INTEGRATED CARE/ COLLABORATIVE CARE

Transcription

1 INTEGRATED CARE/ COLLABORATIVE CARE Pelin Duzenli 2/11/2017

2 WHO Definition of Health Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity (1948). Behavioral Health Psychiatric disorders cause 25% of all disability worldwide.(c. Murray, GBD Study, Lancet 2012) 10% of Years Lived with Disability from depression alone. 3x diabetes,10x heart disease, 40x cancer In the US, one suicide every 14 minutes The Challenge Health Behaviors Behavior determines ~ 50% of all mortality and morbidity Unhealthy behaviors are major drivers of health care costs 40% 50% struggle with treatment adherence Employers struggle with absenteeism and presentism

3 Behavioral Health Integration Care resulting from practice team of primary care and behavioral health clinicians, working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population. Care may address mental health, substance abuse conditions, health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stress-related physical symptoms, ineffective patterns of health care utilization. Source: Peek, C. J., National Integration Academy Council. (2013). Lexicon for Behavioral Health and Primary Care Integration: Concepts and Definitions Developed by Expert Conse nsus. In Agency for Healthcare Research and Quality (Ed.), AHRQ Publication No.13-IP001-EF. 3

4 A Legacy of Separate and Parallel Systems Medical Care Mental Health Care A forced choice between: 2 kinds of problems 2 kinds of clinicians 2 kinds of clinics 2 kinds of treatments 2 kinds of insurance Integrated behavioral health leads to a better match of clinical services to the realities that patients and their clinicians face daily. Original Source: CJ Peek

5 Two Cultures, One Patient

6 Why integrate care? The triple aim of health care reform 1) Improved patient and provider experience Access Satisfaction with care 2) Better health care outcomes for patients and populations of patients 3) Lower health care costs 6

7 How good is current care? Fewer than 2/10 see a psychiatrist or psychologist. 5/10 receive treatment in primary care 2/3 of PCPs complain about poor access to mental health care for their patients ~ 30 million receive an antidepressant Rx in primary care BUT only 25% improve Unutzer, 2011

8 How many of these people with mental health concerns will see a mental health provider? No Treatment Primary Care Provider Mental Health Provider Wang P, et al., Twelve-Month Use of Mental Health Services in the United States, Arch Gen Psychiatry, 62, June 2005

9 PHSYCIAN HEAL THYSELF 5-year longitudinal cohort study of 904 physicians; Alcohol abuse in 50% Opioids in 36% Stimulants in 8% Other substances in 6% 50% reported abuse of multiple substances 14% a hx/o IV drug use 17% previous treatment for addiction certain specialties; anesthesiology, emergency medicine&psychiatry dual-dx; substance use dis combined w/mdd, BP, GAD or Panic dis, McLellan, 2008 physicians are about as likely as the general public to abuse alcohol or illegal drugs, they are more likely to misuse prescription drugs to relieve stress and physical or emotional pain. Doctors Often Relapse JAMA in July 2010, 17% of nearly 1900 responding physicians reported direct personal knowledge of an impaired or incompetent physician in their hospital, group, or practice in the 3 preceding years McLellan, 2008

10 PHSYCIAN HEAL THYSELF The lifetime prevalence of depression among physicians is 13% in men and 20% in women Physician suicide rate; betw 28 to 40 per 100,000, compared with the overall rate in the general population of 12 per 100,000. A survey of American surgeons revealed that although 1 in 16 had experienced suicidal ideation in the past 12 months, only 26% had sought psychiatric or psychologic help. Andrew, 2016 Physicians at high risk for suicide: workaholic white male age 50 or female age 45 who is divorced, single, or currently experiencing marital disruption and is suffering from depression, Bright, physicians/year or about a doctor a day. Each year, it would take the equivalent of 1 to 2 average-sized graduating classes of medical school replace the number of physicians who kill themselves. Andrew, 2016

11 How many of these people with mental health concerns will see a mental health provider? No Treatment Primary Care Provider Mental Health Provider Wang P, et al., Twelve-Month Use of Mental Health Services in the United States, Arch Gen Psychiatry, 62, June 2005

