Scattergood Foundation

Advancing Innovative Strategies for Change in Behavioral Health

Drexel University, College of Nursing and Health Professions

Name of Innovative Program: 
BH-Works - Using Technology to Incorporate Mental Health Screening into Medical Settings
Sponsoring Organization
Drexel University, College of Nursing and Health Professions
Name of Innovative Program Lead: 
Guy Diamond, Ph.D. and the BH-Works Team, Dr. Joel Fein, Dr. Matt Wintersteen and Dr. Allen Tien
E-mail Address of Innovative Program Lead: 
guydiamond@drexel.edu
Project Description: 
The Behavioral Health-Works (BH-Works) program, designed by the nominee and team, integrates screening, prevention, triage, and tracking services for adolescents (12-24) into Primary Care (PC) and Emergency Departments (ED). At the core of BH-Works is the web-based Behavioral Health Screen (BHS) measuring depression, suicidality, trauma, substance use, sexuality, gun access, bullying, violence exposure, and other risk behaviors.  Patients complete the self-report screen during a medical visit. The questionnaire is automatically scored and a report is generated for review during the clinical encounter.  Multiple assessments over time are also graphed.  The PC version takes 7 to 10 minutes to complete and the ED version takes 3 to 5 minutes. It is available in English, Spanish, Mandarin, and Korean.  The BHS is enhanced by web based mental health lectures, resources for improving the referral processes, and support for billing codes.  Data are securely stored in a HIPAA-compliant web hosting center and can be reported by patient, practice, hospital or state.  The BHS is used in 40 Pennsylvania sites screening 1,000 patients per month in PCP offices, EDs, college health centers, schools, and mental health facilities. The New York Department of Health has licensed BH-Works for use in PCP offices across 26 counties.  
Creativity and Innovation: 
Primary care practices and Emergency Departments are clearly potential gatekeepers for youth with depression, suicide and other mental health distress (IOM, 2002; AACAP, 2009; USPSTF, 2009).  Unfortunately the integration of mental health into medical settings is hampered by inadequate screening tools and barriers to administration.  Most screeners are written-only reports on one domain, usually ask about only the past two weeks, and lack psychometric validation.  BH-works addresses all of these limitations. It is web based, integrates with EMRs, covers all the domains recommend by the American Academy of Pediatrics for an adolescent well visit, and fits well into the work flow of a busy medical, clinic or other setting.  In addition, patients can be tracked over time and data can be aggregated for QI reports and research.  This innovative screening program is a creative public private partnership between team members from Drexel University and Mdlogix, a state-of-the-art health informatics company.
Leadership: 
BH-Works is supported by every Pennsylvania State Medical Association, the State Department of Public Welfare, several hospital and mental health systems, and public and private insurance companies.  These organizations promote adoption and address system level barriers that discourage screening.  Dr. Diamond and his team work closely with  medical and mental health leadership to encourage partnerships; recently holding a conference at Children’s Hospital of Philadelphia on the BH-Works integration process. With a live audience and web cast technology, the BH-Works team reached more than 500 observers around the world (e.g., Pennsylvania, Japan, Germany, Brazil). The lectures can be viewed at www.sprc.org/training-institute/behavioral-health-primary-care-clinical-strategies-and-program-models-working-high-risk-youth. Mental health assessment and treatment services are significantly approved with BH-Works  by helping medical providers feel more confident in assessing, referring and treating their adolescent patients behavioral health needs. These efforts support the medical home model where providers and patients create a more collaborative and comprehensive healthcare experience.
Sustainability: 
The  sustainability plan for BH-Works emerges from the partnership between Drexel University, CHOP and Mdlogix' allowing the BH-Works team to continue the clinical and academic development of BH-Works while licensing the system at a reasonable cost.  Mdlogix handles marketing and distribution and Drexel and CHOP provide technical assistance and research development. The first large scale customer is the Department of Health in New York State, adopting this tool as part of their state-wide suicide prevention efforts. Several other states are considering including BH-Works in their SAMHSA-funded suicide prevention grants, or as a resources in their mental health systems (e.g., crisis workers, school counselors, etc.)  In addition to a commercial distribution, Dr. Diamond and his team continue to pursue grant opportunities to support development and adaptation; such as a project to  modify the system to function as an assessment, diagnostic, and outcomes monitoring program for mental health service providers.
Replicability: 
BH-Works development has occurred over ten years. Psychometric studies have demonstrated the reliability and validity of the screening items.  The web technology platform has  gone through extensive development, expansion, and validation. Although the team continues to develop versions of the screener (e.g. the adult and high school version were just launched), replication is now the focus of research and commercialization efforts. The success of BH-Works is demonstrated in the expansion to 40 different sites and provider systems (ED, schools, mental health). Implementation occurs in 3 phases. Initially the team (1) joins with the staff to resolve work flow and IT challenges and build the behavioral health community (start-up); (2)  solidifies work flow procedures for screening and referral (implementation) and (3) transfers operations to the clinic (sustainability). The BH-Works team continues to expand to new PCP sites, hospital systems, and states.
Results/Outcomes: 
Outcomes of BH-Works are measured in several ways. Process outcomes include the number of clinical sites that use BH-Works and the number of patients who are screened per month. Forty sites screen nearly 1,000 youth a month. Intrinsic outcomes include the number of patients assessed as having a serious behavioral health issue, i.e., in a sub sample of 5,050 adolescents, 862 indicated some level of risk for suicide and 210 (4%) had current suicidal ideation, of whom 16% reported having access to a gun.  Co-morbid mental health problems were also prevalent: 22% endorsed at least moderate depression, 29% anxiety, 26% experiencing at least one kind of traumagenic event (abuse, witness to violence), 3% reported eating disorder, 50% reported using alcohol and 22% reported having tried marijuana.  Finally, the team is currently focused on developing software functionality that will facilitate referrals and patient engagement into the appropriate behavioral health care.
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