Top Ten Useful Measures, Assessments, and Tools for Collaborative Practices

(This blog post is a reprint of a piece in the CFHA Blog from January 15th, 2015. Click here for the original post. Reprinted with permission.)

In primary care, more than half of the office visits are for somatic complaints, which are often associated with depression and anxiety. These conditions often go undetected and can have a significant impact on health outcomes. As providers adopt a collaborative approach to care, many have incorporated the use of assessments for screening and early detection of symptoms of mental health and substance use conditions.

With an abundance of assessments, measures, and tools available for use, many collaborative care practices are challenged with determining which are most effective for use in the limited time available during a routine office visit. Screenings are important for all age groups. Below is a list of the top ten tools for use in practices. These ten were selected based on a number of factors, including reliability, validity, sensitivity, efficiency, and cost. In most cases, the tools are available for use at no cost. Most are also available in multiple languages as well.

  1. PHQ-9: The Patient Health Questionnaire (9) is widely used among primary care providers to identify depression. With only nine questions, this tool is easy to use and has been validated for early detection.
  2. AUDIT: The Alcohol Use Disorders Identification Test is a 10-item questionnaire developed by the World Health Organization and is found to be very effective in primary care settings.
  3. GAD-7: The seven-item General Anxiety Disorder screening identifies whether a more complete assessment is needed.
  4. DAST-10: The Drug Abuse Screen Test is a brief 10-item self-report tool that is effect for screening adults and adolescents for drug abuse.
  5. PC-PTSD: This four-item screen is effective for detecting post-traumatic stress disorder in primary care settings.
  6. Pediatric Symptoms Checklist: The 17-item version is easy to use in family practices for detecting developmental and behavioral problems.
  7. SBQ-R: The Suicide Behaviors Questionnaire is a four-question scale for assessing suicide-related thoughts and behaviors.
  8. Brief Pain Inventory: The tool is widely used in medical settings for assessing pain, and is available in 23 languages.
  9. Insomnia Severity Scale: This seven-question screening assessment is effective in identifying problems with sleeping.
  10. MDQ: The Mood Disorder Questionnaire (MDQ) is a 13-item questionnaire used to screen for bipolar disorder symptoms.

In order to limit the list to ten, there are many excellent tools that did not make this list. For example, some providers prefer the CAGE-AID to the AUDIT-7 for alcohol screening. In addition, many will find it very useful to have additional tools on hang to screen for additional conditions, such as:

  • Geriatric depression
  • Eating disorders
  • Postpartum depression
  • Intimate partner violence
  • ADHD
  • Autism

Integrating these tools into your electronic health record, including them in patient kiosks, and/or instructing support staff to make select tools available for completion while in the reception area are ways in which these cools have been included in practices. With routine use of many of these screening tools, collaborative care practices will efficiently and effectively detect signs and symptoms of behavioral health conditions. This enables earlier intervention, resulting in better health outcomes.

What is on your top ten list?

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Integrated Care Thought Leader Series: Dale Klatzker, PhD

The Times, They Are a-Changin’

When Bob Dylan wrote this iconic song, many felt that it captured the spirit of social and political upheaval of the 1960s, much in the same way that we view mental health as “a-changin’.”  And these changes require mental/behavioral health providers to change the manner in which they deliver services.

Reports over the past decade have brought attention to the current mental health crisis:

In addition, over the past few years far too many catastrophic events have brought attention to this mental health crisis, resulting in a public outcry, demanding that changes are made to prevent future tragedies.

But change isn’t easy.

The relatively brief history of community mental health services has been a challenging one. Just a few months ago, as we celebrated the 50th anniversary of President John F. Kennedy’s signing the Community Mental Health Bill into law, the conversations quickly progressed to the subject that is on the minds of virtually all behavioral health providers—and an unusually large number of the general public and policy makers, given the historical lackluster interest in the topic—mental health is in dire need of change.

The economic downturn in the US in 2008 resulted in massive budget cuts in all but a few states. The March 2011 NAMI report, State Mental Health Cuts: A National Crisis, demonstrated the cumulative cut to mental health services in the U.S. during that time was nearly $1.6 billion. Community mental health services plummeted from being barely adequate to the critical point in many states. Safety-net providers were forced to close programs due to the slashed budgets. Many of those affected ended up on the streets or in jail.

The recent announcement on the anniversary of the Sandy Hook tragedy, of the planned infusion of dollars into help repair our broken mental health system, is encouraging. However, the entire mental health system is in dire need of an overhaul. One that looks at the broader healthcare picture and strategically plans for mental health and substance use disorder treatment to be included. A person-centered, whole health approach to treatment is necessary for improving the patient experience of care; improving the health of populations; and reducing the per capita cost of health care: the Triple Aim.

