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Role of Primary Care-Mental Health Integration in Chronic Pain Management Tu Ngo, PhD, MPH

Faculty and Disclosures Tu Ngo, PhD –Nothing to Disclose

Ilene R. Robeck, MD –Nothing to Disclose

Learning Objectives Explain how the VA’s pain, primary care , and primary care mental health integration (PC-MHI) programs interface regarding chronic pain management Describe the rationale and components of offering PCMHI in primary care Identify ways in which PC-MHI staff work with primary care to help manage chronic pain

3 Aligned VA Programs Affecting Chronic Pain Management Primary Care Mental Health Integration (2007) VHA Pain Directive (2009) PACT (2009)

VA Stepped Pain Care RISK RISK

Advanced diagnostics & interventions CARF accredited pain rehabilitation



Treatment Refractory


Pain Medicine Rehabilitation Medicine Behavioral Pain Management Multidisciplinary Pain Clinics SUD Programs Mental Health Programs Routine screening for presence & intensity of pain Comprehensive pain assessment Management of common pain conditions Support from MH-PC Integration, OEF/OIF, & Post-Deployment Teams Expanded care management Opioid Renewal Clinics 6



Primary Care-Mental Health Integration “The greatest mistake in the treatment of diseases is that there are physicians for the body and physicians for the soul, although the two cannot be separated” Plato

“Primary care practitioners are a critical link in identifying and addressing mental disorders... Opportunities are missed to improve mental health and general medical outcomes when mental illness is under-recognized and under-treated in primary care settings” Former Surgeon General David Satcher

What does AHRQ think? “…PCMH will not reach its full potential without adequately addressing the 30-50% of patients with mental health needs. Doing so, however, will likely shift responsibility for the delivery of much mental health care from the mental health sector into primary care….” Thomas W. Croghan, co-author of June 2010 AHRQ report on Integrating Mental Health Treatment Into the Patient Centered Medical Home

PC-MHI is PACT “Behavioral health and primary care are inseparable, and any attempts to separate the two lead to suboptimal care” Patient-Centered Primary Care Collaborative, 2010

– Particularly relevant to two joint principles of the medical home: – Whole Person Orientation – Coordinated/Integrated Care

“Mental health is particularly important to the context of the whole person” Robert Graham Center, 2007

National PC-MHI Office, 2011

Primary Care Realities  What proportion of primary care appointments have a psychosocial component? – Up to 70%

Fries, Koop, & Beadle, 1993

• Psychiatric disorders – full spectrum • Issues with a large behavioral component (IBS, tension headaches, insomnia, nonspecific pains, vague somatic symptoms which most patients view as medical) • Unhealthy lifestyles (smoking, diet, etc.) • Life stressors

– What percentage of scripts for psychotropic medications (e.g., antidepressants) are written by PCPs?

Bigger Realities Mind and body are interconnected and we need to be, too:

–Emotional factors affect physical health –Medical illnesses can lead to psychological distress –Psychosocial distress corresponds with morbidity and mortality risk –Effective treatment of many medical conditions includes a major behavioral component

Patient outcomes are interdependent

– Multiple studies show depression has an independent effect on all-cause mortality

Gallo et al., 2005; Penninx et al., 1999; Bruce and Leaf, 1989

– Data from late-life depression trial shows addressing depression in an integrated fashion in primary care can decrease mortality

Gallo et al., 2007

Uniform Mental Health Services Package VHA Handbook 1160.01 requires that VAMCs, very large* CBOCs, and large* CBOCs integrate mental health services into primary care venues by providing both co-located collaborative care and care management Core disease foci for integrated care are: depression and anxiety disorders; alcohol misuse and abuse; and PTSD screening *Very Large=10,000+ unique patients per year; Large=5,000 to 10,000 unique patients per 13 year

What is Integrated Care?

Integration Defined by VA  Care Management  Co-location  Collaborative – Integrated mental health provider (aka Behavioral Health Provider) is part of primary care team – Shared treatment plan – Deliver services together • Co-visits • Dual interviews • Group Visits

Blended Programs include ALL components

PC-MHI Care Management  Designated Care Manager supporting longitudinal mental health care, commonly an RN  Evaluation and triage, usually telephone-based  Patient activation, education for self-management  Telephone follow-up includes on-going assessment and monitoring of adherence to medication, treatment plan  Guideline-based treatment support  Referral management

Co-located Collaborative Care Mental health provider embedded in primary care clinic with shared responsibility for evaluation, treatment planning and monitoring outcomes Consultation to the PCP Immediate evaluation as needed Brief treatment Educational function

Psychologist Contributions to PACT Team Educate team about the biopsychosocial elements of pain Co-visit with patient and PCP Educate PCP’s on self-management strategies - they can reinforce our efforts (consistency) Educate team on key skills: motivational enhancement, goal setting, communication

Psychologist Contributions to PACT Team  Provide assessment of psycho-social factors to enhance team’s pain case conceptualization – Quality of life – Functional status – Depression and anxiety – Personal goals – Risk factors (for opiate abuse or misuse)

 Provide intervention to improve these factors

Ways to Work Together Collaboration with primary care providers Promoting self-management Pain school (self-management groups) Group Medical Visits: Cooperative Health Care Clinic Care management of pain and depression Health Coaches/Health Behavior Coordinator

Group Medical Visits: CHCC  Cooperative Health Care Clinic  Permanente Medical Group in Colorado  Focus on patient population (high risk or high utilization behavior, i.e. management of chronic pain, diabetes, CHF, hypertension)  Goal to increase access while delivering quality of care  Outcome: – Improve provider and patient satisfaction – Improve patient outcomes – Reduce service (utilization of hospital, ER, and nursing facilities) – Lower costs

Beck et al, 1997

CHCC: Improving Self-Efficacy Significantly more confident about asking their physician about health problems Significantly more comfortable talking to their physician (particularly about personal problems related to health) Understand their medications significantly better Significantly more likely to talk to a pharmacist if medication questions arise Significantly more confident about working out differences with their physician when they arise Scott 2001

Why Group Medical Visits Work  Installation of hope  Universality: disconfirmation of uniqueness  Imparting information  Allaying fears  Modeling behavior  Developing of social skills  Group cohesiveness (bonding)  Catharsis plus cognitive and interpersonal learning  “Creating the therapeutic milieu without doing therapy”

 Assistance with Pain Treatment (APT) vs Treatment as Usual (TAU)  42 primary care clinicians/401 patients  Measures: –Roland Morris Disability Questionnaire –Chronic Pain Grade – Pain Intensity –Patient Health Questionnaire - 9  APT: –Clinician education –Pt assessment, education & activation –Symptom monitoring –Feedback and recommendations –Facilitation of specialty care

Change from baseline to 12 mo f.u. 0 -0.5 -1 -1.5 -2 -2.5





-3 -3.5 -4 -4.5 -5

Dobscha et al. Collaborative care for chronic pain in primary care. JAMA 2009; 301: 1242-1252.

Stepped Care for Affective Disorders 100.00% and Musculoskeletal Pain (SCAMP) vs. 90.00% 80.00% Usual care (UC) 70.00% SCAMP 60.00% – 12 wks optimized antidepressant therapy – 6 sessions of pain self-management – 6 mos continuation

250 patients Measures – Hopkins Symptom Checklist – Brief Pain Inventory – Global Improvement in Pain





30.00% 20.00% 10.00% 0.00% Hopkins MDD



Kroenke et al., Optimized antidepressant therapy and pain self-management in primary care patients with depression and musculoskeletal pain: A randomized controlled trial. JAMA 2009; 301: 2099-2110.

Thank You! Questions?

Role of Primary Care-Mental Health Integration in Chronic Pain Management  

Tu Ngo, PhD, MPH