Lifelong Personal Health Care: Transforming health care through integration of behavioral health into the patient-centered medical home Lifelong Personal Health Care (LPHC) team: Paul Block, Jeff Migneault, Kelly Madden Theresa Costello, Renee Rulin, Jen Bowdoin Jonathan Leviss, Steve Schwartz

Current RI transformation efforts Rhode Island is a national leader in health care reform, in large part because of efforts to transform primary care led by the Health Insurance Commissioner, Chris Koller: Rhode Island is a national leader in health care reform, in large part because of efforts to transform primary care led by the Health Insurance Commissioner, Chris Koller: the rule to increase primary care spending as a percentage of all health care spending the rule to increase primary care spending as a percentage of all health care spendingrule Promotion of the medical home as the way primary care should be delivered, through the most comprehensive all-payer medical home project in the country, the Chronic care Sustainability Initiative (CSI) Promotion of the medical home as the way primary care should be delivered, through the most comprehensive all-payer medical home project in the country, the Chronic care Sustainability Initiative (CSI)CSI

What is the medical home that’s at the core of RI’s (& national) efforts? The medical home reorganizes primary care practices, delivery and payment to improve health and reduce costs. The medical home reorganizes primary care practices, delivery and payment to improve health and reduce costs. Many of the changes, including introduction of a "care manager", are ultimately designed to change patient (and provider) behavior. Many of the changes, including introduction of a "care manager", are ultimately designed to change patient (and provider) behavior. Yet the patient-centered medical home does not necessarily integrate behavioral health expertise into the team offering primary care or into the design of care. Yet the patient-centered medical home does not necessarily integrate behavioral health expertise into the team offering primary care or into the design of care.

This slideshow Introducing a new patient-centered medical home model, Lifelong Personal Health Care (LPHC) Introducing a new patient-centered medical home model, Lifelong Personal Health Care (LPHC) LPHC divides care management into: LPHC divides care management into: Clinical, provided by a behavioral care provider (BCP), and Clinical, provided by a behavioral care provider (BCP), and Administrative, provided by a "care coordinator" (CC) Administrative, provided by a "care coordinator" (CC) The BCP, like the PCP, evaluates every patient's primary care needs and jointly develops treatment plans as part of a team including the patient, family as relevant and desired, the PCP and CC The BCP, like the PCP, evaluates every patient's primary care needs and jointly develops treatment plans as part of a team including the patient, family as relevant and desired, the PCP and CC The result is projected to be more successfully transformed primary care practice, better health outcomes, and significantly lower costs. The result is projected to be more successfully transformed primary care practice, better health outcomes, and significantly lower costs.

Primary care transformation (rationale, evidence, and models) Rationale: Rationale: Why primary care Why primary care The medical home as an improved approach to providing primary care The medical home as an improved approach to providing primary care Evidence: Evidence: Primary care makes health care more affordable and effective Primary care makes health care more affordable and effective The medical home seems obviously better The medical home seems obviously better Models: Models: Nurse Care Manager Nurse Care Manager Chronic Disease Management Chronic Disease Management Coordinated care Coordinated care Medical Neighborhoods Medical Neighborhoods

Why primary care? Better quality

Why primary care? Lower costs

What is a medical home? The patient-centered medical home (PCMH) [was] defined in a 2007 Joint Principles document (American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American College of Physicians (ACP), & American Osteopathic Association (AOA), 2007) endorsed by the leading primary care physician member organizations, championed by the Patient- Centered Primary Care Collaborative (PCPCC), and certified at three tiers of achievement by the National Committee for Quality Assurance (NCQA)…. The patient-centered medical home (PCMH) [was] defined in a 2007 Joint Principles document (American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American College of Physicians (ACP), & American Osteopathic Association (AOA), 2007) endorsed by the leading primary care physician member organizations, championed by the Patient- Centered Primary Care Collaborative (PCPCC), and certified at three tiers of achievement by the National Committee for Quality Assurance (NCQA)…. - deGruy & Etz (2010)

Patient Centered Medical Home WHAT IS A MEDICAL HOME? AHRQ AHRQ The Patient Centered Medical Home (PCMH)… is a way of organizing service delivery in a coordinated manner characterized by a “patient-centered” orientation; comprehensive team-based care with coordination among providers; continuous access to care; and a systems-based approach to quality and safety. NCQA NCQA The patient-centered medical home is a model for care provided by physician practices that seeks to strengthen the physician-patient relationship by replacing episodic care based on illnesses and patient complaints with coordinated care and a long-term healing relationship…. where each patient has an ongoing relationship with a personal physician who leads a team that takes collective responsibility for patient care. The physician-led care team is responsible for providing all the patient’s health care needs

Why the medical home? The medical home as an improved approach to providing primary care The medical home as an improved approach to providing primary caremedical homemedical home Team care Team care Care management Care management Evidence-based practice (registries, guidelines, etc.) Evidence-based practice (registries, guidelines, etc.)

