1. Models of Psychiatric Care Integration, Part 1 David Katzelnick MD Wisconsin Psychiatric Association Fall Conference December 5 th, 2014

3. Access: Availability of outpatient Psychiatrists Posing as patients Called 360 psychiatrists Blue Cross Medicare Out of pocket 2 rounds of calling Success 26% 1 st available appt. 25 days (Range 0-93) Psychiatric Services Oct. 2014

4. Where are the Psychiatrists US: 40,000 psychiatrists largely in urban areas More than 50 % of counties in the US don’t have a single practicing psychiatrist or psychologist.

5. Primary Care Patient 60 year old male who saw his ability to cope with his medical issues collapse in 2005 when his back gave out – job loss. Diabetes (initial HgB A1C 9.8) CVD – previous MI and stent HTN Psychosocial Depressed (PHQ-9 14 ) Unable to afford medications, not taking care of himself.

6. Patient Complexity Social Complexity Chronic medical Illnesses High Utilization of inpatient/ED/specialty with chronic illness Psychiatric Illness Relationships with healthcare system and readiness for change

7. Cartesian Solutions, Inc.™ © Contribution of Mental Conditions to the Total Cost of Care in Patients with Chronic Medical Illnesses All Insured $2,920 Arthritis $5,2206.6%36%$10,710 94% Asthma $3,7305.9%35%$10,030 169% Cancer$11,6504.3%37% $18,870 62% Diabetes $5,4808.9%30%$12,280 124% CHF $9,7701.3%40%$17,200 76% Migraine $4,3408.2%43%$10,810 149% COPD $3,8408.2%38%$10,980 186% Cartesian Solutions, Inc.™--consolidated health plan claims data Illness Prevalence % with Comorbid Mental Condition* Annual Cost with Mental Condition Annual Cost of Care % Increase with Mental Condition Patient Groups *Approximately 10% receive evidence-based mental condition treatment

8. ©2011 MFMER | slide-8

9. Projected Healthcare Cost Savings Through Effective Integration (National, 2012) Payer Type Annual Cost Impact of Integration Commercial $15.8-$31.6 billion Medicare $3.3-$6.7 billion Medicaid $7.1-$9.9 billion Total $26.3-$48.3 billion ©2011 MFMER | slide-9

10. The future of psychiatry in the era of health care reform will involve more team-based integrative care than ever before. That means a shift away from the fee-for-service, volume- based model of care to which psychiatrists are accustomed. "We’re going to have to change the way we do business in order to survive…" Dr. Scully, CEO and medical director of the American Psychiatric Association. Clinical Psychiatry News, 3/2013 Integrative care is the future of psychiatric care

13. How do we close the gap? Train more specialists? Work harder? Work smarter! Leverage mental health specialists more effectively - partnerships (e.g., primary care) - technology (e.g., telemedicine)

14. “Trying harder will not work, changing systems of care will.” Don Berwick Institute for Healthcare Improvement Former CMS Administrator

15. Collaborative Care effectively ‘leverages’ a psychiatrist to reach more people Office Based Private Practice Mental health center Collaborative Care (Psychiatrist Supports Primary Care based Team) Typical active caseload (unique patients) in any given month 35 – 150100 – 300500 – 1000 Typical caseload over 12 months* 50 – 300100 – 5001000 – 2000 Patient contacts / case reviews over 12 months** 15001500 – 20003000 Total population covered*** 1,650 – 9,0003,000 – 15,00033,000 – 66,000 Assumptions: * Typical caseload turns over once / year **1 FTE psychiatrist sees patients 30 hours / week *** 3 % of population has need for mental health services in any given year. Slide from Jurgen Unutzer 2011

16. *All Meaningful effects deemed to be of sufficient magnitude to be of public health benefit by Community Preventive Services Task Force and by subject matter experts. Thota et al / Am J Prev Med 2012;42(5):525-538

17. Impact of Collaborative Care for Depression ‘*Turner et al / N Engl J Med 2008; 358:252-60 ‘** Thota et al / Am J Prev Med 2012;42(5):525-538

18. IMPACT reduces health care costs ROI: $ 6.5 saved / $ 1 invested Cost Category 4-year costs in $ Intervention group cost in $ Usual care group cost in $ Difference in $ IMPACT program cost 5220 Outpatient mental health costs 661558767-210 Pharmacy costs 7,2846,9427,636-694 Other outpatient costs 14,30614,16014,456-296 Inpatient medical costs 8,4527,1799,757-2578 Inpatient mental health / substance abuse costs 11461169-108 Total health care cost 31,08229,42232,785-$3363 Unützer et al., Am J Managed Care 2008. Savings

19. Economic Burden of Depression Total $83.1 Billion in 2000 Greenberg PE et al: J Clin Psychiatry 2003; 64:1465-1475 62% 31% 7% Direct Medical Costs Suicide- related Workplace Costs

20. PROSPECT Study Effect of Depression Care Management on Mortality in Older Adults 20 US Primary Care Practices Intervention= 2 years care coordination N=1226 patients >=60 Mean follow-up=8 years Conclusion: Patients with Major Depressive Disorder in Intervention were 24% less likely to die than patients in usual care. (p=0.05) Gallo J BMJ 2013

