Integrating Mental Health and Primary Care (why would we want to do that?)

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Darrell Ward
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1 Integrating Mental Health and Primary Care (why would we want to do that?) Andrew S. Pomerantz, MD National Mental Health Director, Integrated Services Veterans Health Administration Associate Professor of Psychiatry, Geisel School of Medicine at Dartmouth

2 Summary of the reasons It improves overall health It gets mental health care to people who otherwise would not get it It makes screening the whole population worthwhile It can reduce healthcare utilization It doesn t cost much in the short term and probably saves a lot of money in the long term It conserves highly specialized resources for those who need them the most

3 DEPRESSION IN PRIMARY CARE (Poster child for integrated care) 1970s: BIOLOGICAL UNDERPINNINGS OF MDD 1980s: PCPs CRITICIZED FOR UNDERRECOGNITION 1990s: PCPs CRITICZED FOR UNDERTREATMENT 2000s: PCPs CRITICIZED FOR OVERTREATMENT? 2010s: MH GETS THE MESSAGE AND TRIES TO HELP

4 Improving Depression Care: Quality Improvement and Research Success UPBEAT PROSPECT Study IMPACT Study PRISME Study (Depression, anxiety, or alcohol) TIDES (Telephone) Behavioral Health Laboratory (BHL) White River Model (Co-located care) TEAMcare DIAMOND Initiative 3CM / RESPECT / (RESPECT-Mil*)

5 TREATMENT OF DEPRESSION LEADS TO INCREASED PRODUCTIVITY IMPROVED MEDICAL OUTCOMES MORE RESILIENT FAMILIES AND COMMUNITIES IMPROVED CHILD-REARING INCREASED AND PROLONGED INDEPENDENCE FOR THE ELDERLY BETTER PERFORMANCE IN SCHOOL AND IT MAY OR MAY NOT LEAD TO REDUCED COSTS

6 Contribution to Premature Mortality in the United States Behavioral patterns 40% Genetic predisposition 30% Social circumstances 15% Health care 10% Environmental exposure 5% Schroeder N Engl J Med 2007

7 ALL OTHER THINGS EQUAL PRESENCE OF A MENTAL DISORDER LEADS TO: POORER HEALTH OUTCOMES INCREASED HEALTH COSTS INCREASED MORTALITY LOWER QUALITY OF LIFE AND OTHER CONSEQUENCES TO SOCIETY

8 Primary Care The de-facto mental health system Regier DA, Narrow DE, Rae DS, et al. The de facto U.S. mental and addictive disorders service system: Epidemiologic catchment area prospective 1-year prevalence rates of disorders and services. Archives of General Psychiatry 1993; 50:85-94.

9 How s it working? 21.7% of patients receive adequate treatment for depression. Kessler RC, Berglund P, Demler O, et al: The epidemiology of major depressive disorder: results from the national comorbidity survey replication [NCS-R]. JAMA 2003; 289[23]:

10 Has anyone recommended integration? Surgeon General. Institute of Medicine New Freedom Commission And patients voting with their feet.

11 Any Progress? No. Wang PS, Demler O, Olfson M, et al: Changing profiles of service sectors used for mental health care in the United States. Am J Psychiatry 2006; 163:

12 Where are we? 25% of U.S. adults experience a mental-health issue in a given year 60% of them receive no treatment 68% of adults with a mental-health disorder have at least one medical condition 29% of those with a medical condition have a mental-health issue 50% of care for mental-health disorders is delivered by primary-care providers 66% of visits to family physicians involve stress-related symptoms National Alliance for the Mentally Ill

13 The mental health crisis Increasing demand Decreasing supply relative to demand (the dangers of screening) Shortage of psychiatrists

14 WHY is there a shortage? Retirement: (55% of practicing psychiatrists are over 55 compared to 37% of all physicians) More doing part time work child care, QOL Declining residency applicants Lower pay than most specialties Poor outcomes make front page news Move toward pill pushing Demographics, ACA and parity laws increase the denominator

15 Some published ideas about what to do about it Increase reimbursement for psychiatrists Make psychiatry more interesting for medical students (why does Yale have so many internal applicants?) Return to the good old days Let psychiatrists do more psychotherapy Increase use of telemedicine Others??

16 Spend more money In other words

17 Money Will there ever be enough money to pay for all the things we do and want to do in healthcare? (not just us)

18 Statement of the Problem Which one of these statements is the problem? There will not be enough providers to match the growing demand for treatment of mental disorders There will not be enough access to assessment and treatment to meet the growing demand for treatment of mental disorders

19 the profession may soon be facing the prospect of an oversupply of psychiatrists. Given the present rate of producing psychiatrists, shifts in demands for psychiatric services, changing payment and access patterns regarding specialty medical care, increasing numbers of nonpsychiatrist mental health professionals, and a probable surfeit of primary care physicians, underemployment of psychiatrists may become commonplace. Future psychiatrists will likely be used more as consultants, and the profession will need fewer, but better trained, graduates. Yager J, Borus JF Are we training too many psychiatrists? American Journal of Psychiatry 1987 Aug;144(8):

20 HEALTHCARE HISTORY FULL INTEGRATION AT THE BEGINNING OF CIVILIZATION (AS WE KNOW IT) GRADUAL SEPARATION BEGINNING ABOUT TWO MILLENIA AGO ARE WE BACK TO THE FUTURE?

