1. GA-U Mental Health Pilot Integrating primary care and mental health Jurgen Unutzer, MD, MPH, MA Professor & Vice Chair Psychiatry & Behavioral Sciences University of Washington

2. The Case for Integration  Mental disorders are common, disabling, and expensive  Primary care is the ‘de facto’ health care system for common mental disorders but only 20-40 % of patients get effective treatment.  Patients with severe mental illness (SMI) receive poor medical care and have high rates of mortality

3. Morbidity and Mortality in People with Serious Mental Illness Persons with serious mental illness (SMI) are dying 25 years earlier than the general population Suicide and injury account for about 30-40% of excess mortality, but 60% of premature deaths in persons with schizophrenia are due to medical conditions such as cardiovascular, pulmonary and infectious diseases –Need for improved care of chronic medical disorders in specialty mental health care settings

4. Why treat mental disorders in primary care ?  Limited access to / use of mental health specialists  Treat mental health disorders where the patients are - Established provider-patient relationship - Less stigma in primary care - Better coordination with medical care

5. Integrated care = working effectively ‘across silos’ Primary Care Community Mental Health Center PC CM HC Social services? Alcohol & substance abuse care?

6. 20 years of collaborative care research at UW  Depression in Primary Care  Depression in Diabetes (Pathways)  Late-life Depression (IMPACT)  Depression in Adolescents - in Primary Care - in Schools  Telemedicine Consultation in Child Psychiatry  Anxiety Disorders in Primary Care  PTSD & Substance abuse in Trauma Care

7. Moving towards integrated Care Worst case scenario = compete Usual situation = co-exist Helpful but not sufficient = consult (or) co-locate Ideal = collaborate effectively

8. Evidence for integrated care: depression Meta-analysis by Gilbody et al, Archives of Internal Medicine; 2006 37 trials of collaborative care for depression in primary care (US and Europe) –CC is consistently more effective than usual care –Successful programs include active care management (not case management) support of medication management in primary care psychiatric consultation

9. 1,801 primary care patients with depression and comorbid medical disorders Funded by John A. Hartford Foundation California Healthcare Foundation Example: IMPACT Jürgen Unützer, MD

10. Effective Collaboration Prepared, Pro-active Practice Team Informed, Activated Patient IMPACT Team Care Model Practice Support

11. Integrated care DOUBLES the effectiveness of usual care for depression % patients Participating Organizations 50 % or greater improvement in depression at 12 months Unutzer et al., JAMA 2002; Psychiatr Clin N America 2005

12. Integrated Care Benefits Ethnic Minority Populations Areán et al. Medical Care, 2005 50 % or greater improvement in depression at 12 months

13. Improved Physical Functioning SF-12 Physical Function Component Summary Score (PCS-12) P<0.01 P=0.35 Callahan et al. JAGS. 2005; 53:367-373.

14. Lower long-term (4 year) healthcare costs

15. Other lessons from IMPACT 1)Co-location is NOT sufficient. 2) Initial treatments are rarely sufficient. Several changes in treatment are often necessary (stepped care). To accomplish this, we need - Systematic outcomes tracking (e.g., PHQ-9) to know when change in treatment is needed. - Active care management until patient is improved to facilitate changes in medication, behavioral activation. - Consultation with mental health specialist if patients not improving as expected.

16. DIAMOND Initiative in Minnesota  Integrated care management for depression supported by 8 large commercial payors and the state Medicaid plan in Minnesota - Organized by the Institute of Clinical Systems Improvement (ICSI) - Common payment code for integrated care / care management  State-wide implementation - First group of 14 clinics trained in March 2008 - Goal to have evidence-based depression care management available in ~ 90 primary care clinics state-wide, reaching ~ 1.4 million Minnesotans by 2010

17. Evidence for integrated care: anxiety, alcohol/substance abuse Anxiety disorders: - Roy-Byrne, et al: Integrated care for anxiety disorders - Zatzick, et al: Trauma-center-based care for alcohol / substance abuse problems and PTSD Alcohol / substance abuse: SBIRT (Substance use Brief Intervention Referral and Treatment)

18. GA-U Mental Health Pilot Community Health Plan of Washington GA-U Mental Health Pilot Steering Committee UW Department of Psychiatry