12 Available Psychiatrist Time/Week Ideal United States: Urban United States: Rural 50 minutes 6 minutes 1.5 minutes

13 ANNUAL PER PERSON COST OF CARE COMMON CHRONIC MEDICAL ILLNESSES WITH COMORBID MENTALCONDITION VALUE ADDED OPPORTUNITIES Patient Groups Annual Cost of Care Illness Prevalence All Insured $2,920 10%-15% % with Comorbid Annual Cost with Mental Condition* Mental Condition % Increase with Mental Condition Arthritis $5, % 36% $10,710 94% Asthma $3, % 35% $10, % Cancer $11, % 37% $18,870 62% Diabetes $5, % 30% $12, % CHF $9, % 40% $17,200 76% Migraine $4, % 43% $10, % COPD $3, % 38% $10, % Cartesian Solutions, Inc. --consolidated health plan claims data American Psychiatric Association. All rights reserved. Cartesian Solutions, Inc.

14 How do we close the gap? Train more specialists? Work harder? Work smarter! = Integrated care. Leverage mental health specialists more effectively - partnerships (e.g., integrated with primary care) - technology (e.g., telemedicine) > 80 RCTs of collaborative care vs care as usual: collaborative care consistently more effective. (Archer et al, Cochrane Metaanalysis 2012).

15 Taking effective models to scale

16 PRINCIPLE: PATIENT-CENTERED COLLABORATION PCP Patient BHP/ Care Manager New Roles Psychiatric Consultant University of Washington American Psychiatric Association. All rights reserved.

17 TRADITIONAL MODEL VS. COLLABORATIVE CARE MODEL Traditional Model Collaborative Care Model PCP Psychiatrist? PCP Psychiatrist (Part-Time) Care Manager? Patients Patients American Psychiatric Association. All rights reserved.

18 Psychiatry and Primary Care An evolving relationship: Consultative model Sees patients in consultation in his / her office away from primary care. Co-located model Sees patients in primary care Collaborative model Responsibility for a caseload of primary care patients and works closely team of PCPs and behavioral health providers.

19 Levels of Integration

20 PSYCHIATRISTS SUPPORTING TEAMS Care Manager 4 Care Manager 1 Care Manager 3 Care Manager patients/caseload 2-4 hrs pscyh/week/ care manager = a lot of patients getting care American Psychiatric Association. All rights reserved.

21 STEPPED CARE APPROACH 1. Different people need different levels of care for the same problem 2. Monitoring outcomes helps determine the right level 3. Stepped care can improve outcomes and contain costs BH specialty short term tx BH specialty long term tx Psychiatric Inpatient tx BHP, Psychiatric Caseload Review 1 Care + Brief Consult Self- Management 1 o Care Psychiatric Consultation 2 1 Vonkorff WJM American Psychiatric Association. All rights reserved.

22 A Different Kind of Note Traditional Consult Note Integrated Care Case Reviews Note 1: January Pt still has high PHQ One consult note Note 2: March Side effects Note 3 - Pt improved!

23 COLLABORATIVE CARE: CORE COMPONENTS AND TASKS Patient Identification and Diagnosis Engagement in Integrated Care Program Evidence Based Treatment Systematic Follow-up, Treatment Adjustment, Relapse Prevention Communication, Care coordination and Referrals Systematic Case Review and Psychiatric Consultation Program Oversight and Quality Improvement American Psychiatric Association. All rights reserved. 27

24 Liability PCP: Oversees overall care and retains overall liability AND prescribes all medications/additional studies CM/BHP: Responsible for the care they provide within their scope of practice / license INFORMAL CONSULTATIVE Curbsides, advice to PCP and BHP, no charting, not paid and not supervisor of BHP Olick et al, Fam Med 2003 Sederer, et al, 1998 Sterling v Johns Hopkins Hospital., 145 Md. App. 161, 169 (Md Ct. Spec. App COLLABORATIVE Curbside with BHP, document recommendations in chart and paid FORMAL Direct with patient after other steps unsuccessful, written opinion SUPERVISORY Consultation ranges from informal to formal. Is there a doctorpatient relationship? Psychiatric provider administrative and clinical supervisor of BHP ultimately responsible Collaborative care should reduce risk: -Care manager supports the PCP -Use of evidencebased tools -Systematic, measurement-based follow-up -Psychiatric consultant 24

