Seamless: Integrating behavioral health and primary care

Transcription

1 Seamless: Integrating behavioral health and primary care Benjamin F. Miller, PsyD Director of the Office of Integrated Healthcare Research and Policy Department of Family Medicine University of Colorado Denver School of Medicine The health care delivery system is incapable of meeting the present, let alone the future needs of the American public. (IOM, 2002) We have developed a health care system that is unable to deal with the varied roles that mind and body play in so called physical illness. (Levant, May, & Smith, 2006)

2 But first A STORY

3 % in Of and 4 adults over suffer = 57.7 from million a people (U.S. disorder Census in a Primary the of 40% care patients referred has become with from mental the primary de health facto care needs mental to rely given Bureau, solely year on 2005) their 26.2% primary (Kessler, care Chiu, physician Demler, (Brody, & Walters, specialty health system mental (Regier health et al, services 1993) only about Khaliq, 2005) & 10% Thompson, will follow 1997) up (Cummings, 2002) U.S. Kessler Brody, Reiger, Census RC, D.S., D. Bureau Chiu Khaliq, A., Narrow, Population WT, Demler A.A., & W. O, Thompson, E., Estimates Rac, D. Walters EE. T.L. S., by Manderscheid, Prevalence, (1997). Demographic Patients Characteristics. R. Table 2: Annual Estimates of the Population by Selected Age Groups and severity, perspectives W., Locke, B., Sex for and the comorbidity on & Goodwin, the United States: of management F. (1993). April twelvemonth emotional of The 1, 2000 to de facto July 1, DSM IV distress US mental 2004 (NC EST ) disorders in primary health and in the Source: National care addictive settings. disorders Cummings, N. (2002, December). Integrated Population Comorbidity Journal practice Division, Survey of service Internal system: in U.S. the Replication 21st Medicine, Epidemiologic Census century. Bureau (NCS R). 12, Paper Catchment Area prospective. Archives of General Psychiatry, 50, Release Archives presented Date: of June at Brief General 9, Therapy Psychiatry, Conference, 2005 Jun;62(6): Orlando, Fl.

4 5 ways INTEGRATION IS INEVITABLE #1 Recognize fragmentation has spread Physical Health Care Delivery Mental Health Payment Training and Education Public Perception Primary Care

5 #2: Mental health needs are going unmet 84% of the time, the 14 most common physical complaints have no identifiable organic etiology 1 80% with a behavioral health disorder will visit primary care at least 1 time in a calendar year 2 50% of all behavioral health disorders are treated in primary care 3 1. Kroenke & Mangelsdorf, Am J Med. 1989;86: Narrow et al., Arch Gen Psychiatry. 1993;50: Kessler et al., NEJM. 2006;353: % with a behavioral health disorder do not get behavioral health treatment % of referrals from primary care to an outpatient behavioral health clinic don t make first appt 2,3 1. Kessler et al., NEJM. 2005;352: Fisher & Ransom, Arch Intern Med. 1997;6: Hoge et al., JAMA. 2006;95: Two-thirds of primary care physicians (N=6,660) reported not being able to access outpatient behavioral health for their patients. Cunningham, Health Affairs. 2009; 3:w490-w501.

6 Those receiving BH care Those Who Might Benefit From BH Services Those not receiving BH care #3: The patient centered medical home Joint Principles of PCMH Personal Physician Physician Directed Practice Whole Person Orientation Care is Coordinated and/or Integrated Quality and Safety Enhanced Access to Care Payment to Support PCMH

7 #4 We must begin to address comprehensiveness in an entirely new way Spitzer, R. L., J. B. W. Williams, et al. (1994). "Utility of a New Procedure for Diagnosing Mental Disorders in Primary Care: The PRIME MD 1000 Study." JAMA 272(22): Clinical Measurement Range Mental Health Presentation Medical issues with psychosocial barriers to care Medical issues requiring behavioral or psychological intervention Mental Health and Substance Use Presentations Mental and Physical Health Multimorbidity Severe Mental Illness and/or Substance Abuse Psychosocial Support Services Behavior Change Education & Evidence Based Treatments Mental health treatment plan Coordination of mental and physical health treatment plans Full coordination with specialty care Example Targeted Service Response

8 #5 Fragmentation is Costly Annual Cost those without MH condition Annual Cost those with MH condition Heart Condition $4,697 $6,919 High Blood Pressure $3,481 $5,492 Asthma $2,908 $4,028 Diabetes $4,172 $5,559 Petterson S, Phillips B, Bazemore A, Dodoo M, Zhang X, Green LA. Why there must be room for mental health in the medical home. American Family Physician. 2008;77(6):757. Phillps, R. L., B. F. Miller, et al. (2011). "Better Integration of Mental Health Care Improves Depression Screening and Treatment in Primary Care." American Family Physician 84 (9): 980.

9 Miller, B. F., Teevan, B., Phillips, R. L., Petterson, S. M., & Bazemore, A. W. (2011). The importance of time in treating mental health in primary care. Families, systems & health : the journal of collaborative family healthcare, 29(2), doi: /a Massa, I., B. F. Miller, et al. (2012). "Collaboration between NCQA Patient Centered Medical Homes and specialty behavioral health and medical services." Translational Behavioral Medicine: 1 5.