Dale Klatzker, PhD

Dale Klatzker, PhD

Dr. Dale Klatzker knows that, although it isn’t easy, change is vital for community behavioral health providers.

It’s exciting to be able to offer a look at integrated care from the perspective of a provider, particularly a provider who has demonstrated leadership excellence in integrating behavioral health and primary care services. Dr. Klatzker currently serves as the Chief Executive Officer of The Providence Center in Providence, Rhode Island. He has been a leader in behavioral healthcare for more than 35 years. Since becoming president/CEO of The Providence Center in 2004, Dr. Klatzker, a visionary, has transformed the system of care, quality of service delivery, and social policy decision making at The Providence Center and the state of Rhode Island.  Click here for Dr. Dale Klatzker’s bio.

The Providence Center and the Providence Community Health Centers have created a successful partnership to meet the whole-health needs of the people they serve within their community; a need that is clearly outlined in the literature. According to the Robert Wood Foundation’s Mental Disorders and Medical Comorbidity authored by Dr. Benjamin Druss and Elizabeth Walker, comorbidity between medical and mental conditions is the rule rather than the exception:

In 2002, more than half of disabled Medicaid enrollees with psychiatric conditions also had claims for diabetes, cardiovascular disease (CVD), or pulmonary disease, substantially higher than rates of these illnesses among persons without psychiatric conditions. The authors conclude that the high prevalence of psychiatric diagnoses among people with chronic medical conditions should be an impetus for prioritizing the improved integration of behavioral and medical care.

What advice do you have for healthcare leaders?

Dr. Klatzker:  Change is a good thing. Most CMHCs haven’t changed a lot. They haven’t prepared themselves to change a lot and have marginalized themselves and the people that they serve by not being more a part of the mainstream. We have sets of skills that are integral to wellness and to health across a wide spectrum. We need to be proud of what we do, but also to expand it and extend it because this is the perfect time for this. We have a lot of things to offer that others are trying to replicate.

Things don’t stay static. You have to look though the windshield but also through the rear-view mirror. You have to know where you are but you also have to know where you’re going.

As executive director/CEO of a behavioral health organization, you have the obligation to push yourself, and that will push your organization, to do what is necessary so that your mission is reinforced but also to serve the needs of the community. It’s hard to do that if you’re doing the same thing you did 20 years ago. We do our consumers a disservice if we do that.

Person-centered approach to care

Dr. Klatzker: What we’ve embraced here – what’s part of the DNA of the organization at The Providence Center – we  believe in a person-centered approach to care. No two people are exactly the same. The people that we work for deserve as much access to a wide array of both health and social supports as anyone. That’s how you have to guide yourself. When you’re thinking of those things, primary care integration, working much more toward the mainstream of traditional healthcare is imperative for us.(7:14)

What we’ve found is, if you can build those relationships and find the right connections, then others will embrace you and value you for what you bring to the table. In fact, we bring a lot. Partnership is always the first choice, the default.

We don’t chase dollars, we don’t create programs because it’s the idea du jour from some funder somewhere, we consciously look on our mission as our touchstone and build upon that to provide as much choice to the people we serve. We can be very person-centered because there aren’t many gaps in what we’re providing. (They provide a wider array of services than the average CMHC) We’ve consciously built out a wide array because we think it’s the right thing to do. Rather than to take a “no,” if we can’t partner, we build.

Example of a successful integrated care partnership

Dr. Klatzker: The Providence Center is closely connected to one the largest federally qualified health center in the state of Rhode Island, the Providence Community Health Center. We have become the largest community mental health center. Neither had a desire to replicate the services that the other provided. Over the years we’ve built this into a “no wrong door” integrated collaborative effort so that in the mental health center, the FQHC runs a full-service practice with 1100-1200 patients. In the FQHC, we are integrated in their physician practices building and we also have a separate section of their building where we provide longer term care and some other types of specialty care. We’ve integrated our records with each other. We meet frequently to process and to try to figure out how to make our care efficient and effective. We are working closely with them now on adopting our health home model to integrate a modified health home into the FQHC.

Yes, the times they are a-changin’. And so are healthcare providers. (At least the forward-thinking providers like The Providence Center.) They are heeding the findings from the numerous expert reports and research. They are thinking outside the box, adopting a person-centered approach that enables better outcomes for the many who place their trust in them—trusting them to take care of their whole-health needs.

Behavioral Health Integration 2013 in Review

2013 has been a very good year for Behavioral Health Integration Blog! Our popular Integrated Care Thought Leader Series began this year, providing insights into the minds of some of the most prominent thought leaders in integrated care, including Dr. Alexander “Sandy” Blount, Dr. Benjamin Druss, Larry Fricks, and Dr. Benjamin Miller. Stay tuned in 2014! We have several excellent integrated care thought leaders lined up, to provide their expert perspectives on whole health and integrating behavioral health and primary care for enhancing health outcomes, reducing healthcare costs, and improving access to healthcare.

