1. SUSAN C DAY, MD, MPH Director of Quality and Practice Improvement Division of General Internal Medicine University of Pennsylvania CFHA Presentation: Integrating Behavioral Health into an Academic Practice

2. Description of DGIM Practices 3 Internal medicine practices on UPENN Campus; 1 located in suburbs (not in pilot) Total IM faculty: approx 30 (including part-time) Total residents – 104 Categorical and Med-Peds – 22 Primary Care All 3 practices are NCQA Level 3 recognized; 1 is a participant in SEPA Chronic Care Collaborative All practices on EPIC, electronic health record

3. Practice Volume Office Visits per year (September 2010- August 2011)  Edward S. Cooper Internal Medicine Associates: 25,601  PennCare Internal Medicine Associates: 21,559  Penn Center for Primary Care: 17,298

4. Baseline Behavioral Health Resources 2 social workers knowledgeable re local resources; help with referrals Penn Behavioral Health – UPHS does not accept several of major insurers, including medical assistance, except in resident psychiatric practice – Capacity at resident practice limited Emergency care available through Psychiatric Emergency Center “Check the back of your card”

5. Goals of Co-location Pilot 1) To provide triage of all patients, regardless of insurance, for short term care when appropriate and link to outside services if needed 2) To improve outcomes in patients with chronic illness where behavioral health issues key (PCMH) 3) To facilitate identification of covered providers for patients with non-UPHS covered mental health services

6. Planning DCPS identified 3 of their top providers for project Beginning with 1 practice, they met with providers, staff, social workers to establish relationship and work flow Rolled out at approx 2 month intervals to the remaining 2 practices

7. Patient Flow: DCPS co-location project Patient Identified by PCP office for on site mental health evaluation Patient Refuses/Unreachable; referral Documented in PCP medical Record DCPS notifies PCP N=140 Patient accepts and PCP office staff have patient complete DCPS release form Doctor’s office faxes signed form to DCPS N=406 DCPS staff contacts patient and schedules initial appointment at the PCP mental health site N=266 Initial evaluation occurs Therapist makes treatment recommendation Reports back to PCP N=178 Therapist recommends ongoing Treatment at the local DCPS site Office consult is mailed to PCP – Patient participates in depression outcomes tracking Three sessions occur and treatment is completed (Brief intervention model) Patient refuses further Treatment and PCP is notified Therapist recommends ongoing Treatment and refers patient to another facility where patient’s financial and insurance needs are met. Consult mailed to PCP No show N=88

8. Summary of 6 month pilot 406 patients were referred – 140 (36%) could not be contacted after 3 attempts 266 appointments were made – 88 (33%) no showed – 178 evaluated

9. Insurance Mix

10. Evaluation: Goal #1 Provide triage of all patients regardless of insurance – High (33%) no show rate – Disproportionate referral of Medicaid patients – Inability/unwillingness to pay co-pay (only 31% paid co-pay) – Difficulty linking to appropriate behavioral health services Lack of identified psychiatric back up Lack of medical assistance providers for ongoing care

11. Evaluation: Goal #2 Improve outcomes in patients with chronic illness where behavioral health issues key Depression, anxiety felt to be cause for failure to advance care in patients with chronic medical disease HOWEVER Providers tended to refer patients with pre- existing psychiatric disease, not patients with chronic disease needing counseling to improve adherence

12. Pre-existing medical and psychiatric diagnosis and meds Medical and Psychiatric Diagnoses Among Patients Seen by DCPS N% 1 chronic condition*5329.6% >1 chronic condition*179.5% 1 psych med10960.9% >1 psych med4223.5% *DM, CHF, COPD, Chronic Pain

13. Goal #3: Facilitate identification of covered behavioral health providers Providers greatly appreciated being able to contact behavioral health provider for advice and ability to provide a personal referral to patients Most providers (90%) either did not have a list of behavioral health providers they used for referrals or were looking for additional referral sources

14. Faculty Survey Which of the following patient groups would it be most important to have improved access to behavioral health services for: YOU in YOUR practice?RESIDENTS in our practice? Moderately or Very Important Psychiatric emergencies (psychotic breaks, suicidal) 50%100% Chronic psychiatric disease (schizophrenia, bipolar) 62.5%100% Depression or Anxiety 87.5%100% Somatization 87.5%100% Dysfunctional Social Environments 62.5%100% Substance Abuse 75%100% Non-adherent 86%66%

15. Provider Survey, cont’d There are three proposed models for behavioral health services in a Primary Care setting. Please rank your choice for an ideal integrated model in order of preference. The majority of respondents ranked the options as follows: Embedded psychologist on site in a primary care practice to allow ongoing and seamless care for patients in the practice who could benefit from treatment of common mental health conditions, such as depression and anxiety, and help with adherence to a medical regimen. It assumes the ability to provide longitudinal care for patients, and that patients with more complex psychiatric illness will be sent elsewhere for care. 1 st Choice Provide short term (2-3 visits) therapy within a practice, but then refers patients requiring ongoing or chronic care to appropriate behavioral health providers. 2 nd Choice Full spectrum of mental health conditions, from neurosis, depression and behavioral modification through psychosis. The provision of care to patients with complex psychiatric illness would include onsite presence of a psychiatrist to oversee care and medication management. 3 rd Choice

16. Positive Outcomes Good will of DCPS providers and willingness to see all patients were very positively received New connections made for future referrals were established Experience was gained in terms of setting up a system for referral and triage Real time needs assessment uncovered significant psychiatric comorbidity and need for psychiatric back-up and consultation

17. Lessons learned Unmet need within our practices is for patients with medical assistance/under- insured Business model unsustainable without either subsidy/grant or limited patient selection Building relationships takes time (and work) Need to define expectations/model for ongoing collaborations