10 Before we get to the solutions, let s consider the evidence EMPIRICALLY SUPPORTING INTEGRATION Quantitative & qualitative reviews 1-4 Depression 1-4 Panic Disorder 1-2 Other Studies 5 Tobacco Alcohol Misuse Diabetes IBS GAD Chronic Pain Primary Insomnia Somatic Complaints Improved Patient Satisfaction 1-5 Improved Primary Care Provider Satisfaction 6,7 1. Butler et al., AHRQ Publication No. 09- E003. Rockville, MD. AHRQ Craven et al., Canadian Journal of Psychiatry. 2006;51:1S-72S. 3. Gilbody et al., British Journal of Psychiatry, 2006;189: Williams et al., General Hospital Psychiatry, 2007; 29: Hunter et al., Integrated Behavioral Health in Primary Care: American Psychological Association, Chen et al., American Journal of Geriatric Psychiatry. 2006; 14: Unutzer et al., JAMA. 2002; 288: Katon et al., JAMA. 1995; 273: Katon et al., Archives of General Psychiatry. 1999; 56: Katon et al., Archives of General Psychiatry. 1996; 53: Gallo et al., Annals of Family Medicine. 2004; 2: Levine et al., General Hospital Psychiatry. 2005; 27:

11 What s Been Done? 1)Collaborative relationships between PCP s and BH providers require preparation, time and supportive structures. 2) System-level integration requires preparation, reorganization & time to develop. 3) Co-location is important for both providers and patients. 4) Degree of integration does not in itself appear to predict clinical outcome. Badamgarav, 5)Integrated care 2003 with treatment guidelines--better results for pts with depression. 6)Those with severe depression 38 trials, differentially through impacted October by 2005 integrated care. 7)Systematic Craven, 2006follow-up for depression Includes related Non-US to trials positive clinical outcomes. 8)Efforts Gilbody, 2003 to increase medication Only adherence RCT through integrated care were a component of many successful studies. However analysis of the studies found no clear direct Gilbody, 2006 relation between medication adherence and clinical outcome. 9)Integration Gunn, 2006 alone has not been shown to produce skill transfer or enduring changes Skultety, in PCP 2006 knowledge or behaviors in the treatment of depression. 10)Enhanced pt education-a component of studies with good outcomes. Smith, However, 2007 the reviewers suggest that future research is needed to determine what Williams, if any contribution 2007 patient education makes to successful integrated care. 11)Patient choice about tx modality may be an important factor. Vergouwen, 2003 Craven, M. A. & Bland, M. (2006). Better practices in collaborative mental health care: An analysis of the evidence. Canadian Journal of Psychiatry, Vol, 51, pg. 1S-72S. What s Been Done? What is the impact of integrated care on outcomes? Integrated RCT + high care quality programs quasi-experimental improve outcomes design studies N=33 (26 on depression care, four examining anxiety disorders, one Effects somatizing for symptom disorder, severity one attention consistently deficit favors and hyperactivity integrated care disorder, for depression and one and depression anxiety, and but not alcohol for somatization, disorder) at risk drinking, and ADHD The authors conclude that while integrated care has positive outcomes, it is Treatment response and remission rate for depression and anxiety exhibit the difficult to delineate between the added attention a disorder receives and the same pattern of positive outcomes specific strategy used on that disorder. Results Additionally, for both the depression authors call and for anxiety the field show to begin a weakening to examineffect within the first specific 6-12 elements months of collaborative care, and which of these elements are necessary to achieve the desired outcomes. Butler M, Kane RL, McAlpin D, et al. Integration of Mental Health/Substance Abuse and Primary Care No. 173 (Prepared by the Minnesota Evidence based Practice Center under Contract No ) AHRQ Publication No. 09 E003. Rockville, MD: Agency for Healthcare Research and Quality; October 2008

12 A few ideas ADVANCING INTEGRATION IN YOUR COMMUNITY Brilliance Brilliance Brilliance Brilliance Brilliance

13 Fragmentation as a Parallel Process What we do (models) What data we collect (clinical) What we call ourselves (integrated) What we need for sustainability (money) Who we talk to (ourselves) What we want (change) Advancing integration RESEARCH

14 Lexicon (language critical) First and second steps for the field in research Metrics for evaluating integration Unite the field and move it forward Descriptive Evaluative Evaluative research How would integrated mental health influence hypertension outcomes? Collaboration between mental health and primary care providers Descriptive research What components of integrated mental health care correspond to collaboration? Can these components be measured at the provider level? At the practice level?

15 Research questions Descriptive How do populations of patients with comorbid mental health and physical health presentations vary depending on method of detection of mental health? What integrated care elements differentiate practices that exhibit high vs low levels of collaboration between mental health and primary care providers? Evaluative (cause and effect) Research questions For patients with comorbid hypertension and anxiety disorder, how do hypertension outcomes vary depending on level of collaboration between PCPs and BHPs? Do practices characterized by elements of integrated care thought to facilitate collaboration have patients with better hypertension outcomes?

16 Access Detection Treatment Practice Experience Patient Experience Improvement Cost System Experience Peek (2008) Three World s of Healthcare Clinical Operational Financial Berwick (2008) Triple Aim Care Health Cost 31 Oh yeah ELECTRONIC MEDICAL RECORDS

17 One story Upon visiting a self proclaimed trail blazer for integrated care, one question was asked to the HIT team that ruined their day: What percentage of the information in your EMR is structured and what percentage is free text? free text structured

18 In closing TRANSFORMATION Mental health and primary care are inseparable; any attempts to separate the two leads to inferior care (IOM, 1996) Primary care Usual Care Fragmented (siloed) Not coordinated Behavioral health care mental health substance abuse Primary care Specialist care - Prevention Other care - Acute Care - Chronic Care Behavioral health Other licensed healthcare providers Specialists

19 Take a deep breath QUESTIONS? Thank you BENJAMIN.MILLER@UCDENVER.EDU CFHA.NET INTEGRATIONACADEMY.AHRQ.GOV