Integrated Medicine Case Studies Part 2
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Behavioral Medicine for Mental Health Professionals
A Training Resource
By Jim Messina, Ph.D., CCMHC, NCC, DCMHS-T
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What is integrated health care?
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Potential Role of Clinical Mental Health Counseling Professionals In Integrated Primary Care Services
- Conduct Depression, Anxiety and other Mental Health Assessments (see http://www.coping.us/cliniciantreatmenttools/assessmenttools.html for samples of the types of assessments which can be used in primary care settings)
- Address the stressors which lead folks to seek out medical attention in the first place
- Assist in increasing compliance of patients with the medical directives given them by primary care staff
- Wellness educational programming to help ward off chronic or severe illnesses
- Assisting clients to cope with the medical conditions for which they are receiving medical attention
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AMHCA’s 2011 Expanded Clinical Standards for Training of CMHC’s include these Integrated Medicine related Factors
1.Evidence-Based Practices
a.Diagnosis and Treatment Planning using EBP’s
b.Diagnosis of Co-Occurring Disorders & Trauma
2.Biological Basis of Behaviors
a.Knowledge of Central Nervous System
b.Lifespan Plasticity of the Brain
3.Psychopharmacology
4.Behavioral Medicine
a.Neurobiology of Thinking, Emotion & Memory
b.Neurobiology of mental health disorders (mood, anxiety, psychosis) over life span
c.Promotion of optimal mental health over the lifespan
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What is the Role of a Behavioral Health Care Consultant in an Integrated Medical Setting?
The role is based on the Principles of the Integrated Medical Model:
Principle #1: The Behavioral Health Consultant’s role is to identify, treat, triage & manage primary care patients with medical and/or behavioral health problems
Principle #2: The Behavioral Health Consultant functions as a core member of primary care team, providing consultative services
Principle #3: The Primary Care Behavioral Health Model is grounded in a population-based care philosophy
Principle #4: The Behavioral Health Consultant seeks to enhance delivery of behavioral health services at primary care level & works to support smooth interface between primary care & specialty services (Mental Health & Substance Abuse Treatment).
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A Toolkit identifies:
What are the competencies needed in Integrated Medicine for Behavioral Health Consultants?
It is the "Primary Care Behavioral Health Toolkit" (Mountainview Consulting Group, 2013)
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Role of Behavioral Health Consultants in Integrated Medicine Settings
Behavioral Health Consultant (BHC) in Primary Care Behavioral Health (PCBH) has following role:
BHC role is a behavioral health provider who:
1.Operates in consultative role within primary care team utilizing PCBH Model
2.Provides recommendations regarding behavioral interventions to referring Primary Care Clinician (PCC)
3.Conducts brief interventions with referred patients on behalf of referring Primary Care Clinician PCC
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The Responsibilities of a Behavioral Health Consultant
The Behavioral Health Consultant:
1. Maintains visible presence to PCCs during clinic operating hours
2. Is available for “curbside” consultation (a brief interaction between PCB & PCC) by being in clinic or available by phone or pager
3. Is available for same day and scheduled initial consultations with patients referred by PCCs
4. Performs brief, limited follow-up visits for selected patients
5. Provides a range of services including screening for common conditions, assessments & interventions related to chronic disease management programs
6. Conducts risk assessments, as indicated
7. Provides psycho-education for patients during individual and group visits
8. Assists in development of clinical pathway programs, group medical appointments, classes & behavior focused practice protocols.