25 HIPPA HIPAA allows sharing of PHI, for the coordination of care, without a signed release. The only exception is if there is a stricter state law or if you are a substance abuse treatment facility or provider(42 CFR) 25

26 BHPS/CARE MANAGERS- HIRE THE RIGHT PERSON Who are the BHPs/CMs? Typically MSW, LCSW, PhD, PsyD, RN could be MA, CHW Variable clinical experience Need brief intervention skills BA, MI, PST, SFBT, DTS Health Behavior Change Experts What makes a good BHP/CM? Organization Persistence- tenacity Creativity and flexibility Strong patient advocate Willingness to beinterrupted Ability to work in a team CAUTION: Prefer traditional approach to therapy Not willing to be interrupted Timid, insecure about skills American Psychiatric Association. All rights reserved.

27 PSYCHIATRISTS BEST SUITED FOR THIS WORK Flexible expect the unexpected Adaptable - child and other populations Willing to tolerate interruptions Able to manage liability concerns Like teaching Enjoy being part of a team Willing to lead **Extending psychiatric expertise to a larger population Blessed are the flexible for they shall not get bent out of shape American Psychiatric Association. All rights reserved.

28 ROLES OF PRIMARY CARE PROVIDER IDENTIFY individuals who need BH support and ENGAGE them in the treatment model Willing to prescribe medications for behavioral health Collaborate and consult with BHP and Psychiatric prescriber to enhance BH Care WARM HAND OFFS Utilize screening tools to track progress (e.g., PHQ-9) American Psychiatric Association. All rights reserved.

29 REGISTRIES TO TRACK PROGRESS Caseload Overview University of Washington FREE UW AIMS Excel Registry ( ) Allows proactive engagement ( no one falls through the cracks ) and treatment adjustment American Psychiatric Association. All rights reserved.

30 Commonly Used Screeners Mood Disorders Anxiety Disorders Psychotic Disorders Substance Use Disorders Cognitive Disorders PHQ-9: Depression GAD- 7: Anxiety, GAD Brief Psychiatric Rating Scale CAGE-AID Mini-Cog PCL-C: PTSD MDQ: Bipolar disorder CIDI: Bipolar disorder OCD: Young-Brown Social Phobia: Mini social phobia Positive and Negative Syndrome Scale AUDIT Montreal Cognitive Assessment

31 PHQ-9 PHQ 9 > 9 < 5 none/remission 5 - mild 10 - moderate 15- moderate severe 20 - severe American Psychiatric Association. All rights reserved.

32 EVIDENCE-BASED BRIEF INTERVENTIONS Motivational Interviewing Distress Tolerance Skills Behavioral Activation Problem Solving Therapy American Psychiatric Association. All rights reserved.

33 HOW WELL DOES IT WORK WITH MENTAL DISORDERS? Evidence Base Established Depression - Adolescent Depression - Depression, Diabetes, and Heart Disease - Depression and Cancer - Depression in Women s Health Care Anxiety Post Traumatic Stress Disorder Chronic Pain Dementia Emerging Evidence Substance Use Disorders ADHD Bipolar Disorder American Psychiatric Association. All rights reserved.

