Integrating Care for the Whole Person: Collaborative Teams for Behavioral Health and Medical Conditions
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1 Integrating Care for the Whole Person: Collaborative Teams for Behavioral Health and Medical Conditions February 16, 2016 Presented by Dr. Paul Ciechanowski 2/25/2017 1
2 Opening Remarks Purpose Welcoming Dr. Ciechanowski Q&A Dr. Adrienne Mims Vice President & Chief Medical Officer
3 Featured Guest Speaker Paul Ciechanowski, MD, MPH Founder/Chief Medical Officer of Samepage Health Clinical Associate Professor (affiliate position with the Department of Psychiatry and Behavioral Sciences at the University of Washington)
4 Integrating Care for the Whole Person: Collaborative Teams for Behavioral Health and Medical Conditions February 16, 2016 Presented by Dr. Paul Ciechanowski 2/25/2017 4
5 Objectives 1. Review core components of effective multicondition collaborative care 2. Define clinical inertia, and understand how collaborative care reduces its impact 3. Understand clinical trial evidence for collaborative care treatment for behavioral and medical conditions
6 Clinical Inertia
7 Clinical Inertia defined as lack of treatment intensification in a patient not at evidence-based goals for care.
8 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.
9 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):
10 Glucose control Blood pressure Cholesterol Bundled benchmark 81% of those with diabetes FAIL TO ACHIEVE the bundled benchmark Casagrande et al., Diabetes Care, 2013
11 Glucose control Blood pressure Cholesterol Bundled benchmark Achieving 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
12 What Is It Costing You?
13 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 RISING RISK Early Stage Chronic Early State Behavioral & Risk Factors $80BN $150BN 18.1MM 51.3MM 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
14 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 RISING RISK Early Stage Chronic Early State Behavioral & Risk Factors $80BN $150BN 18.1MM 51.3MM 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
15 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. Such care is continuously evaluated through improvement processes and effectiveness measurement. ahrq.gov
16 PCP Patient
17 Care Manager PCP Patient
18 Care Manager PCP Patient Psychiatric and Medical Case Review
19
20 A1c Blood pressure Cholesterol (LDL) Depression
21 Outcome domain Collaborative Care Focusing on Multiple Conditions Comparison Studies Focusing on One Outcome Description Depression Effect size: 0.65 Effect size: 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:
22 One or More Med Adjustments in 12 months Katon et al. N Engl J Med 2010; 363:
23 Clinical and Utilization Outcomes in 17 Weeks 41% 74% 69% 29% 50% A1 Testing Patients with Depression Patients with A1c < 9% (HEDIS Goal) Patients with BP < 140/90 (HEDIS goal) Emergency Department visits Patients were enrolled into the Multi-Condition Collaborative Care program implemented by Samepage Health 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.
24 Collaborative Care Cycle Identify Goals PCP Participation Behavioral Strategies Systematic Case Review Monitor Progress Treat-to- Target
25 Comprehensive Collaborative Care Solution PCP Participation Identify Goals Behavior Strategies Weekly Reporting Systematic Case Review Monitor Progress Treat-to- Target Analytics-based Patient Identification And Predictive Modeling Patient Enrollment Evidence-based Clinical Intervention Patient on Target Returned to Regular Care
26 Systematic Case Review 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 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
27 Fortney et al., 2013
28 Addressing Depression & Co-Morbidities 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
29 Summary Addresses depression and anxiety in setting of comorbid medical conditions Addresses the how to the analytics what Addresses health behavior as well as behavioral health Population health approach vs. being indexed to admission/discharge Benefits: rapid improvement; reduced silos of care; a bio-psycho-social approach; inclusion of PCP every step of the way; built-in curbside consultation from psychiatry and internal medicine (+ pharmacy and social work).
30 Thank You!
31 Closing Thank you! For more information, please contact: Dr. Paul Ciechanowski at
32 Contact Information Adrienne Mims, MD MPH,FAAFP, AGSF Vice President and Chief Medical Officer
33 This material was prepared by NCC and adapted by GMCF, for Alliant Quality, the Medicare Quality Innovation Network Quality Improvement Organization for Georgia and North Carolina, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. 11SOW-GMCFQIN-G
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