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Collaborative Care in Primary Care and Behavioral Health: Are We at the Tipping Point? Henry Chung, M.D. Vice President and Chief Medical Officer Care.

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Presentation on theme: "Collaborative Care in Primary Care and Behavioral Health: Are We at the Tipping Point? Henry Chung, M.D. Vice President and Chief Medical Officer Care."— Presentation transcript:

1 Collaborative Care in Primary Care and Behavioral Health: Are We at the Tipping Point? Henry Chung, M.D. Vice President and Chief Medical Officer Care Management Company of Montefiore Medical Center And Clinical Associate Professor of Psychiatry New York University School of Medicine

2 Agenda Why does Integration Matter for the Health of Our Patients? Is Integrated Care the Same as Collaborative Care? What are the key ingredients of Collaborative Care? Quality Outcomes and Measurement Health Homes and ACO’s – the Promised Land?

3 Health and Behavioral Health Challenges Basic medical and behavioral health services must be available in all clinical settings –most people with behavioral health disorders are seen in medical settings NOT specialty settings Specialty behavioral health settings must have excellent access to medical services - most people with severe and persistent mental illness or severe addiction have excess morbidity and mortality due to premature CV disease All health settings must have care coordination capability in the appropriate continuum depending on case mix and severity – episodic point of care treatment is INEFFECTIVE resulting in major gaps in treatment; in high cost complex safety net patients, medical and behavioral health readmissions are a HUGE excess cost to the system Care management for patients with multiple disorders as well as specialty care management must be used in a stepped care manner – locus of patient care and costs should be accounted for in the segmentation process


5 Primary Care and Behavioral Health Integration Models (Mechanic D) Enhanced screening, treatment and referral - Trained primary care providers screen, identify, treat and /or refer to mental health specialists (usually off site) for treatment Co-location of services –behavioral health clinicians provide consultation and/or short term treatment Systematic integration with shared protocols, health information, and quality metrics and outcomes

6 Key Principles of Depression Integration in Primary Care Training of PCP to Screen and Diagnose Starting Treatment (almost always medication) Patient Education Follow Up and Stepped Care Easy Access to Specialty Care BUT?

7 What are the Limitations? Organizational Commitment Cultural Tailoring necessary Payment Alignment Problems Sustainability Problems “Quest for Cost Offset!” Working Through the Cultural Values of Primary Care and Behavioral Health

8 Landmark Randomized Controlled Trials in Depression IMPACT – Older Adults and Depression RESPECT-D – Primary Care Patients and Depression ? PRISMe – Older adults with depression in primary care or at-risk drinking randomized to collaborative care vs enhanced specialty care

9 RCT for geriatric patients presenting in primary care settings (VA, FQHC, academic) with depression randomized to Integrated care or enhanced specialty care with more realistic resource allocations (ie limited!) Rationale : assess real world outcomes with greater generalizability for integrated care compared to improved specialty mental health; ie no algorithms, no treat to target interventions Main hypotheses: Improved Engagement in Integrated Settings; Equivalent 6 month outcomes; Why PRISM-E?

10 Appointment available within 2-4 weeks of PCP dx of depression/ at risk alcohol Licensed MH/SA professionals with some indication of geriatric expertise Coordinated followup contacts with PCP and patient if they missed first visit Concrete services incl transport if necessary Availability of urgent and emergency appointments PRISM-E Enhanced Specialty Mental Health Model Requirements

11 Engagement and treatment of depression in PRISM-E N=599N=621 71% 29% 49% 37%

12 Very high refusal rates in PC settings, except for VA PC settings Higher engagement in PC than in specialty settings No difference in outcomes at 3 or 6 months Patients with both depression and SA did slightly better in specialty settings (but very small sample) PRISM-E Outcomes for Hazardous Drinking

13 “TRYING HARDER WILL NOT WORK. CHANGING SYSTEMS OF CARE WILL.” Don Berwick Institute for Healthcare Improvement

14 What is Collaborative Care?

15 Collaborative (Chronic) Care Model Effective chronic illness care requires a re-organization of the health care system to manage chronic or recurring illnesses more effectively Application of evidence at point of care Patient activation to promote effective self- management and patient-provider collaboration Systematic outreach to ensure appropriate monitoring and follow-up care

16 Care Management/Coordination Holistic and coordinated approach for conditions often put into separate silos in the delivery system Offers flexibility in patient-centric treatment modalities and settings sensitive to cultural and economic barriers to treatment Supports adherence through self- management and active care coordination for multiple chronic illnesses

17 Self Management Goal directed patient behaviors that enhance clinical & functional outcomes: Medication management and adherence Psychotherapy previewing and adherence Self-monitoring of symptoms, treatment status Managing effects of illness on social role function Reducing health risks (alcohol misuse, smoking) Preventive maintenance (e.g., exercise, screening check-ups) Working with health care professionals

18 Organizing Framework for Team Based Care Peer Based Learning with clinical application (rapid piloting) Patient Centered Care Coordination as a Foundational Concept = Population Based Health QI principles tied to Specific Measures = Accountable Care Ability to Incorporate Latest Evidence Base into The Model Patient Self Management = Empowerment Sustainability is paramount Why is the model effective?

