Clinical Inertia. The Promise of Collaborative Care for Treating Behavioral Health and Chronic Medical Conditions. Study: 161,697 Patients 4/12/17

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1 The Promise of Collaborative Care for Treating Behavioral Health and Chronic Medical Conditions Paul Ciechanowski, MD, MPH Clinical Associate Professor, University of Washington Chief Medical Officer, Samepage Health Seattle, WA Clinical Inertia defined as lack of treatment intensification in a patient not at evidence-based goals for care. a major factor that contributes to inadequate chronic disease care in patients with diabetes mellitus, hypertension, dyslipidemias, depression, coronary heart disease, and other conditions. Study: 161,697 Patients 20-23% Poor Adherence Adequate Adherence Clinical Inertia: 30-47% lacked treatment intensification by healthcare team. Schmittdiel et al., J Gen Intern Med. 2008; 23(5):

2 Glucose control Blood pressure Cholesterol Bundled benchmark Glucose control Blood pressure Cholesterol Bundled benchmark 81% of those with diabetes FAIL TO ACHIEVE the bundled benchmark Casagrande et al., Diabetes Care, 2013 To achieve the bundled benchmark, healthcare systems will require improved methods to increase adherence to prescribed medications, physical activity, healthy dietary choices, and access to support, including motivation and maintenance of behavior change. Casagrande et al., Diabetes Care, 2013 Literature Review 2

3 What Is It Costing You? This article recommends that the Triple Aim be expanded to the Quadruple Aim, adding the goal of improving the work life of health care providers, including clinicians and staff. COMPLEX CARE End of Life Frail Elder $158BN $125BN 4.7MM 7.7MM COMPLEX CARE End of Life Frail Elder $158BN $125BN 4.7MM 7.7MM COMPLEX CHRONICS Poly Chronics/ Complex Chronic with Extensive Social Needs $334BN $136BN 29MM 15.4MM COMPLEX CHRONICS Poly Chronics/ Complex Chronic with Extensive Social Needs $334BN $136BN 29MM 15.4MM RISING RISK Early Stage Chronic Early State Behavioral & Risk Factors $80BN $150BN 18.1MM 51.3MM RISING RISK Early Stage Chronic Early State Behavioral & Risk Factors $80BN $150BN 18.1MM 51.3MM HEALTHY Generally Healthy $185BN 121.7MM HEALTHY Generally Healthy $185BN 121.7MM Adapted from: Oliver Wyman Analysis, Kaiser, CMS, Census Bureau, CSC, Oliver Wyman Health Innovation Center. Exec. Summary. Convergence: Consumer & Patient-Centered Business Designs. Oct 2013 Ideation Session. Found online. Note: Data excludes the uninsured and VA populations, year = 2012 Adapted from: Oliver Wyman Analysis, Kaiser, CMS, Census Bureau, CSC, Oliver Wyman Health Innovation Center. Exec. Summary. Convergence: Consumer & Patient-Centered Business Designs. Oct 2013 Ideation Session. Found online. Note: Data excludes the uninsured and VA populations, year =

4 Collaborative Care: A team with a shared mission, using improved clinical systems to deliver improved care to a patient population supported by operational and financial systems. PCP Patient Care Manager Such care is continuously evaluated through improvement processes and effectiveness measurement. ahrq.gov Psychiatric and Medical Case Review 4

5 A1c Blood pressure Cholesterol (LDL) Depression Outcome domain Collaborative Care Focusing on Multiple Conditions Comparison Studies Focusing on One Outcome Depression Effect size: 0.65 Effect size: 0.25 Description 37 Collaborative Depression Trials HbA 1c Change: 0.58% Change: 0.42% 66 Diabetes Trials Systolic BP Change: 5.1 mmhg Change: 4.5 mmhg 44 Trials A significant change in LDL of 6.9 mg/dl in the Collaborative Care Study $1116 lower outpatient costs per Medicare patient at 24 months Katon et al. N Engl J Med 2010; 363: One or More Med Adjustments in 12 mo. Satisfaction with Depression Care Antidepressants Oral Hypoglycemic Agents P<.001 P= % 87% 90% Insulin Antihypertensive Agents P=.006 P<.001 Intervention Control 50% 51% 47% 62% 55% Intervention Control Lipid Lowering Agents P=.08 0% 20% 40% 60% 80% 100% Katon et al. N Engl J Med 2010; 363: % P<.001 P<.001 Baseline 6 Months 12 Months 5

6 Satisfaction with Diabetes/CAD Care Clinical and Utilization Outcomes in 17 Weeks 100% 90% 50% 70% 68% 68% 86% 70% Intervention Control 41% A1 Testing 74% Patients with Depression 69% 29% Patients with A1c < 9% (HEDIS Goal) Patients with BP < 140/90 (HEDIS goal) 50% Emergency Department visits 0% P<.001 P<.001 Baseline 6 Months 12 Months Patients were enrolled into the Multi-Condition Collaborative Care program implemented by Samepage in a large Health Delivery Network Patients had an average of 9.6 chronic conditions and the majority had depression and out-of-target diabetes or hypertension. Patients were enrolled for a median duration of 17 weeks. Collaborative Care Cycle Identify Goals PCP Participation Behavioral Strategies India: Delhi Vizag. Chennai Systematic Case Review Treat-to- Target Monitor Progress 6

7 Comprehensive Collaborative Care Solution Systematic Case Review PCP Participation Systematic Case Review Identify Goals Treat-to- Target Behavior Strategies Monitor Progress Weekly Reporting Data In Registry with recent values for each patient: PHQ-9, A1c, BP, LDL, GAD-7, etc. Psychiatric Case Reviewer +/- Pharmacist +/- Health Navigator Care Managers Systematic Case Review +/- Diabetes Educator PCP Case Reviewer +/- Psychologist Data Out Detailed action steps for each patient shared immediately with PCP Analytics-based Patient Identification And Predictive Modeling Patient Enrollment Evidence-based Clinical Intervention Patient on Target Returned to Regular Care Weekly systematic case review lasts 1-2 hours patients reviewed per 1 FTE care manager equivalent Population management: all patients outcomes/treatment discussed Detailed outcome values/detailed action steps shared by team members Process: Treat-to-target and measurement-based care Addressing Depression & Co-Morbidities CM Rx Nav CM Mgr IM Edu CM CM CM Psy Navigate Psycho-education Administering screens (PHQ-9, GAD-7, PCL-C) Screening for co-morbid conditions Screening for self-harm Reviewing and titrating meds Addressing side effects Problem solving treatment Behavioral activation Decisional balance Relapse prevention 7

8 Can collaborative care be implemented effectively using telemedicine? Fortney et al., 2013 Mrs. J. 54 yr. old librarian with severe neuropathy pain - Uncontrolled T2D (A1c = 9.7%) - Hypertension (BP = 153/94 mmhg) - Hyperlipidemia (LDL = 141 mg/dl) - Obesity (BMI = 31.1 kg/m 2 ) - PHQ 19/27 - Smokes 1.5 packs per day Medications: glyburide, lisinopril, atenolol, atorvastatin, levothyroxine, venlafaxine ER 8

9 Adverse Childhood Experiences Attachment Theory 101 9

10 Attachment Styles Model of Self Secure 45-55% Preoccupied 10-15% Adapted from Bartholomew et al., Dismissing 25-35% Fearful 10-22% Attachment Styles I prefer not to depend on others or have others Model depend of Self on me + - I always want to have the ability to do things myself it's very difficult to ask people for help. Interviewer: Before Secure you had diabetes, Preoccupied are you someone that typically + went 45-55% to the doctor? 10-15% Patient: No. I stay away from those people I worry that Attachment I will be hurt Styles if I allow myself to become Model too close of Self to others + - You don t want to stand up and start asking questions and say Yeah, but what about this? or anything. You just kind of sit back and take it Secure 45-55% Preoccupied 10-15% because we ve all been raised to sit back and take + it, you know. - Dismissing 25-35% Fearful 10-22% - Dismissing 25-35% Fearful 10-22% Adapted from Bartholomew et al., 1991 Adapted from Bartholomew et al.,

11 Health care provider: Rushed Guidelinefocused Brusque MISSED VISITS GO-IT-ALONE ATTITUDE I m self-sufficient hard to trust Hurt Fear Rejection Abandonment important to be independent reaching out is difficult Health care system: Rushed POOR COLLABORATION Fragmented Long waits DISSATISFACTION Ciechanowski et al Likelihood of missed appointments Fearful Preoccupied Dismissing % Patients with HbA1c >8% % patients Ciechanowski et al * Secure Dismissing Fearful Preoccupied Attachment Style 5-Year Mortality Rates in Primary Care Patients with Diabetes Deaths/Thousnd Ciechanowski et al Secure + Preoccupied Attachment Style Dismissing + Fearful 11

12 Attachment Influence x Provider of Clinician Communication Care vs. Quality HbA1c on Outcomes levels Collaborative Care 8.6 HbA1c (%) Poor Ciechanowski et al Secure Good Provider Communication Dismissing * p <.001 Ciechanowski et al CASE MANAGEMENT Secure + Preoccupied CASE MANAGEMENT Dismissing + Fearful Multi-Condition Collaborative Care Whole patient vs. Single condition Health behavior vs. Behavioral health How vs. What Population health vs. Individual patient Collaborative vs. Co-located Provider behavior + Patient behavior Bio-Psycho-Social Quadruple Aim Thank You! 12