Health and Mental Health Collaborations- How do we begin?

Transcription

1 Health and Mental Health Collaborations- How do we begin? Mario Cruz, M.D. Associate Professor of Psychiatry Medical Director- Outpatient Services UNMPC Grand Rounds Presentation Department of Family Medicine University of New Mexico School of Medicine 5/11/2011

2 At the end of this presentation, you will: Understand why health-mental health collaborations are needed; Appreciate the multi-level system issues that need to be addressed for effective healthmental health collaborations; Appreciate effective evidence-based approaches to health and mental health collaborations.

3 Why must we collaborate? Barriers to collaboration Strategies to Overcome Barriers Evidence-based collaborative interventions Systems change- Mental Health Measures in Primary care and UNM PC Referral Changes How do we begin?

4 Why must we collaborate?

5 Treatment PC BH Other Regier et al., Archives of General Psychiatry. 1978;35(6):

6 Leading Causes of Years of Life Lived with Disability (YLD) in 15- to 44-Year-Olds (WHO, Mental Health: New Understanding, New Hope, 2001) % total 1 Unipolar depressive disorders Alcohol use disorders Schizophrenia Iron-deficiency anemia Bipolar affective disorder 4.7

7 Prevalence of Major Depression in Patients with Physical Illnesses General population Up to 10% Myocardial infarction Up to 22% Diabetes Hypertension Epilepsy Stroke Cancer Up to 27% Up to 29% Up to 30% Up to 31% Up to 33% HIV/AIDS Tuberculosis Up to 44% Up to 46% 0% 10% 20% 30% 40% 50% WHO, 2003.

8 Comorbidities Among Depressed Patients Comorbidity % of Depressed Patients with Comorbidity Arthritis 48.1% Heartburn / Acid Reflux 42.1% Hypertension 34.7% High Cholesterol 29.7% Migraines 23.5% Bowel Problems 20.1% Asthma 15.2% Diabetes 14.9% Skin Problems 13.7% Menstrual Problems 9.3% Source:

9 SDMI General Medical Comorbidity Diabetes: 20% in VA sample with bipolar disorder (Kilbourne et al. Bipolar Disorder, 2004) Cardiovascular disease: HBP 34%, Heart 15.6% Weight gain and obesity (2x) Smoking (2x) Other: breast cancer (9.5x), HIV (8x), Hepatitis B (5x) and C (10x)

10 Quality of Care for Cardiometabolic Risk: Vulnerable Groups, Clinical Significance Percentages: National Psychosis Registry-VA EPRP Serious Mental Illness Depression No Mental Health Dx % BP >160/100, HTN Dx (n=24,016) % BP <140/90, HTN Dx % Hyperlipidemia Screen (n=46,430) 90.4*** % LDL <100 mg/ml, DM Dx 59.1*** % Foot sensory exam (n=10,943) 77.7*** % Retinal exam 73.6*** % Renal testing 62.8* % HbA1C >9 19.0* *P<0.05; ***P<0.001; Results similar after adjustment for demographic, clinic factors Kilbourne AM et al. JGIM, 2008

11 Depression Anxiety Why Behavioral Health and General Health Care? Preventive / chronic illness care for people with Severe Disabling Mental Illness

12 Local Concerns Mental Health Service Capacity UNM PC receiving 10.5 referrals per day 48.0 referral to intake time Barriers-to-Care UNM PC is now The safety net for the community Primary Care capacity for SDMI population Limited access to primary care services

13 Barriers to Collaboration

14 Historical Conceptual Patients / Consumers Providers Practices / Delivery Systems Plans Managed Care Organizations (MCO)/ Managed Behavioral Health Organizations (MBHO) Purchasers Public / Private Population / Community Professors- Training

15 Do you see what I see?

16 Recognition and Treatment of Mental Illnesses in Primary Care Settings E B C G D F H A Adapted from Goldberg & Huxley, 1980 Legend A. See PCP B. Have Mental Illness C. Illness recognized D. Illness appropriately recognized and treated E. Illness not recognized, not treated F. Illness recognized, not appropriately treated G. Recognized but not correct Mental Illness H. Have Mental Illness, but do not see PCP

17 PCP vs. DSM Frameworks Primary Care Identified Mental Health Condition + _ Psychiatry/DSM Identified Mental Disorder _ 4 3

18 Do you work like I work?

19 Primary Care Providers Action-Oriented Lab Tests Disease Subthreshold-Complex Carved-in HIPAA Social Service, HSC, NMPS Cross-cultural, Socioeconomic Traditional Medical Psychiatrists Introspective/Reflective Measures Disorder Complex Carved-out/Payment disparity Special HIPAA, Competency Social Service, Criminal Justice, Consumer/Family Groups, State Cross-cultural, stigma, denial, shame, socioeconomic Multidisciplinary

20 PCP Provider Barriers Time Interest Tools: DSM-PC, PHQ-9 Training

21 Practices / Delivery System Issues Organization does not enhance patient-provider interactions & promote successful outcomes Who is responsible for care? Limited communication and teamwork between primary care and mental health specialties How should care be provided? Consultative? Collaborative? Integrated? When should care be provided? Lack of longitudinal focus

22 Strategies to Overcome Barriers

23 Wagner, Improving Chronic Illness Care, 2002

24 Economic Model Reinforce clinical model Realign financial and non-financial incentives Alter contractual / organizational arrangements Pay for: PCP depression, anxiety, and bipolar care MHS consultation Care management Distinguished performance Unique issues in local context