19. Steering Committee Graydon Andrus Marc Avery Amandalei Bennett Esther Bennett Jane Beyer Teri Card Abie Castillo Mervyn Chambers Ann Christian Frances Collison Mark Dalton David DiGiuseppe David Dula Stephanie Earhart Trudi Fajans Sharon Farmer David Flentge Harvey Funai Mark Johnson Rebecca Kavoussi Earl Long Barbara Mauer Linda McVeigh Evan Oakes Virginia Ochoa Ed O’Connor Amnon Schoenfeld Anne Shields Rose Soohoo Karen Spoelman Doug Stevenson Tom Trompeter Jurgen Unutzer Richard Veith Steve Vervalin Grace Wang

20. GA-U Program State-only funded program that provides: - cash grants (up to $339/mo) - limited medical care - no mental health care For adults who are: - physically or mentally disabled - unemployable for more than 90 days

21. Co-occurring diagnoses DSHS | GA-U Clients: Challenges and Opportunities August 2006

22. Most common Dx and Rx DSHS | GA-U Clients: Challenges and Opportunities August 2006

23. GA-U Mental Health Pilot Based on experiences with managed medical care pilot: - difficulty managing medical care without addressing mental health issues

24. GA-U Mental Health Pilot Overview 2 year demonstration pilot –Pierce & King counties –Partnership between CHP, Community Health Centers, Community Mental Health Centers, and UW Department of Psychiatry Goals of Mental Health Pilot –Build on success of GA-U medical pilot Structure of Mental Health Pilot –Level I: MH Treatment in Primary Care –Level II: Community Mental Health Care for severely mentally ill –Goal: Improved access, coordination of care & outcomes

25. Goal: Integrated care GA-U Client Level II Care Care Coordinator Consulting Psychiatrists CSO CD Treatment Level I Care (~ 1,500) PCP DVR Other clinic- based mental health providers* * Available in some clinics

26. Goals Integrated physical health, mental health and substance abuse services to GA-U clients where they seek care Goals: - improve patient outcomes - reduce costs

27. Level 1 mental health care Clients with behavioral health needs are treated by primary care providers with: - support from care coordinators and other practice-based mental health staff (if available) - support from consulting psychiatrist

28. Psychiatric Consultation in Level 1 Ongoing case consultation with care managers re: Level 1 mental health treatment - scheduled and ad hoc consultation to care managers and PCPs - systematic, based on clinical needs and outcomes - In-person evaluation, if needed

29. Participating Health Systems Community Health Care (Pierce) Community Health Centers of King County Country Doctor Clinic (King) Puget Sound Neighborhood Health Centers (King) Harborview Medical Center (King) International Community Health System (King) SeaMar (Pierce, King)

30. Intensive mental health services (Level 2) Community Mental Health services CMHC case manager coordinates with Level-1 Care Coordinator to insure continuity of care

31. Participating CMHCs Greater Lakes (Pierce) Community Psychiatric Clinic (King) Downtown Emergency Service Center (King) Harborview Mental Health (King) Highline-West Seattle (King) SeaMar (Pierce, King) Sound Mental Health Therapeutic Health Services (King) Valley Cities (King)

32. Integrated care GA-U Client Level II Care Care Coordinator Consulting Psychiatrists CSO CD Treatment Level I Care (~ 1,500) PCP DVR Other clinic- based mental health providers* * Available in some clinics

33. Mental Health Integrated Tracking system (MHITS):  Helps CHP, CHCs, CMHCs, and care coordinators keep track of and care for client population  Facilitates communication between providers (e.g., CHC and CMHC), referrals, and mental health consultation

34. How does MHITS help? Keeps track of all GA-U Mental Health clients Up to date client contact information to facilitate contact and follow-up Who is being treated in level 1 and 2? Who has been referred for services (e.g., CD, CSO, DVR, level 2 care) and who is getting services? Tells you quickly who needs additional attention Who is improving or not improving? Reminders for clinicians & managers Customized caseload reports

35. How does MHITS help? (cont.) Facilitates mental health specialty consultation Facilitates communication between treating providers Supports care and care coordination across settings of care (e.g., level 1 and 2) Provides updates on program developments, clinical tools, etc. Facilitates management decisions

36. Integrated mental health care: a vision  WA could be the 1 st state with a truly integrated MH care system  Improved access and capacity in primary care  Less stigma  Better medical care for patients with SMI  Improved communication between mental health, primary care,  Information systems to facilitate cost- effective care across systems.  Improved population health