21 Mental Health Services in the Medical Home the Patient Centered Medical Home will not reach its full potential without adequately addressing patients mental health needs. Doing so, however, will likely shift responsibility for the delivery of much mental health care from the mental health sector into primary care. Croghan TW, Brown JD. Integrating Mental Health Treatment Into the Patient Centered Medical Home. AHRQ Publication No EF. Rockville, MD: Agency for Healthcare Research and Quality. June 2010.

22 (AHRQ didn t stop there) A change many stakeholders will likely oppose.

23 VA findings support AHRQ position Integrated mental health care... Improves identification of prevalent mental health conditions Improves access to appropriate evaluation and treatment Improves treatment engagement and adherence Increases probability of receiving high quality care Improves clinical and functional outcomes Increases patient satisfaction Reduces no show rates for those referred to specialty care 23

24 AHRQ definition 2013 The care that results from a 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. This care may address mental health and substance abuse conditions, health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stress-related physical symptoms, and ineffective patterns of health care utilization. Peek CJ and the National Integration Academy Council. Executive Summary--Lexicon for Behavioral Health and Primary Care Integration: Concepts and Definitions Developed by Expert Consensus. AHRQ Publication No.13-IP001-1-EF. Rockville, MD: Agency for Healthcare Research and Quality Available at:

25 The modern trajectory of integrated care 1990s: Chart review study demonstrates treatment planning improves outcomes, reduces cost 1990s onward: care management RCTs improve outcomes: named Integrated or Collaborative Care 1990s: co-location loses 2007 (VA): combines Co-location and collaboration (Colocated Collaborative Care) with Care Management 2011: (VA) PCMHI becomes absorbed into the Patient Centered Medical Home (Patient Aligned Care Team=PACT)

26 VA 101 VA = Department of Veterans Affairs (since 1989) Three subcomponents: Veterans Benefits Administration (VBA) National Cemetery Administration Veterans Health Administration (VHA) Vet Centers Medical facilities and their associated Community Based Outpatient Clinics (CBOCs) Organized into 22 regions called Veterans Integrated Service Networks (VISNs) Distinction between Department of Defense Care and VA care DoD provides care to active duty Service members and their families, and after discharge to some who had a significant career in the military VA provides lifetime care to all eligible Veterans who choose to seek VA health care VHA does not determine benefits but does provide relevant clinical information to VBA

27 Enhancing the Way We Provide Care We are creating a healthcare system that is, first and foremost, patient centered and characterized by team care We re also striving, every day, for a healthcare system that is continuously improving, data driven, evidence based, and characterized by excellence at every level. Robert A. Petzel, M.D. Under Secretary for Health Department of Veterans Affairs

28 Future of VA Health Care Past VA What can I fix? Physician Case-Based Paper Medical Record We ll address your immediate concern. Present VA How can we help what is wrong with you? Clinical Team Disease-Based Electronic Medical Record You have a risky problem, please follow this plan to improve by your next visit. Future VA How can we help you live the life you want to live? Veteran, Family and Health Care Team Whole-Person Electronic Health Record We can design your personalized health plan to meet your goals.

29 PACT Team 29

30 Themes: Mental Health As An Integral Component of Overall Health Primary Care/Mental Health Integration Interdisciplinary team care Recovery-oriented mental health services and Patient Centeredness in all VA health care 30

31 Theme 2: Interdisciplinary Team Care Interdisciplinary Health Care emphasizes a high degree of collaboration in: Patient evaluation Treatment planning Outcome evaluation NOT Multidisciplinary Ideally, the patient and family members (when appropriate) are included as team members 31

32 Continuum of MH Care

33 Principles of Integrated Care in VA Open or advanced access (temporal and spatial integration) in VA medical homes [Patient Aligned Care Teams] Problem-focused assessment and treatment: tend to what the Veteran wants tended to On-site clinicians in primary care: Consultation, collaboration, assessment Stepped care Measurement-based care Care management Referral management when needed

34 Primary Care-Mental Health Integration [PC-MHI] in VA Two components: Care management Co-located collaborative care Blended programs link these complementary components as appropriate Focus primarily on common mental health conditions: Depressive and anxiety disorders Alcohol misuse and abuse PTSD screening/assessment Health Behavior Coordinators implement health psychology programs along with Health Promotion/Disease Prevention Program Managers 34

35 PATIENT ALIGNED CARE TEAM PACT Handbook: Mental health staff are part of the interdisciplinary team, along with health behavior coordinators, HPDP, social work, clinical pharmacy, clinical dietetics and others Mental health staff integrated in PACT can serve as first step of treating mental and behavioral problems in the primary care