The WordPress.com stats helper monkeys prepared a 2013 annual report for this blog.

Here’s an excerpt:

A New York City subway train holds 1,200 people. This blog was viewed about 4,800 times in 2013. If it were a NYC subway train, it would take about 4 trips to carry that many people.

Click here to see the complete report.

Happy Thanksgiving from Behavioral Health Integration

Thanksgiving is a time for giving thanks and expressing gratitude. I am so grateful for the increasing focus on integrated care. There seems to have been a surge in collaborative spirit among the healthcare industry. Policy changes have enabled more collaborative approaches to care as well. As healthcare providers increased their focus on integrating behavioral health and primary care services and adopting a whole health/wellness approach to healthcare, we have the opportunity for making a greater impact on the health outcomes of the people we serve.

I would also like to express my deep gratitude to all of the outstanding thought leaders who have taken the time to share their expertise with us over the past year. It is through the sharing of ideas that enables us to foster those changes in thinking and in practice that are necessary for transformation. I’m happy to announce that we have several new integrated care thought leaders lined up for the months to come, each with a unique perspective on an aspect of integration. If you have a recommendation of an integrated care thought leader who we might feature in this blog, please forward the details to me at cherylh@behavioralhealthintegration.com.

I can’t begin to express my thanks to each and every one of you who has taken the time to stop by Behavioral Health Integration Blog to read the posts and offer your thoughts. And thank you to all of you who have subscribed to the blog as well. I look forward to the opportunity to continue to share my insights on integrated care and hope that you will find the content to continue to meet your expectations. It is my sincere hope that each of you has a Thanksgiving filled with loved ones, good health, and happiness.

Celebrate Mental Illness Awareness Week, World Mental Health Day, and National Depression Screening Day

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Celebrate World Mental Health Day 2013

This is Mental Illness Awareness Week and today has been designated as both World Mental Health Day and National Depression Screening Day. Social media has numerous posts this week promoting mental health awareness and related topics as we try to educate the general public. We strive for increased awareness of the importance of good mental health as well as the challenges related to the stigma surrounding mental illness.

Integrating mental health and substance use disorder treatment with primary healthcare provides the opportunity to both increase awareness and decrease the stigma associated with behavioral health issues. Integrated care helps to improve access, reduce costs, and improve outcomes. Integrated care is better care!

In 1990, the U.S. Congress established the first full week of October as Mental Illness Awareness Week (MIAW) in recognition of the National Alliance on Mental Illness’s (NAMI) efforts to raise mental illness awareness. Since then, mental health advocates across the country have joined with others in their communities to sponsor activities, large or small, for public education about mental illness.

Today, 10/10/13, is designated as World Mental Health Day. This year’s theme is “Mental Health and Older Adults.” The day is celebrated at the initiative of the World Federation of Mental Health (WFMH) and the World Health Organization (WHO) supports this initiative through raising awareness on mental health issues using its strong relationships with the Ministries of health and civil society organizations across the globe.

Today is also National Depression Screening Day. National Depression Screening Day raises awareness and screens people for depression and anxiety disorders. NDSD is the nation’s oldest voluntary, community-based screening program that gives access to a validated screening questionnaire and provides referral information for treatment. More than half a million people each year have been screened for depression since 1991.

Let us work together to promote good mental health locally and around the world.

The Role of Integrated Care in Mental Health: Mental Health Blog Day 2013

Blog for MH 2013

I’m happy to be participating in blogging for mental health today. I’m joining in on this year’s blog party because mental health awareness is so important. Each mental health blogger has a unique perspective, addressing important topics such as awareness, recovery, wellness, public policy, services, co-occurring mental health and substance use disorders, etc., providing a personal, professional, or business perspective – or any combination of the three. These interesting and informative mental health blogs will provide an abundance of good reading for blog connoisseurs today!

Integrated care, a whole-health approach to healthcare, plays a very important role in mental health. This perspective has been gaining more and more attention over the past decade or so. It is not uncommon for people who receive mental health treatment to have little or no coordination of services with their primary care provider. Conversely, many people seeking primary care services have unmet mental health and/or substance use disorder treatment needs. This lack of coordination frequently results in sub-par outcomes, yet is often much more expensive as a result of duplicate or counter-indicated procedures and treatment. Lack of coordination results in costly emergency department visits, providing episodic treatment rather than a much more effective chronic care regimen and focus on prevention.

In my last post, I suggested that Integrated Care Awareness Day be recognized during Mental Health Month. As we increase awareness of the need to focus on healthcare in a holistic way, we begin to change the perception of mental health, not only for healthcare providers and policy-makers, but also for the public at large. Through improving access to services, controlling healthcare costs, and through tracking and improving health outcomes, we as a society can transition toward a wellness approach in healthcare.

