1. Lynne DiCaprio October 2011

2. Introduction Differences in practice needs Statistical Follow Up (PHQ9) Obstacles encountered Next Steps

3. Delaware County Professional Services (DCPS) Founded 1986 - first in Delaware County Serving Philadelphia, Delaware and Chester Counties - 5 locations and 6 co-located PCP sites 53 therapists including Psychologists, LCSW’s, LPC’s and Psychiatrists On-site co-located integration since December 2007

4. Pilot Integration NSIM (Allan Crimm, MD) Evolution of Integration: from on-site schedule to PRN. Evolution of the degree of collaboration: ~ From patient evaluations to practice and program involvement. Reciprocal collaboration.

5. Similarities with smaller practices: Began by scheduling patients on particular days and times Reduced set schedules to PRN Increased PCP telephonic collaboration Available for same day/crisis evaluations Collaborative Process All patients sign release and contacted by DCPS to schedule All patients are scheduled for initial evaluation regardless of insurance Practices receive a typed consultation within 72 hours. Practices are notified regarding any medication script written by a DCPS psychiatrist. Practices receive written communication about patient appointments and adherence /non-adherence issues.

6. Penn Medicine – Division of General Internal Medicine Penn Internal Medical Associates (PIMA) PennCare - Edward S. Cooper Practice of Internal Medicine PennCare Primary Care Physicians (PCPC) Six month pilot; currently the collaboration is suspended – Payer mix critical component for this pilot as explained by Dr. Day

7. Largest Primary Care Practice Developing and evolving relationship Programs (diabetic group) Staff stress management Resident training (shadowing) Currently schedule 2-3 full days weekly Posted schedule for staff and providers Majority of the patients commercially insured – all patients seen Patients are seen on site and in DCPS offices

8. PHQ9 : a nine question depressive screening tool (Pfizer) Public Domain DCPS Data n = 671 (Patients who had at least one follow score after intake Information gathered between 1/1/2010 - 7/20/2011 Average initial PHQ9 score = 16.48 (baseline) Average improvement = (-7.88) Average final PHQ9 score = 8.59 PHQ9 Uses – Each Physician Practice receives a full outcomes report every 6 months.

9. Practice needs, patient makeup, and practice flow vary dramatically. Understand the practice composition- both diagnostic and financial. Meet regularly with the practice team to regulate the work flow and address necessary changes. Meet with all staff (physicians, nurses, staff etc.) Be flexible, more flexible, and most flexible

10. Start Slowly Begin integration as a small pilot flow and grow from there Establish shared expectations and data Good communication is essential Patient / Payer Awareness

11. Next steps…….. Look for improvement across healthcare utilization – Aetna is the only commercial insurer currently supporting this model Look for impact of easy access and mental health treatment on functional status Explore the impact of a decrease in depressive symptoms and improved medical conditions

12. Ninth Street Internal Medicine (NSIM) Allan Crimm, MD, FACP Jefferson Family Medicine Richard Wender, MD Chair of the Department of Family Medicine Medical Group at Marple Commons Daniel Wolk, MD Broomall Family Practice Robert J. Braunfeld, DO

13. Jefferson Internal Medicine Barry S. Ziring, MD; Director, Division of Internal Medicine Penn Internal Medical Associates (PIMA) PennCare - Edward S. Cooper Practice of Internal Medicine PennCare Primary Care Physicians (PCPC) Susan Day, MD

14. Depression 42% Adjustment Disorders 38% Anxiety 18% Eating Disorders 1% Miscellaneous 1%

15. Resistant patient Identified by PCP office for on site mental health evaluation Patient Refuses appointment - Documented in PCP medical records Patient accepts and PCP office staff have patient complete DCPS release form Doctor’s office faxes signed form to DCPS 484-468-1412 DCPS staff contacts patient and schedules initial appointment at the PCP mental health site Initial evaluation occurs Therapist makes treatment recommendation Reports back to PCP Therapist recommends ongoing Treatment at the local DCPS site Office consult is mailed to PCP Three sessions occur and treatment is completed (Brief intervention model) Three sessions occur and patient’s Mental health treatment is transitioned to DCPS office or other appropriate treatment site Patient refuses further Treatment and PCP is notified DCPS reaches out, schedules, evaluates and reports back to PCP