.1 Original Version Montreal Cognitive Assessment (MoCA) Version 7.2 Alternate Version Montreal Cognitive Assessment (MoCA) BLIND Administration and Scoring Instructions Montreal Cognitive Assessment (MoCA) BLIND Version 7.1 Original Version
Michigan Alcoholism Screening Test-Geriatric Version (MAST-G) Current Opioid Misuse Measure (COMM) Participant Medication Agreement Form Life Events Checklist for DSM-5 (LEC-5) PTSD Checklist for DSM-5 (PCL-5) Clinician-Rated Dimensions of Psychosis Symptom Severity Abnormal Involuntary Movement Scale (AIMS) Mini-Mental State Examination (MMSE) Caregiver Burden Scale The Saint Louis University Mental Status (SLUMS) Examination Safety Plan Aid to Capacity Evaluation (ACE) Psychotherapy Outcome Reporting
Functional Assessment Staging (FAST) Treating Behavioral Disturbances and Intervention Grid Global Deterioration Scale (GDS) Behavior Logs for Tracking Behavioral Disturbance Associated with Dementia Clinical Dementia Rating (CDR) Behavioral Care Plan A SPECIAL THANK YOU TO NPA SUPPORT STAFF Teresa Belgin, (former) Member Services Manager Shawn Bloom, President and CEO Sam Kunjukunju, Director of Project Management
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