Access to Services

Stigma is a huge barrier to receiving mental health services. Integrated care allows people to access services through mental health providers or primary care providers. They have the choice to receive mental health services where they are most comfortable.

Controlling Healthcare Costs

Coordination of care and focus on prevention help to control overall healthcare spending. The Affordable Care Act has provided the opportunity for changing the way that healthcare is delivered. Medicaid Health Homes are an example of this.

Improving Health Outcomes

Making use of health information technology enables providers to track outcomes, develop disease registries, and to share information for enhancing the coordination of care. As a result, people have improved health outcomes. They are healthier.

I hope you will stop by again soon. The next several posts to come will be a Thought Leader Series, a conversation with the visionary leaders who are instrumental in developing integrated care through research, policy, practice, and their steadfast passion for improving the lives of so many.

Happy Mental Health Blog Day 2013!

May is National Mental Health Awareness Month: Let’s Include Integrated Care Awareness Day

On 4/30/2013, President Obama became the first president to sign a proclamation declaring May as National Mental Health Awareness Month. “As a nation, it is up to all of us to know the signs of mental health issues and lend a hand to those who are struggling,” he said. “Shame and stigma too often leave people feeling like there is no place to turn. We need to make sure they know that asking for help is not a sign of weakness—it is a sign of strength.” (Click here for a full copy of the Presidential Proclamation – National Mental Health Awareness Month, 2013.) This endorsement and recognition are important steps toward acceptance of mental health. However, mental health and physical health are inseparable. And as more healthcare providers provide integrated services, issues of shame and stigma are reduced, thus creating an environment in which asking for help becomes less difficult. The Affordable Care Act has provided numerous opportunities for the integration of behavioral health and primary healthcare.

Mental Health Awareness Month began in 1949 through the vision of Mental Health America to raise awareness about mental illness and the need for services. This year’s theme is Pathways to Wellness:

Key Messages

  1. Wellness – it’s essential to living a full and productive life. It’s about keeping healthy as well as getting healthy.
  2. Wellness involves a set of skills and strategies that prevent the onset or shorten the duration of illness and promote recovery and well-being. Wellness is more than just the absence of disease.
  3. Wellness is more than an absence of disease. It involves complete general, mental and social well-being. And mental health is an essential component of overall health and well-being. The fact is our overall well-being is tied to the balance that exists between our emotional, physical, spiritual and mental health.
  4. Whatever our situation, we are all at risk of stress given the demands of daily life and the challenges it brings-at home, at work and in life. Steps that build and maintain well-being and help us all achieve wellness involve a balanced diet, regular exercise, enough sleep, a sense of self-worth, development of coping skills that promote resiliency, emotional awareness, and connections to family, friends and community.
  5. These steps should be complemented by taking stock of one’s well-being through regular mental health checkups and screenings. Just as we check our blood pressure and get cancer screenings, it’s a good idea to take periodic reading of our emotional well-being.
  6. Fully embracing the concept of wellness not only improves health in the mind, body and spirit, but also maximizes one’s potential to lead a full and productive life. Using strategies that promote resiliency and strengthen mental health and prevent mental health and substance use conditions lead to improved general health and a healthier society: greater academic achievement by our children, a more productive economy, and families that stay together.

As we focus on the importance of good mental health, it’s also an opportune time for increasing awareness of the importance of focusing on whole health rather than segregating mental health and substance use disorder issues. Contrary to popular belief, mental health services are largely provided outside of the mental health system. According to the Milbank Memorial Fund report, Evolving Models of Behavioral Health Integration in Primary Care, as many as 70 percent of primary care visits stem from psychosocial issues. While patients typically present with a physical health complaint, data suggest that underlying mental health or substance abuse issues are often triggering these visits.

According to the Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report, Mental Illness Surveillance Among Adults in the United States Supplements 9/2/11 – 60(03);1-32:

Mental illness exacerbates morbidity from the multiple chronic diseases with which it is associated, including cardiovascular disease, diabetes, obesity, asthma, epilepsy, and cancer (12–16). This increased morbidity is a result of lower use of medical care and treatment adherence for concurrent chronic diseases and higher risk for adverse health outcomes (17–20). Rates for injuries, both intentional (e.g., homicide and suicide) and unintentional (e.g., motor vehicle), are 2–6 times higher among persons with a mental illness than in the overall population (21,22). Mental illness also is associated with use of tobacco products and alcohol abuse (23).

May has 31 days, so perhaps we can designate one of the days in May as Integrated Care Awareness Day. A day set aside to bring awareness of the benefits of looking at one’s health as a whole rather than segregating mental health from physical health. With this year’s theme, Pathways to Wellness, it is an ideal time to increase awareness.

“The body must be treated as a whole and not just a series of parts.”
– Hippocrates (460 BC – 380 BC)