19 SBIRT for Alcohol Copyright © 2011 The National Center on Addiction and Substance Abuse at Columbia University SBIRT Components Screening Brief strategy to identify at-risk population Brief Intervention One or more discussions with clinician (10-15 min each): 1.Assessment & feedback on drinking 2.Advice, goal setting, agree on plan 3. Follow-up contact Referral to Specialty Treatment Patients with more severe problems require more than a brief intervention

20 SBI for Alcohol in Primary Care Effectiveness and Cost-Effectiveness Most effective intervention for alcohol problems based on clinical trials research Solberg et al. (2008): SBI for alcohol ranked among top of 25 USPSTF- recommended screening practices based on effectiveness and cost-effectiveness Similar in ranking to screening for hypertension or colorectal cancer Copyright © 2011 The National Center on Addiction and Substance Abuse at Columbia University

21 Life-Years Saved, Costs, And Savings From 20 Evidence-Based Clinical Preventive Services (2006 Dollars) Clinical preventive service Life-years saved per 10,000 people per year of intervention Medical cost of service per person per year Medical savings of service per person per year Annual net medical costs per person per year Childhood immunizations1,233.1$306$573−$267 Influenza immunization23.828208 Pneumococcal immunization6.446113−67 Discuss daily aspirin use63.02187−66 Smoking cessation advice and assistance 97.51050−40 Alcohol screening and brief counseling 7.0920−11 Breast cancer screening45.064361 Cholesterol screening27.812824104 Colorectal cancer screening40.8463115 Depression screening0.0420 Hypertension screening10.7795029 Source Authors’ analyses; sources for data used in each model are available from the authors. Health Affairs September 2010 29:9

22 Other Promising Collaborative Care Models in the Arsenal GAD and Panic Disorder Bipolar Disorder PTSD Opioid Abuse and Dependence using Buprenorphine Others?

23 Behavioral Health and Measurement: A Quality Imperative Why Measurement? Improve individual outcomes by assisting in treatment planning Group level outcomes can serve as benchmarks and goals that can be used as critical information to confirm or address effectiveness of service model changes Creates a common language across disciplines and providers to promote effective collaboration

24 Translating PHQ-9 Depression Scores into Initial Planning ScoreDescriptionActions 1-4Community NormsNo further action 5-9Mild SymptomsWatchful waiting, periodic re-screening, education, patient activation and evaluation 10 – 14Moderate SymptomsDevelop treatment plan, consider counseling, education, assertive follow- up and evaluation, pharmacotherapy 15 – 19Moderate -SevereImmediate institution of treatment including medication and/or counseling ≥ 20SeverePharmacotherapy, counseling & referral to mental health specialist

25 Using the PHQ-9 to Monitor & Adjust Treatment at 4-6 Weeks PHQ-9Treatment ResponseTreatment Plan Drop of 5 points from baselineAdequateNo treatment change needed Follow-up in four weeks Drop of 2-4 points from baseline Possibly InadequateMay warrant an increase in antidepressant dose Drop of 1 point, no change or increase InadequateIncrease dose; Augmentation; Informal or formal psychiatric consultation; Add psychotherapy

26 APA NDLMI Psychiatry (Psychiatrist and Non-Physician Co-Leader) Depression Measurement Informed Care Project

27 PHQ9 was helpful in Tx decisions93% (n=6,096 Patient Contacts) For contacts where PHQ9 was helpful, how did PHQ9 influence Tx? (n=5,578 Patient Contacts) - Change Tx40% - Confirm Tx60%

28 Impact of Measurement on Psychotherapy Treatment Outcomes* * Harmon, S. Cory, Lambert, Michael J., et al. (2007). Enhancing outcome for potential treatment failures: Therapist-client feedback and clinical support tools. Psychotherapy Research, 17(4), 388

29 Health Homes and Accountable Care Organizations

30 Superb Access to Care Patients can easily make appointments and select the day and time. Waiting times are short. eMail and telephone consultations are offered. Off-hour service is available. Patient Engagemen t in Care Patients have the option of being informed and engaged partners in their care. Practices provide information on treatment plans, preventative and follow-up care reminders, access to medical records, assistance with self-care, and counseling. Clinical Information Systems These systems support high-quality care, practice-based learning, and quality improvement. Practices maintain patient registries; monitor adherence to treatment; have easy access to lab and test results; and receive reminders, decision support, and information on recommended treatments. Care Coordin ation Specialist care is coordinated, and systems are in place to prevent errors that occur when multiple physicians are involved. Follow-up and support is provided. Team Care Integrated and coordinated team care depends on a free flow of communication among physicians, nurses, case managers and other health professionals (including BH specialists). Duplication of tests and procedures is avoided. Patient Feedba ck Patients routinely provide feedback to doctors; practices take advantage of low-cost, internet-based patient surveys to learn from patients and inform treatment plans. Publically available information Patients have accurate, standardized information on physicians to help them choose a practice that will meet their needs. 8 Source: Health2 Resources 9.30.08 Defining the Medical Home