Why the medical home? Evidence is developing: Evidence is developing:Evidence “The findings from our updated review are entirely consistent with those of our 2009 report: Investing in primary care patient centered medical homes results in improved quality of care and patient experiences, and reductions in expensive hospital and emergency department utilization. There is now even stronger evidence that investments in primary care can bend the cost curve, with several major evaluations showing that patient centered medical home initiatives have produced a net savings in total health care expenditures for the patients served by these initiatives” -Grumbach & Grundy, (2010). Outcomes of Implementing Patient Centered Medical Home Interventions: A Review of the Evidence from Prospective Evaluation Studies in the United States, Patient-Centered Primary Care Collaborative

Medical home models Team: Team: NCM: Nurse Care Manager NCM: Nurse Care Manager CDM: Chronic Disease Management CDM: Chronic Disease Management Coordinated care: High volume specialists Coordinated care: High volume specialists Often with care managers coordinating Often with care managers coordinating Medical Neighborhoods Medical Neighborhoods

Rationale for integration of behavioral health expertise into the core of the medical home team Behavior- rather than medicine- is more likely to determine someone’s health. The best prescription is one that urges people to follow a few simple rules, such as exercising regularly (30 minutes a day, 5 days a week), eating 5 servings of fruit and vegetables a day, avoiding tobacco, illicit drugs and excessive alcohol, engaging only in responsible sexual behavior and participating daily in relaxing and stress- reducing activities. Former U.S. Surgeon General David Satcher, at Black Health Forum, Brown University Former U.S. Surgeon General David Satcher, at Black Health Forum, Brown University

Rationale for integration of behavioral health expertise into the core of the medical home team People are not likely to do anything that's hard, such as… taking care of one's health — no matter how good the incentives are…. A new health care system could use psychology to figure out ways to give better medical care, not just more health care. Peter Orszag, director of the Office of Management and Budget Peter Orszag, director of the Office of Management and Budget Other supporters of integrating behavioral health into primary care: HRSA (Smith), 2004; Institute of Medicine, 2005

Health behavior and lifestyle drive a large proportion of medical concerns and presenting issues in primary care Health behavior and lifestyle drive a large proportion of medical concerns and presenting issues in primary care e.g., Bakken, 1992; Kroenke & Mangelsdorff, 1989 e.g., Bakken, 1992; Kroenke & Mangelsdorff, 1989 Inadequate identification and treatment of mental health/substance abuse problems in primary care have dramatic effects on effectiveness and costs of medical care Inadequate identification and treatment of mental health/substance abuse problems in primary care have dramatic effects on effectiveness and costs of medical care e.g., Thomas, Waxmonsky, McGinnis, & Barry, 2006 e.g., Thomas, Waxmonsky, McGinnis, & Barry, 2006 Rationale for integration of behavioral health expertise into the core of the medical home team

Integrating behavioral health into medical care improves outcomes and reduces costs for mental health/substance abuse and medical problems, with potential for generating the largest untapped healthcare savings Integrating behavioral health into medical care improves outcomes and reduces costs for mental health/substance abuse and medical problems, with potential for generating the largest untapped healthcare savings e.g., Blount, Kathol, O’Donohue, Peek, Rollman, Schoenbaum, & Thompson, 2007; Chiles, Lambert, & Hatch, 1999; Pincus, Pechura, Keyser, Bachman, & Huntsinger, 2006 e.g., Blount, Kathol, O’Donohue, Peek, Rollman, Schoenbaum, & Thompson, 2007; Chiles, Lambert, & Hatch, 1999; Pincus, Pechura, Keyser, Bachman, & Huntsinger, 2006 PCPs report deteriorating work satisfaction. Their numbers are shrinking (e.g., National Resident Matching Program, 2006), but satisfaction is significantly higher among providers co-located with behavioral health specialists (Gallo et al., 2007) PCPs report deteriorating work satisfaction. Their numbers are shrinking (e.g., National Resident Matching Program, 2006), but satisfaction is significantly higher among providers co-located with behavioral health specialists (Gallo et al., 2007) Rationale for integration of behavioral health expertise into the core of the medical home team

Kroenke and Mangelsdorff, 1989; Berkman and Breslow, 1983; Bridges and Goldberg, % 15-20% 10-15% 74% 10% 16% Causes of presenting complaints bringing patients to see their primary care doctor

Offering mental health treatment reduces overall medical costs, especially when behavioral services are targeted at medical conditions Offering mental health treatment reduces overall medical costs, especially when behavioral services are targeted at medical conditions - Lambert, Chiles, and Hatch, 1999; Cuffel, Goldman, & Schlesinger, 1999 Cuffel, Goldman, & Schlesinger, 1999 (researchers from United Behavioral Health) (researchers from United Behavioral Health) Mental health services reduce costs

Medical home teams may not be ideally designed to manage health behaviors effectively (ethics: whose needs determine how care will be organized, payers’? Providers’? Or patients’?)

