Southeast Texas Medical Associates, LLP James L. Holly, M.D. Southeast Texas Medical Associates, LLP

Transforming Your Practice - Behavioral Health
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    Behavioral health is a term that covers the full range of mental and emotional well-being - from the basics of how we cope with day-to-day challenges of life, to the treatment of mental illnesses, such as depression or personality disorder, as well as substance use disorders and other addictive behaviors.  While they are not precisely synonyms, behavioral health and mental health are functionally the same.  The following is a published description of mental health.  It is a level of psychological well-being, or an absence of a mental disorder; it is the "psychological state of someone who is functioning at a satisfactory level of emotional and behavioral adjustment." From the perspective of positive psychology, mental health may include an individual's ability to enjoy life, and create a balance between life activities and efforts to achieve psychological resilience.

    According to the World Health Organization (WHO) mental health includes "subjective well-being, perceived self-efficacy, autonomy, competence, intergenerational dependence, and self-actualization of one's intellectual and emotional potential, among others.: WHO further states that the well-being of an individual is encompassed in the realization of their abilities, coping with normal stresses of life, productive work and contribution to their community. However, cultural differences, subjective assessments, and competing professional theories all affect how "mental health" is defined.  A person struggling with his or her behavioral health may face stress, depression, anxiety, relationship problems, grief, addiction, ADHD or learning disabilities, mood disorders, or other psychological concerns. Counselors, therapists, life coaches, psychologists, nurse practitioners or physicians can help manage behavioral health concerns with treatments such as therapy, counseling, or medication. The new field of global mental health is "the area of study, research and practice that places a priority on improving mental health and achieving equity in mental health for all people worldwide."

    In the Medical Home Model of healthcare, it is imperative that the patient participates in their own care.  Terms like “activated,” “engaged,” and “shared decision making” are important descriptions of the dynamic of the patient participating in and actually “taking charge” of their own care.  As part of this process, it is important that the patient’s preparation to change be sustained.  In other tools, SETMA discusses the power of “What if Scenario,” which addresses the providers ability to quantify for the patient that fact that “if they make a change, that that change will make a difference in their health.”  This is principally done through the Framingham Risk Scores and the ability to display the difference a change in behavior will make.  That tool can be reviewed in either:

    1. SETMA’s Disease management tools for Diabetes, Hypertension and Lipids used for patient activation and engagement via written plans of care and treatment plans.

    2. Framingham Heart Study Risk Calculators Tutorial

    The assessment of a patient’s preparation to make a change can most effectively be done through the Transtheoretical Model Assessment of the Stages of Change which can measure the patient’s preparation of making the changes recommended in SETMA’s “What if Scenario.”  The following steps explain how to use SETMA’s deployment of the Transtheoretical Model.

    Health and Human Services through CMS is becoming increasingly more  involved with preventive care and more payments are being made for screening and preventive care which will ultimately make a difference in the care, the health and the cost of care for Medicare beneficiaries.  Two new services are:  Intensive Behavioral Therapy (IBT) for Obesity (G0477) and Intensive Behavioral Therapy (IBT) for Cardiovascular Disease (G0446).

    Only about half of smokers are ever advised to quit smoking by their physicians. The Agency for Health Care and Policy and Research recommends that physicians should discuss the dangers of smoking with their patients and should continue to encourage them to quit at every office visit. Physicians are in an ideal position to advise against smoking because 70 % of smokers see their primary care physician about three to four times a year. Research indicates that success rates for unaided smoking cessation doubles from 5% to 10% of attempts when instigated by simple advise to quit from the clinician. Yet, the literature continues to document the failure of physicians and other healthcare professionals to intervene with all of their patients who smoke, with only half of current smokers reporting having been encouraged to quit and even fewer receiving specific counseling.  Healthcare settings provide an important teachable moment for smoking cessation intervention. Seventy-five percent of the adult population visits a physician at least once a year, with the average adult making five visits per year. In the physician's office, patients are often conscious of their health and most receptive to risk factor intervention, providing an important opportunity for change.

    This is one of the greatest health threats to all elderly patients but particularly to those who are in long-term residential care.  Through the review of seven categories, a score is developed which indicates whether the patient is at high risk or low risk of falls.

    Depression is a serious and often life-threatening problem in the elderly and particularly in the elderly in long-term residential care facilities.  In addition, the complexity of mediation treatment of the elderly is greater because they are often on multiple drugs which have serious interactions.  While this template is mostly educational, it is key to the successful treatment of residents of long-term care facilities.

    As part of SETMA’s Patient-Centered Medical Home, we annually complete five questionnaires for each patient to assess each of the following:  Fall Risk, Pain Assessment, Functional Assessment, Wellness, Stress.  The standard is that each should be completed on all patients at least once a year and more frequently if a change in conditions dictates.  The Fall Risk should be completed on all patients over 50 and on younger patients who as a result of chronic condition are at risk of falling.

    SETMA’s Weight Management Program is built on the AMA’s Adult Weight Management Program which was published in February, 2004.  It is premised on the proposition that excess weight and/or frank obesity is not simply coincidental with virtually every disease which we treat but is either contributory and/or directly causative of those conditions including hypertension, congestive heart failure, diabetes, metabolic syndrome, hyperlipidemia, coronary artery disease, and a number of types of cancer, among many others.  SETMA’s weight management program is designed to make it simple for health care providers to determine and to document whether or not patients are qualified for treatment with medication or surgery, based on sound scientific evidence.  This tutorial will help all providers learn to utilize this suite of templates either for intensive weight management of a patient, or for giving the patient a weight-management assessment, and/or to help a patient understand why they do, or do not qualify for pharmaceutical and/or surgical treatment of their weight.  The weight management assessment is a part of SETMA’s LESS Initiative which is utilized with every patient we see.

    The premiere primary preventive health initiative of SETMA is the LESS Initiative. LESS is an acronym for: lose weight, exercise, and stop smoking. Included in the LESS Initiative are diabetes prevention, hypertension prevention and insulin resistance risk analyses. The following procedure is the proper way to complete the LESS Initiative.  The LESS Initiative is explained in the TCPI section of this website under its own drop down.

    As end-of-life planning becomes increasingly an important part of patient care, it is important to find ways of quantifying patient’s qualification for hospice care and where possible, a means of quantifying a reliable estimate of survival time for patients.  While there will never be an absolute, four scores are being used to aid in this process.  The first, the Karnofsky Scale, was first described in 1949; the second, the Palliative Performance Scale has been used in cancer patients since 1996; the third the Braden Clinically Unavoidable Skin lesions and the fourth Functional Assessment Testing Alzheimer’s and Related Conditions (FAST).  SETMA has deployed all four of these scores, along with a fifth which is the Lansky Scare.  The Lansky is like the Karnosky Scale but is used with patient under 16.  These tools can be found by going to GP Master Template.  In the second column you will find these four scales.  They are also deployed on the Master Template in the Hospital Care Summary and Post-Hospital Plan of Care and Treatment Plan Suite of templates. 

    Pain Management

    In an effort to decrease the inappropriate use of antipsychotic medications in Texas Nursing Homes, The Texas Medical Foundation and the Texas Department of Aging and Disability provided this toolkit.  Because SETMA provides care to over 90% of the long-term care residents in Southeast Texas, which comprises a five county area, and because SETMA documents the care of those patients in our electronic patient record (EMR), we have taken this tool kit and created a Clinical Decision Support tool to improve the care of the patients for whom we have responsibility.