31 Health Homes Overview Beneficiary criteria - At least two chronic conditions, one chronic condition and at risk for another, or one serious and persistent mental health condition. Chronic conditions include mental health condition, substance abuse disorder, asthma, diabetes, heart disease, being overweight (BMI over 25). Designated Providers -Physicians, clinical group practices, rural health clinics, community health centers, community mental health centers, home health agencies; interdisciplinary health teams. Payment - flexibility in designing the payment methodology including structuring a tiered payment methodology that adjusts for severity of illness and the “capabilities” of the designated provider. 3131

32 All Medicaid by Clinical Risk Groups (CY 2008) Entire Medicaid by CRG Recips Total Member Months Pct Total Member Months Avg MM Pct of Total Member Months Sum Total Claim Expenditures Pct of Total Claim Expenditures Total Claim PMPM 1) Healthy 2,891,590 26,366,51153.65% 9.1253.65% $ 6,256,508,37614.30% $ 237 2) Maternity/Delivery 227,175 2,060,9554.19% 9.074.19% $ 1,501,611,8493.43% $ 729 3&4) Minor Conditions 333,807 3,656,2257.44% 10.957.44% $ 1,801,754,3884.12% $ 493 5) Single Chronic 741,860 7,915,44716.10% 10.6716.10% $ 8,925,736,96120.40% $ 1,128 Pairs & Triples 6) Pairs Chronic 628,772 7,132,39614.51% 11.3414.51%$ 16,778,912,69238.34%$ 2,352 % of Memb Mos % of $ 7) Triples Chronic 76,427 870,3771.77% 11.391.77% $ 3,457,392,1777.90% $ 3,97216.28%46.24% 8) Malignancies 25,157 255,4220.52% 10.150.52% $ 839,000,5181.92% $ 3,285 9)Catastrophic 31,219 342,6640.70% 10.980.70% $ 2,236,148,1315.11% $ 6,526 10) HIV / AIDS 49,589 549,3841.12% 11.081.12% $ 1,964,903,8224.49% $ 3,577 Total 5,005,596 49,149,381100% 9.82100.00% $ 43,761,968,915100.00% $ 890 3232

33 Goal: Improve quality of medical care for SPMI patients at one CMHC Method: 12 month RCT of Patients in one CMHC randomized to nursing care management (MI, coaching, navigation, followup with appts) versus encouragement and PCP list Demo: 85% of patients had schizophrenia, depression and bipolar. 25% had co-occurring SA disorders. Most common CMI were: HTN, arthritis, dental, diabetes. Primary Care Access Referral and Eval (PCARE) Study - Proof of Concept for Health Home

34 PCARE Improvement in Medical Care Druss, Von Esenwein, Am J Psychiatry 167:2, February 2010

35 Health Care Reform: ACOs The Accountable Care Act provides for a shared savings program: that promotes accountability for a patient population and encourages investment in infrastructure and redesigned care processes for high quality and efficient service delivery. Under such program: –groups of providers meeting pre-determined criteria may work together to manage and coordinate care for Medicare fee-for-service beneficiaries through an accountable care organization (referred to in this section as an ‘ACO’); and –ACOs that meet quality performance standards are eligible to receive payments for shared savings



38 PCMH as Foundation for Accountable Care Organizations 38 Source: Premier Healthcare Alliance ACOs are defined as a group of providers that has the legal structure to receive and distribute incentive payments to participating providers.




42 65 Quality Measures in 5 Domains in : Patient/Caregiver Experience (7) Care Coordination (12) Patient Safety (2) Preventive Health (9) At Risk Pop/Frail Elderly in Chronic Conditions (20) Specific Behavioral Health Measures: ONLY 1? HUH!? ACO Quality Measures

43 So Are We at a Tipping Point? (Gladwell) Point at which a movement/event/intention becomes inevitable, inescapable, when everything changes all at once Transformation occurs through initial infection (idea) then contagiousness (others latch on, tell others), little actions having big effects (multiple pilot testing, things begin to work, new application seems to work), change is often sudden (then everybody gets it) Examples – flu epidemic, internet usage, Google. NCDP © New York University

44 Key Ingredients to Reach a Tipping Point 1.Law of the Few a.Connectors – People who know everyone and create intersections and opportunities b.Mavens – People who are credible information hounds and validate ideas and methods c.Salesmen – People who are able to use information and people to spread idea to the skeptical Case example: “The Midnight Ride of Paul Revere” NCDP © New York University

45 Key Ingredients to Reach a Tipping Point 2. The Stickiness Factor a.Memorable – evokes strong feelings b.Minimal barriers to entry – can’t avoid seeing it or seeing others do it – “why not me?” c.“Cool” factor – in the know, the in crowd, identification with status d.Little things make a difference in making big changes, example – PDSA’s NCDP © New York University

46 So Are We There Yet?

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