25 Health Plans Money Flow, Risk and Communication Indemnity Model Health Plan No risk Legend Primary Care Provider Behavioral Health Specialist High communication Low communication Money Flow B. Carve-out Model No Shared Risk C. Integrated Model Shared risk Mental Health Plan

26 Clinical Model: Major Components Leadership Practice design Clinical information systems Decision support Self management support Community resources Accountability Vision Resources Patient registry Protocols Mental Health care manager Red flags Feedback to provider on clinical progress Support care manager Guidelines Provider training Expert / specialist consultation Referral pathways Patient preferences Information on depression, anxiety, bipolar disorder, and medications Information on and for consumer groups and other services Access to non-provider sources of care

27 Models of Linkage / Integration Embedded PCP in BHS Co-location of BHS in PCP B P P B Unified Coordination / Collaboration B P B P

28 Relative Degree of Involvement of PCPs and Behavioral Health Specialists (BHS) PCP PCP BHS in Primary Care Settings BHS in Specialty Settings None Subthreshold Simple Complex Severe Type of Problem / Disorder

29 Phases of Depression Treatment No Depression Remission Relapse Recovery Recurrence Symptoms Response Syndrome Treatment Phases Acute Continuation Maintenance Kupfer DJ. J Clin Psychiatry. 52(5s):28-34,1991.

30 High Low The Four Quadrant Clinical Integration Model for SPMI Quadrant II BH PH Behavioral Health (BH) Case Manager w/ responsibility for coordination w/ Primary Care Provider (PCP) PCP (with standard screening tools and BH practice guidelines) Specialty BH Residential BH Crisis/ER Behavioral Health IP Other community supports Quadrant IV BH PH PCP (with standard screening tools and BH practice guidelines) BH Case Manager w/ responsibility for coordination w/ PCP and Disease Mgr Care/Disease Manager Specialty medical/surgical Specialty BH Residential BH Crisis/ ER BH and medical/surgical IP Other community supports Stable SPMI would be served in either setting. Plan for and deliver services based upon the needs of the individual, consumer choice and the specifics of the Stable SPMI would be served in either setting. Plan for community and deliver and services collaboration. based upon the needs of the individual, consumer choice and the specifics of the community and collaboration. Quadrant I BH PH PCP (with standard screening tools and BH practice guidelines) PCP-based BH* Low Quadrant III BH PH PCP (with standard screening tools and BH practice guidelines) Care/Disease Manager Specialty medical/surgical PCP-based BH (or in specific specialties)* ER Medical/surgical IP SNF/home based care Other community supports Physical Health Risk/Status Physical Health Risk/Status *PCP-based BH provider might work for the PCP organization, a specialty BH provider, or as an individual practitioner, is competent in both MH and SA assessment and treatment High National Council for Community Behavioral Health (Winter, 2004)

31 Evidence-based Collaborative Interventions

32 Chronic Disease Clinical Models Hypertension Congestive heart failure (CHF) / Coronary artery disease (CAD) Stroke COPD (Chronic Obstructive Pulmonary Disease) DM (Disease Management) Asthma Multiple comorbidities Transitional care management

33 Chronic/Collaborative Care Clinical Models Depression Anxiety Bipolar

34 Systems Change- Primary Care Mental Health Measures

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42 UNM PC Referral Changes

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44 PSYCHIATRY REFERRAL FORM Date: MRN: Patient (name and phone number): Referring provider and clinic (name and phone number): PCP (name and phone number): Patient s payer source (name and phone number): Policy number: Important! If you think that you will be unable to continue to write prescriptions for medications we might recommend, you should not refer your patient to us. Reason for referral: depression anxiety bipolar co-occurring disorder psychosis other (please list): DOB: SSN: Services required (check all that apply): Evaluation & recommendation only (i.e. consultation) Co-management of patient Psychopharmacologic recommendations Diagnostic assessment Psychotherapy treatment CCSS Services * If referring patients for depression, anxiety, or bipolar disorder the patient will need to have adequate trials of two or more antidepressants or at least one mood stabilizer. Specify the medications the patient has tried: * If this is a psychiatric emergency, please refer the patient directly to a Psychiatric Emergency Department. * If you are outside of the UNMH system, we require all pertinent clinical information supporting this referral. * If the patient is solely requiring treatment for substance abuse please refer patient to AMCI (505) or ASAP (505) I authorize my clinician, care manager, and the mental health professional to discuss my diagnosis, and treatment as it relates to my medical condition. May discuss drug/alcohol issues. Yes No Patient Signature: Date: Please note: UNMH Psychiatric Center does not provide: pain management, sex offender treatment, treatment to sex offenders with psychiatric problems who are on probation or parole (may be seen through psychiatric emergency services for emergencies), medical marijuana evaluations, disability evaluations, primary substance abuse treatment, psychosocial housing assessments and ongoing care for individuals suffering from mental illness who are developmentally disabled, custody and other forensic evaluations. Please fax this form to: (505) For questions please call: (505) Incomplete / Illegible forms will be returned!

45 PUCC Hours: Monday Friday Closed holidays Location: 2600 Marble NE next to Psychiatric Emergency Services

46 PES Hours: Location: 24/7/ Marble NE Capacity: Five (5) rooms

47 How do we begin?