21. Large Scale Behavioral Healthcare Integration Programs ProjectPopulation COMPASS/TEAMCareDepression+ Chronic Medical Condition MHIP Washington StateMultiple psychiatric disorders, public sector clinics DIAMOND/IMPACTDepression in Primary Care RESPECT-Mil: ArmyDepression and PTSD IAPT UKPsychotherapy for Depression and Anxiety Disorders, all UK PC-MHI VHAMultiple Psychiatric Disorders: Primary Care

22. Characteristics of Rapidly Disseminated Innovations Fitzgerald L Health and Social Care in the Community 11(3), 219-228 Robust scientific evidence Applicable to many patients or without innovation patients will suffer severe adverse events Cost neutral or savings Raises patient satisfaction Not complicated to implement

25. Start Small

26. Improvement Hold Gains Spread Creating a New System Improvement Hold Gains Spread BETTER

28. DIAMOND Insurance Payments - Initiated by employer group that were concerned about the impact of depression on employees and on company’s profitability. - Most major insurers in Minnesota in 2008 agreed to pay monthly fee to support care coordinator and psychiatrist time.

29. DIAMOND: Depression Improvement Across Minnesota Currently 80 primary clinics across Minnesota Consistent with evidence on collaborative care: Four Processes: 1. Consistent method for assessment/monitoring (PHQ-9) 2. Presence of tracking system (registry) 3. Stepped care approach to intensify/modify treatment 4. Relapse prevention Two Roles: 1. Care manager for follow up, support, coordination 2. Consulting psychiatrist for caseload review and recommendations

30. New Role for Psychiatry Traditional consultation/liaison role is seeing patients identified by primary care providers One patient at a time Patients can wait 2-3 months to be seen Many “no shows” Frustrating to patients, PCPs and psychiatrists New model Review patients with care manager Many more patients addressed in same time frame Patient problems are addressed within days of intake Can focus on those needing attention

31. COMPASS A 3-year grant from CMS (Center for Medicare and Medicaid studies) to implement a well researched model of care for patients with diabetes, cardiovascular disease and depression in primary care clinics and study if this evidence- based model can be sustained in the real world. Primary grant awardee is ICSI Implementing the model in several states Mayo implementing in eight primary care sites Two academic centers – Rochester and Florida Eight rural family medicine clinics in Minnesota

32. Triple Aim Measures of Success Population health Increase remission/response rates for patients with depression Improve control rates for diabetes and cardiovascular disease and their risk factors Reduce risky substance use Experience of care Improve quality for patient and provider satisfaction Affordability Decrease readmissions, admissions and ED visits to reduce health care costs

33. Supported by Cooperative Agreement The project described in this slide set was supported by Cooperative Agreement Number 1C1CMS331048-01-00 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. Its contents are solely the responsibility of the authors and have not been approved by the Department of Health and Human Services, Centers for Medicare & Medicaid Services. 33

34. Core Elements of COMPASS Thorough Initial Evaluation Computer Registry Treatment Intensification Maintenance Plan/ Relapse Prevention Care Manager/Coordinator Physician Consultant Aggregate Data Evaluation Transitions of Care Coordination SYSTEMATIC CASE REVIEW

35. CARE MANAGER PCP Longitudinal Care Consultant Psychiatrist Longitudinal Care Consultant SYSTEMATIC CASE REVIEW TEAM

36. Patient burden in COMPASS Psychiatry Endocrine Cardiology Pain management SCRCare coordinatorPCP

37. Comparison of Clinical Outcomes COMPASS at Mayo and TEAMCare Randomized Trial TEAMcare Intervention Group- 6 months* n=105 Mayo COMPASS 6-11 months n=312 TEAMcare Intervention Group- 12 months* n=105 Mayo COMPASS 12 months or greater n=312 Depression Severity Percent Response >=50 % decrease 59%44% 60%63% Change A1c**-0.72-0.48 -0.81 Change LDL** -10.0-14.9-11.6 Change Systolic BP** -3.8 -4.1-4.7-6.0 *Katon W. NEJM 2010 Dec 30;363(27):2611-20 ** Includes all patients with baseline A1C, LDL and Systolic BP.

38. Mayo Additions to DIAMOND CALM: Coordinated Anxiety Learning and Management EMERALD: Early Management and Evidence- Based Recognition of Adolescents Living with Depression SBIRT: Screening, Brief Intervention and Referral to Treatment

39. Complex Care Model Care Transition Program Care Coordinator & Systematic Care Review Care Coordinator with Self Management and M.I. Navigator/Panel Manager Preventive Care Mayo Clinic Complex Care Group 2014

40. “Oh, if only it were so simple.”

41. Continuing Challenges Single vs. multiple diseases? Combine Mental health with non-mental health chronic illnesses? Telephone vs. in-person coordination? Models for small clinics? Time needed to see ROI? Financial models for mental health specialty care?

42. Summary The current model of Psychiatry needs to change. Mental Health needs to be an integral part of the care of patients with complex needs. Collaborative Care works and is cost effective Multiple successful real world implementations of Collaborative Care Fee for service has been a barrier to expansion of Collaborative care Changes in healthcare financing incentivize Collaborative Care

43. Questions and discussion?