9. Provides brief behavioral and cognitive behavioral interventions for patients
10. Triages patients with severe or high-risk behavioral problems to CBHS or other community resources for specialty MH services consistent with Step-up/Step-down criteria
11. Provides PCCs with same-day verbal feedback on client encounters either in person or by phone
12. Facilitates and oversees referrals to specialty MH / SA services and when appropriate, support a smooth transition from specialty MH / SA services to primary care and supports collaboration of PCCs and psychiatrists concerning medication protocols
Read more about within the Primary Care Behavioral Health Toolkit available at: http://www.pcpci.org/sites/default/files/resources/PCBH%20Implementation%20Kit_FINAL.pdf
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Impact of Mental Illness on Physical Health
Persons with mental health problems have higher rates of health risk for smoking, obesity, and physical inactivity
Persons with mental health problems have higher rates of diabetes, arthritis, asthma, and heart disease
Persons with both chronic disease and mental illness have higher costs and poorer outcomes
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Assess for ACE Factors and Adult Trauma in Integrated Medical Settings
Traumatic life experiences, especially multiple traumas, raise the risk for:
- Alcoholism and alcohol use, substance use
- Obesity
- Respiratory difficulties
- Heart disease
- Multiple sexual partners
- Poor relationships with others
- Smoking
- Suicide attempts
- Unintended pregnancies
What are the ACE factors?
ACE (Adverse Childhood Experiences)
Abuse
1. Emotional Abuse
2. Physical Abuse
3. Sexual Abuse
Neglect
4. Emotional Neglect
5. Physical Neglect
Household Dysfunction
6. Mother was treated violently
7. Household substance abuse
8. Household mental illness
9. Parental separation or divorce
10. Incarcerated household member
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Primary Care Provider Model in Integrated Medicine
- Brief, problem focused communication
- Immediate solution driven care
- Productivity measured in terms of number of patients seen
- Many evidence based interventions
- Disease management as standard part of practice
- Risk/liability concerns
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Skills Needed by Mental Health Professional in Integrated Medical Setting
Skills and knowledge needed to effectively function on an integrated health team include:
- Medical Literacy
- Consultation Liaison skills with medical problems
- Population Screening
- Chronic Disease Management
- Care Management Skills
- Educating medical staff about integrated care
- Evidence-Based Interventions
- Group Interventions
- Working within the fast-paced, action-oriented ecology of primary care
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Knowledge needed by Mental Health Professional in Integrated Medicine Setting
Basic knowledge about key health behaviors and physical health indicators (normal, risk and disease level blood chemistry measures ) routinely assessed and addressed in an integrated system of care, including:
- body mass index
- blood pressure
- glucose levels
- lipid levels
- smoking effect on respiration (e.g., carbon monoxide levels)
- exercise habits
- nutritional habits
- substance use frequency (where applicable)
- alcohol use (where applicable)
- subjective report of physical discomfort, pain or general complaints
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Skills needed by Mental Health Professional in Integrated Medical Approach
- Engaging, Connecting, and Enhancing Motivation Skills
- Teaching skills: Imparting Information Based on the Principles of Adult Education
- Comprehensive Integrated Screening and Assessment Skills
- Brief Behavioral Health and Substance Use Intervention and Referral Skills
- Comprehensive Care Coordination Skills
- Health Promotion, Wellness and Whole Health Self-Management Skills in Individual and Group Modalities
- Basic Cognitive-Behavioral Interventions
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Examples of Behavioral Medicine Interventions
- Biofeedback
- Cognitive Behavioral Therapy (CBT)
- Meditation
- Guided Imagery
- Mindfulness
- Clinical Self-Hypnosis
- Yoga
- Tai Chi
- Relaxation Training
- Progressive Muscle Relaxation
- Transcendental Meditation
- Self-Regulation Skills-learn to put control of health under one’s own personal locus of control
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Examples of Outcome Goals of Behavioral Medicine Interventions
- Prevent disease onset
- Lower blood pressure
- Lower serum cholesterol
- Reduce body fat
- Reverse atherosclerosis
- Decrease pain
- Reduce surgical complications
- Decrease complications of pregnancy
- Enhance immune response
- Increase compliance with treatment – medication plans
- Increase relaxation
- Increase functional capacity
- Improve sleep
- Improve productivity at work & school
- Improve strength, endurance, and mobility
- Improve quality of life
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Case Study: Obesity
Joey an African American young man was brought to an Integrated Medical Care Center because he was found to be not only obese but also prediabetic. Joey is 11, he is five feet tall and weighs 210 pounds. He has an A1C of 6.3 and his BMI is 41.