34 SAMPLE CONSULTATIONS ~ 30 MIN REASON FOR CONSULT DIAGNOSIS RECOMMENDATION Side effects from lithium BP 1 Switch to valproic acid SE from lisdexamfetamine ADHD Try another per protocol Lithium level is1.2 BP 1 Continue unless having side effects Inc depression symptoms MDNOS TSH, if normal start lamotrigine Poss SE from quetiapine BP 1/PD Decrease Seroquel to 100 mg Paroxetine not effective MDD Add bupropion Regular lamotrigine or XR? BP 2 No difference Side effects with citalopram MDD Switch to bupropion Depression symptoms increase BP1 Check lithium level first, maximize if low, may need to add lamotrigine Suicidal, acute distress PD Safety plan, DBT referral High doses of meds, confused MDD Stop hydroxyzine, reduce lorazepam, call collateral Anxious, wants alprazolam, nipple 38 pain GAD No alprazolam, increase sertraline, coping skills 2016 American Psychiatric Association. All rights reserved.

35 ENGAGED Do you/care managers meet routinely with the psychiatrist for the weekly 2 hour meetings? Is the psychiatrist friendly and helpful with your/cm review of patients in your caseload? Does he/she give feedback, direction, suggestions for both pharma and other therapeutic approaches to getting the patient to goal Do the psychiatrist and PCP s ever connect? If the PCP contacts the consulting psych in between the weekly sessions, does he/she typically get back to the PCP in a timely manner? Has the psychiatrist done any other types of in-services or education sessions for your PCPs, your care managers, and/or care teams? Do you have any concerns about the consulting psychiatrist working on your team? American Psychiatric Association. All rights reserved. Whitebird, et al. Am J Manag Care. 2014;20(9):

36 Improved Provider Satisfaction Primary care physicians like integrated care for a variety of reasons 1 Behavioral health specialists are also satisfied with working in integrated settings 2 photo courtesy: 36 Sources: 1 Gallo et al, Ann Fam Med, 2004:2: Levine et al., Gen Hosp Psych. 2005; 27:

37 PCPs Embracing the Model Before Implementation This is going to slow me down I don t have time to address one more problem This is going to be an anchor I already do a good job of treating mental illness After Implementation This takes a load off my plate This speeds me up I always want to practice like this I am giving better care to may patients This gives me time to finish my note If you aren t uncomfortable with your practice, you aren t practicing integrated care. PCP - Colorado

38 Business Case: IMPACT reduces health care costs ROI: $ 6.5 saved / $ 1 invested Cost Category 4-year costs in $ Intervention group cost in $ Usual care group cost in $ Difference in $ IMPACT program cost Outpatient mental health costs Savings Pharmacy costs 7,284 6,942 7, Other outpatient costs 14,306 14,160 14, Inpatient medical costs 8,452 7,179 9, Inpatient mental health / substance abuse costs Total health care cost 31,082 29,422 32,785 -$3363 Unützer et al., Am J Managed Care ROI $6.50: $1

39 Improved Mental Health Outcomes Over 75 trials in collaborative care in nearly 2 decades have proven significant benefit for depression and anxiety disorders 1 Interventions work in a wide variety of settings in a wide variety of mental health conditions 2 Improved Outcomes 2 Improved adherence to evidence-based treatment 3 39 Sources: 1 Archer et al, Cochrane Syst Data Rev, 2012: Woltman et al, AJP, 2012: 169: Gilbody et al, Arch Int Med, 2006:166:

40 Triple Aim Six Reasons Why Behavioral Health Should be Part of the PCMH 1. High prevalence of behavioral health problems in primary care (needing long-term follow-up) 2. High burden of behavioral health in primary care 3. High cost of unmet behavioral health needs 4. Lower cost when behavioral health needs are met 5. Better health outcomes the map to PCMH success 6. Improved satisfaction Behavioral health integration achieves the triple aim. 40

41 Affordable Care Act 2010 Insurance Expansion Triple Aim Initiatives better outcomes, lower costs, better experience of care Innovation Grants Collaborative Care Payment Structures Behavioral Health Homes SPAs Expand CHC Expand PBHCI

42 Squirrel Hill Health Center

43 Behavioral Health Services

44 Behavioral Health Team Psychiatry LCSW/ Therapist Primary care providers/dental staff Care navigator RNs Front office staff Medical assistants OB/GYN Americorp members Administrative staff ACA counselor

45

46 Working in Collaborative Care Daniel s Story