SBM - Society of Behavioral Medicine



Anxiety Clinical Pathway OutlineIdentification of Patients for Anxiety PathwayCriteria for inclusion into anxiety clinical pathway: Patients meeting the following criteria should be asked to attend an IBHC appointment as part of their standard evidence-based team healthcare:Patients newly diagnosed with anxiety disorderPatients scoring 3 or higher on GAD-2 (screened at PCM appointment)Active Duty patients who report anxiety/stress-related symptoms on the PHA/PDHRAPatients who are prescribed a psychotropic medication for anxietyPatients who are diagnosed with an anxiety disorderProcess for identification: Multiple methods should be used to identify anxiety patients for referral to the IBHC.Morning huddle review of PCM patient rosterIdentification of patient by nurse/tech during screening for PCM appointmentIdentification of patient by PCM during PCM appointmentPatient self-referralReferral of patient by otherPatients with 3+ score on GAD-2Data pull from AHLTA or Care Point (diagnosis, PHQ-9, prescriptions, etc.)Methods of Linking Identified Patients with the IBHC During a PCM appointment with a patient who meets any of the inclusion criteria, the PCM, nurse, and/or other designated team member ensures the patient receives a same-day appointment with IBHC (warm handoff) or schedules a future IBHC appointment.If patients are identified through monthly data pull from AHLTA or Care Point:PCMH nurse or technician calls patient to schedule a future IBHC appointment. Caller uses standard pathway telephone script.PCMH nurse, technician, PCM, or IBHC may also send secure email to encourage an IBHC appointment.If patient refuses to see the IBHC, the PCM, nurse, or technician will ask the IBHC to review the available medical record and information from the PCM and document recommendations for care based on available medical data. Initial IBHC AppointmentBiopsychosocial functional assessment questions for anxiety management: Brief description of symptoms (emotional, cognitive, behavioral, physical)Duration of problem (How long have you had these symptoms?) Factors correlated with onset (Have you noticed anything that triggers these symptoms?) Frequency of symptoms (How often do you experience these symptoms?) Severity of symptoms (How severe or how intense are these symptoms? Can use 0 to 10 severity scale to measure severity/intensity) Psychosocial factors: (Are there things in your environment or relationships that impact your symptoms?) Aggravating/alleviating factors (Is there anything that you have tried that makes your symptoms worse or better?) Current treatment (Are you currently receiving any treatment for these symptoms?)Past history (Have you ever had MH treatment before? If so when and for what condition?) Functional Impact (How have these symptoms impacted your ability to do your job, your family relationships, your quality of life, etc.?) Assessment MeasuresAt each IBHC appointment the Behavioral Health Measure-20 (BHM-20), a broad spectrum measure of behavioral health, is given. Use the GAD-7 as an objective measure to track symptom progress. This is recommended at each visit. Ensure patient has been screened for anxiety in the past month. If not, administer GAD-7. Intervention Options: There are numerous evidence-based interventions that can be helpful for improving anxiety. The IBHC and patient should collaboratively select the intervention(s) that are most appropriate given the nature of the patient’s difficulties as well as readiness for change. Possible interventions include:Education regarding various factors related to the development and maintenance of anxiety (including biological, cognitive, behavioral, and environmental factors) (See Handout 1 “Anxiety Overview”)Role of caffeine and tobacco in exacerbating anxietyBody awareness/sensitivity (e.g., over/underestimating physical sensations or misinterpreting these as negative or dangerous, all of which can exacerbate anxiety)Autonomic Nervous System (ANS) role; flight-or-flight response and role in anxiety (positive and negative)Self-monitoring of triggers and symptoms (See Handout 2 “Anxiety Monitoring Form”)Relaxation training (See Handout 1 “Anxiety Overview,” Handout 2 “Anxiety Monitoring Form”, and Handout 5 “Relaxation: Diaphragmatic Breathing”)Cognitive disputation/restructuring for decreasing anxious thinking (See Handout 1 “Anxiety Overview” and Handout 4 “Questioning Anxious Thinking”)Strategies to increase use of stress reducing techniques (yoga, exercise) Use of “Worry Time” method (See Handout 3 “The Problem of Worry”)Use of “Worry Log” method (See Handout 3 “The Problem of Worry”)Use of “Facing Worry” (Worry Exposure) method (See Handout 3 “The Problem of Worry”)Training in problem solving (See Handout 3 “The Problem of Worry”)Behavioral modification for anxietyHabituationExposureExposure and response preventionSleep enhancement strategies (stimulus control, sleep hygiene)Discuss possible specialty behavioral health or medication treatment options (prolonged exposure or cognitive processing therapy for PTSD; cognitive behavioral therapy; psychotropic medication; BH care facilitation) and referrals for these treatmentsFollow-Up IBHC AppointmentsRecommended follow-up interval: The time between appointments with the IBHC will vary depending on the IBHC’s assessment of the patient’s readiness to change, their ability to successfully make changes with self-management approach, and the nature of the intervention selected. For many patients the follow-up interval is between 2 to 4 weeks, which may also coincide with PCM follow-up visits, making it more convenient for the patient.Recommended number of IBHC appointments:1 to 4 IBHC appointments may be sufficient for many patients to improve anxiety-related symptoms.If the severity of symptoms is significant enough that the patient is unable to make improvements within 4 visits, it is strongly encouraged to refer them to specialty mental health for more intensive services. Assessment at follow-up appointments:BHM-20 (required)GAD-7 (recommended) ................
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