What would you do as a Behavioral Health Consultant if Joey came to you during this visit with his Primary Care Physician?
FIRST THINGS FIRST: What you need to Know
What is the A1C test?
The A1C test is a blood test that provides information about a person’s average levels of blood glucose, also called blood sugar, over the past 3 months. The A1C test is sometimes called the hemoglobin A1c, HbA1c, or glycohemoglobin test. The A1C test is the primary test used for diabetes management and diabetes research.
Diagnosis A1C level
Normal Below 5.7 percent
Diabetes 6.5 percent or above
Prediabetes 5.7-6.4 percent
You can download the A1C Conversiont Table by clicking here
Patients and their health care provider should discuss an A1C goal that is right for them. For most people with diabetes, the A1C goal is less than 7. An A1C higher than 7 means that the patients have a greater chance of eye disease, kidney disease, heart disease, or nerve damage. Lowering patients’A1C by any amount can improve their chances of staying healthy. If their A1C is 7 or more, or above their A1C goal, the health care team will need to consider changing the patients’ treatment plans to bring the A1C number down.
What is the BMI Scale?
The BMI is determined by comparing the height of the individual and the individual's weight
BMI Score Diagnosis
19-24 Normal
25-29 Overweight
30-39 Obese
40-54 Extremely Obsese
The BMI is calculated by taking the height and weight of the individuals Example: a Male 5’10” weighing 210 pounds has a BMI of 30 and is considered low end of being obese
You can download the BMI Scale Chart by clicking here
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What Joey needs is Lifestyle Change!
Our patient Joey needs a lifestyle change
He and his mother and family need assistance from
- Primary care physician to continuously monitor his BMI and A1C
- Dietician to help his family plan healthy nutritional intake for Joey & family
- Physical therapist or Personal Trainer to initiate and maintain a healthy exercise program for Joey and other members of his family if needed
- Behavioral Health Consultant to work with his Mother and family members to control Joey’s need to “always” be eating some goodies which they have in the cupboards or fridge
- His mother and/or family members need a Mental Health Professional to help dispute the irrational thinking which keeps them a hostage from being more direct and consistent in maintaining a healthy lifestyle for the entire family
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Case Study: Diabetes
Mr. Morella is a 55-year-old man who was diagnosed with type 2 diabetes 10 years ago. His diabetes is not well-controlled with an oral hypoglycemic agent; his A1c at his last visit was 7.8%. His BMI is 41. He argues that with a BMI of 41 he is not obese because "all of my friends are this size". He reports that it is very difficult to eat a consistently low-carbohydrate diet because his large family enjoys Italian food, especially on social occasions, and it is hard for him not to participate in family meals. He has heard that taking vinegar with his meals can improve control of his blood sugar.
As a Behavioral Health Consultant in an Integrate Medical Practice, what would you say and do with Mr Morella?
Mental Health Professionals need to to get acquainted with working with patients with Diabetes
Use http://www.bd.com/us/diabetes/hcp/main.aspx?cat=3065&id=3117
By doing so a Mental Health can get used to:
1.Tests used in diagnosing and treating Diabetes
2.The range of medical treatments used
3.What lifestyle changes are encouraged for patients to better control their diabetes
4.How to deal with non-compliant patients who resist doing what they need to do to take better control over their blood sugar issues
For an example of how Nurse practitioner works with a diabetic client look at this article: http://spectrum.diabetesjournals.org/content/16/1/32.full.pdf+html
Medscape has many case studies on Diabetes and this particular one addresses a patient who is non-compliant and looking for another route to lower blood sugar: http://www.medscape.com/viewarticle/758599
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Case Study-Asthma
Lorena is an 8-year-old Hispanic Female with asthma who was seen in the ER yesterday with respiratory distress due to an acute exacerbation. She was sent home with an immediate therapy and her mother was told to bring Lorena in to her Primary Care Physician’s Integrated Medicine Center to get long term care. During this visit, Lorena reported that she adores her cat Rafael and he goes everywhere with her even to bed at night. She also said that even though she would like her mom not to smoke, mom does smoke not only in the house but also in the car when they go places, and in fact yesterday before mom took her to the ER they were in the car when her respiratory crisis hit. You are on the multidisciplinary treatment team who is identifying a number of issues related to poor long-term control of asthma and you and the team need to establish a plan to address them.