Better: Integrated Team Care Integration is exquisitely difficult and is at the heart of what makes primary care work. Integration should not be confused with coordination. Coordination implies ordering and sequencing, while integration implies creating something new - in this case, something fitted to a particular individual patient. - deGruy & Etz (2010)

What is integrated primary care? Building on descriptions by Blount, Kathol, O’Donohue, Peek, Rollman, Schoenbaum, & Thompson (2005), the Allied Advocacy Group for Collaborative Care (2002), the Rhode Island Policy Roundtable on Collaborative Care (2003), and Block, Costello, & Fine (2004): Integrated care is based on the principle that mental, social, and physical are indivisible, and accordingly that health care must target the whole person. Integrated care is based on the principle that mental, social, and physical are indivisible, and accordingly that health care must target the whole person.

What is integrated primary care? Building on descriptions by Blount, Kathol, O’Donohue, Peek, Rollman, Schoenbaum, & Thompson (2005), the Allied Advocacy Group for Collaborative Care (2002), the Rhode Island Policy Roundtable on Collaborative Care (2003), and Block, Costello, & Fine (2004): Integrated services routinely define all healthcare issues in terms of physical, social, and behavioral components. Integrated services routinely define all healthcare issues in terms of physical, social, and behavioral components.

What is integrated primary care? Building on descriptions by Blount, Kathol, O’Donohue, Peek, Rollman, Schoenbaum, & Thompson (2005), the Allied Advocacy Group for Collaborative Care (2002), the Rhode Island Policy Roundtable on Collaborative Care (2003), and Block, Costello, & Fine (2004): The integrated healthcare team includes medical and behavioral providers who mutually design one treatment plan for each person receiving care. The integrated healthcare team includes medical and behavioral providers who mutually design one treatment plan for each person receiving care.

What is integrated primary care? Building on descriptions by Blount, Kathol, O’Donohue, Peek, Rollman, Schoenbaum, & Thompson (2005), the Allied Advocacy Group for Collaborative Care (2002), the Rhode Island Policy Roundtable on Collaborative Care (2003), and Block, Costello, & Fine (2004): Integrated healthcare services are offered concurrently by all members of the team as relevant, each addressing every issue for which their perspective and expertise can make a significant contribution. Integrated healthcare services are offered concurrently by all members of the team as relevant, each addressing every issue for which their perspective and expertise can make a significant contribution.

What is integrated primary care? Building on descriptions by Blount, Kathol, O’Donohue, Peek, Rollman, Schoenbaum, & Thompson (2005), the Allied Advocacy Group for Collaborative Care (2002), the Rhode Island Policy Roundtable on Collaborative Care (2003), and Block, Costello, & Fine (2004): Integrated healthcare interventions are actively coordinated and presented to the patient as a single treatment approach designed to best serve their needs. Integrated healthcare interventions are actively coordinated and presented to the patient as a single treatment approach designed to best serve their needs.

Is anything like this realistic? Or only fantasy?

Later is here “It is inconceivable that whole person care can occur absent attention to and incorporation of the full psychosocial dimension of health and healthcare— mental healthcare, family and community contexts, substance abuse, and health behavior change (here collectively referred to as behavioral healthcare). Any PCMH that neglects this dimension is incomplete and will be ineffective. It will fail. A solid edifice of empirical evidence supports this rather uncompromising assertion.”

Later is here “Comprehensive Primary Care Requires Negotiation Of Team Roles With Other Clinicians. We call this horizontal collaboration, which means collaboration with clinicians of more or less equal status… to produce functional team-based care…. Integration of behavioral healthcare into the PCMH is difficult…. The wins - for the health of our citizens, the restoration of our workforce, the effectiveness of our healthcare system, the advances in our science, and the health or our nation’s economy - far outweigh [the] costs.” - deGruy & Etz (2010)

An effective, complete PCMH model: Lifelong Personal Health Care (LPHC)

Give me a break!

The LPHC model A fully integrated patient-centered medical home with behavioral care management For more information about LPHC, contact: