1. Arthur E. Kelley, MD Medical Director, Partnership for Community Care (CCNC) Psychiatric Consultant, Cornerstone Healthcare, High Point, NC

2. The Context Source: naviglinlp.blogspot.com

3. Primary Care: the De Facto Mental Health System National Comorbidity Survey Replication Treated in Primary Care 23% Treated in MH System 18% Wang et al, Arch. Gen. Psychiatry, 63, June,2005 Untreated 59%

4. Co-Morbidity Percentages 2001-2003

5. DEPRESSION Chronic Pain 40-60% CANCER 10-20% NEUROLOGIC DISORDERS 10-20 % GERIATRIC SYNDROMES 20-40 % HEART DISEASE 20-40% DIABETES 10-20 % University of Washington AIMS Center

6. No Health Without Mental Health From: Center for Health Care Strategies, 2010

7. LACK OF ACCESS Half of the Counties in US Have No Practicing Psychiatrist or Psychologist Source: Unutzer, Psychiatric News, November 1, 2013

8. Changing Healthcare Environment Source: www.wcorha.org

9. PCMH The main vehicle for the coming change. PCSP The medical “neighborhood”

10. Impact Model for Collaborative Care of Depression in Primary Care Source: www.uwaims.org

11. Core Components of Collaborative Depression Care Two ProcessesCare Manager RoleConsulting Psychiatrist Role Systematic diagnosis and outcomes tracking (facilitated by PHQ-9) 1.Diagnostic Assessment 2.Patient Education/self management support 3.Close follow-up to prevent patients from “falling through the cracks” Caseload consultation Diagnostic consultation on difficult cases Stepped Care Change treatment according to evidence based algorithm if patient not improving Relapse prevention once patient is improved Support antidepressant treatment by the PCP Brief Counseling Facilitate treatment change Triage to community Relapse prevention Consultation is focused on patients who are not improving as expected Recommendations for additional treatment/referral according to evidence-based guidelines Adapted from AIMS Center, Univ. of Washington

12. Collaborative Care Improves Outcomes “ Comparative Effectiveness of Collaborative Care Models For Mental Health Conditions Across Primary, Specialty and Behavioral Health Settings: Systematic Review and Meta-Analysis” Am. J. Psych.,169(11), Aug 2012 Statistically Significant Effects Across All Mental Disorders For: 1. Clinical Symptoms 2. Mental Quality of Life 3. Physical Quality of Life 4. Social Role Functioning WITH: NO NET INCREASES IN TOTAL HEALTH CARE COSTS

13. Lowers Healthcare Costs for Patients with Depression Impact Study : $841 per annum/per patient over 4 years Diamond Study: $1300 per annum/per patient over 4 years Unutzer, Harbin, Schoenbaum. and Druss, CMS Information Resource Center Brief,, 2013

14. Lowers Costs for Other Disorders Diabetes and Depression Panic Disorder SPMI Patients Katon et al, Diabetes Care. June 2008:31(6): 1155-1159 Katon et al, Archives of General Psychiatry. December 2002: 59(12): 1098-1104 Druss et al, American J. of Psychiatry. November 2011: 168(11): 1171-1178

15. Cornerstone Care Outreach Clinic Our Team David Talbot, MD, Director Eileen Weston, NP, Clinician Mary Keever, LCSWA, Behavior Health Care Mgr. Art Kelley, MD, Consulting Psychiatrist Our Patients: Medicaid, Medicare, or Dually Eligible Current Enrollment: 360 (10/31/2013) Other Clinicians

16. Our Experience Importance of our tweaked EHR (Allscripts) Screening Issues The Registry Triage Issues

17. Our Statistics: Definitions Positive PHQ-9 : score of > 10 Response: 50% improvement in PHQ-9 score Remission: PHQ-9 score of < 5 Usual care: 20% of treated patients achieve a response. Source: Rush et. al., Biological Psychiatry. 2004: 56(1): 46-53

18. Our Results # ACHIEVING RESPONSE7 (21%) # ACHIEVING REMISSION9 (27%) # ACHIEVING NEITHER17 (51%) PROTOCOL PATIENTS (N=33) 48% achieved response or remission

19. Non-Protocol Patients 88 (73%) of patients with positive PHQ-9 did not enter the depression protocol Reasons: 1. Depression comorbid with another disorder too complicated for primary care 2. Already under psychiatric care 3. Refused 4. Lost to follow-up

20. Future Issues for CCOC Is response/remission in 48% good enough? How to improve medication/psychotherapy adherence. What are the characteristics of good community partners in terms of referral? Can we improve our numbers in regard to patients accepting Impact Model care? Can we improve the medical numbers?