What would you do as a Behavioral Health Consultant in this case?
Issues in dealing with Patients with Asthma
1.Reluctance to use the steroid inhalers
2.Prescribe inhalers only after patients have been trained and have demonstrated satisfactory technique
3.Create a Self-Management Treatment Plan: Self-management is effective and needs to be offered to all patients with asthma which is reinforced with a written asthma action plan that gives patient-specific advice on signs of deteriorating asthma and appropriate actions to take
The asthma action plan should contain the following:
- Medication use and potential adverse effects
- Indication for follow-up with provider including contact number
- Symptoms of worsening asthma
- Triggers to avoid such as: animal dander - do not allow animals to sleep with patient and smoke - household members need to smoke outside and never in car with patient
Case Studies on Asthma available from the Kansas University Medical Center is available at: http://classes.kumc.edu/cahe/respcared/asthma/asthma.html and from Medscape at: http://www.medscape.org/viewarticle/493652_6
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Case Study: Gastrointestinal Disorder
Mina is a 45 year Asian American, who has been coming into to your integrated medical center for the past six months for dyspepsia. Her Primary Care Physician asked you to see Mina today because he believes that she has severe anxiety and he would like to have Mina address her anxiety issues since the treatments she has been getting have not made any difference in her stabilizing her physical symptoms. He also raised the question as to which came first her anxiety or her dyspepsia and he would like your help to clarify this with Mina so that she can relax and have a reduction of her physical symptoms.
So what would you do? GI issues are known to be comorbid with Anxiety Disorders and Mina needs help to lower her stress levels and stabilize to see if her medications can lessen her issues with dyspepsia.
Some Common Functional GI Disorders Disorder Prevalence in the General Population
Functional Dyspepsia 20% to 30%
Irritable Bowel Syndrome 10% to 20%
Functional Constipation Up to 27%
Pelvic Floor Dysfunction 5% to 11%
There is a Head-Gut connection in many GI disorders and there is a need to address the emotional issues which aggravate these life-long disorders
There is also a need to refer to dieticians to address the aggravating foods which exacerbate the GI symptoms
Example of case study for GI on Medscape: http://www.medscape.com/viewarticle/776367_8
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Case Study: Cancer
Marlene is a 36 year old Caucasian female, mother of three and a teacher in a local school. Today in your integrated medical setting she was given the news of a diagnosis of Stage Three Uterine Cancer. She and her husband are sitting in your office telling you about what the doctors are saying about the treatments which Marlene will undergo over the next year. They are shaken and upset and are not sure how they are going to handle all of this within their family given Marlene is the primary bread winner in the family and her husband Chuck is the stay at home father.
As a Behavioral Health Consultant in this integrated practice, how would you handle Marlene and Chuck?
Ideal Integrated Medicine Approach to Cancer Treatment
- Mental Health and Family Counseling to help lessen the emotional burden of cancer for patients and their loved ones
- Support Groups to provide a setting in which patients, families and caregivers can talk about living with cancer with others who may be having similar experiences
- Clinical Case Manager to facilitate appointments and follow up care
- Nutritional Support during cancer treatments to support patients’ nutritional needs
- Pain Management Services to help to relieve pain as well as associated physical or psychological symptoms
- Patient Resource Center to provide patients with tools and information they need to help educate themselves on their illness
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So How About You? Are you Ready?
To support your upgrading your knowledge base about integrated medicine approaches I have on my website the following tools:
1.Clinician Treatment Tools: Assessment & Treatment Plans, Clinical Assessment Instruments, Clinical Worksheets and Handouts, Clinical Treatment Apps that work, Reference Guide to Treatment Manuals for Treatment Planning and Evidence Based Practices (EBPs) at: http://www.coping.us/cliniciantreatmenttools.html
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