36 Mental Health Care Management (based on 20 years of RCTs) Disease-specific Care Management Evaluation and triage, usually telephone-based Guideline-based treatment support Patient activation, education for self-management Telephone follow-up includes on-going assessment and monitoring of adherence to medication, treatment plan, behavioral activation, problem solving Referral management VA: Translating Initiatives for Depression into Effective Solutions [TIDES] and Behavioral Health Laboratory [BHL]

37 Co-located Collaborative Care (evolving evidence base) Mental health provider(s) embedded in primary care clinic with shared responsibility for evaluation, treatment planning and monitoring outcomes Consultation and education to PACT Open or advanced (same day) access Assessment and brief treatments within PACT Present in PACT meetings for case discussion may provide advice or assessment

38 Most common interventions by embedded staff (Funderburk et al., 2011) Cognitive-behavioral therapy interventions Psychoeducation Supportive psychotherapy Pharmacological intervention 38

39 LEVELS OF CARE IN WELL DEVELOPED PC-MHI PROGRAMS, 70-80% OF ALL MENTAL ILLNESS CAN BE EFFECTIVELY MANAGED IN PC WHAT ABOUT THE OTHERS? NEED SECONDARY AND TERTIARY CARE: SPECIALTY MENTAL HEALTH CARE

40 Integrated care evidence base Improved identification o Improved identification of depression, psychiatric co-morbidities and substance misuse (Oslin et al., 2006, 2013) o Improved identification of depression (Watts et al., 2007) Improved access o Increased rates of treatment (Alexopoulos et al., 2009; Watts et al., 2007; Bartels et al., 2004; Hedrick et al., 2003; Liu et al. 2003; Unützer et al., 2002; Brawer et al., 2010) o Reduced wait times (Pomerantz et al., 2008) 40

41 PC-MHI Evidence Base Improved engagement and adherence o Improved engagement in mental health treatment (Zanjani et al., 2008; Wray et al., 2012) o Improved engagement and adherence in treatment for depression and atrisk alcohol use (Bartels et al., 2004) o Greater antidepressant adherence (Hunkeler et al., 2006; Katon et al., 1999, 2002) o Improved no-show rates (Pomerantz et al., 2008; Zanjani et al., 2008; Guck et al., 2007) Higher quality care o Increased probability of receiving guideline-concordant treatment (Watts et al., 2007; Roy-Byrne et al., 2001) o Higher patient perceptions of quality of care (Katon et al., 1999) 41

42 PC-MHI Evidence Base Better clinical and functional outcomes o Improved short and long term clinical (remission; symptom reduction) and functional outcomes compared to standard care for depression (Alexopoulos et al., 2009; Gilbody et al., 2006; Hunkeler et al., 2006; Katon et al., 2002; Unützer et al., 2002; Roy-Byrne et al., 2001; Katon et al., 1999) o Similar remission rates and symptom reduction for depression compared to enhanced specialty referral (Krahn et al., 2006) o Decrease in at-risk alcohol use comparable to enhanced specialty referral (Oslin et al., 2006) o More rapid clinical response (Alexopoulos et al., 2009; Hedrick et al., 2003) o Higher fidelity to integrated care model resulted in better patient response and remission rates (Oxman et al., 2006) Increased patient satisfaction (Pomerantz et al., 2008, 2010; Hunkeler et al., 2006; Chen et al., 2006; Areán et al., 2002; Unützer et al., 2002) 42

43 WHAT ABOUT PRIMARY CARE FOR INDIVIDUALS WITH SERIOUS MENTAL ILLNESS? PROVIDERS: PATIENTS WE DON T UNDERSTAND THEM THEY DON T UNDERSTAND ME THEY TAKE TOO LONG THEY AREN T PATIENT WITH ME THEY DON T DO WHAT WE SAY THEY WANT TO CONTROL ME THEY SCARE ME THEYSCARE ME

44 VA MODELS FOR SMI IN THE PACT TYPICAL PACT ENHANCED CARE COORDINATION COHORT TEAMLET PC TEAMLET WITH EXTRA TRAINING, REDUCED CASELOADS SMI PACT BRINGS PC AND OTHER NECESSARY DISCIPLINES INTO SMI PROGRAMS

45 THE SMI PACT CAVEAT Including patients with serious mental illness in a PACT that provides care to a range of patients is a key objective of recovery. Effective treatment for patients with SMI requires collaboration between mental health providers, mental health case managers, PC-MHI providers, and PACT staff. Some facilities may choose to establish a Special population PACT for some patients with serious and persistent mental illness (SMI- PACT). Nonetheless, the underlying goal is to eventually help those patients transition to a primary

46 ARE WE THERE YET? Healthcare providers are mental health care providers Mental health care providers are healthcare providers Patient-centered care is centered around the patient

Integrating MH/SA Treatment in Primary Care Firm Clinics: The Behavioral Health Clinic

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