1. No Health Without Mental Health: Using Collaborative Care to Deliver Value Anna Ratzliff, MD, PhD TCPI National Faculty APA-SAN University of Washington
This presentation is provided free-of-charge and is supported by Grant Number 1L1CMS from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services. The contents provided in this webinar are solely the responsibility of the presenters and do not necessarily represent the official views of HHS or any of its agencies.

2. TCPI National Faculty Anna Ratzliff, MD, PhD
Dr. Anna Ratzliff is an Associate Professor in the Department of Psychiatry & Behavioral Sciences at the University of Washington. Dr. Ratzliff currently serves as the Director of the UW Integrated Care Training Program, Associate Director for Education for the AIMS Center and trains psychiatrists in Collaborative Care at the University of Washington and as part of the American Psychiatric Association Support and Alignment Network. Her clinical expertise includes primary care consultation and providing mental health care to underserved populations. Dr. Ratzliff’s academic pursuits include developing strategies to provide mental health education to members of integrated care teams. Please visit the AIMS Center Website (aims.uw.edu) for Collaborative Care information.

3. Why Mental Health? TCPI COMMON MEASURES
NQF 0018: Controlling High Blood Pressure in Patients with Hypertension             
NQF 0052: Use of Imaging Studies for Low Back Pain       
NQF 418: Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan                   
PQRS 402: Tobacco Use and Help with Quitting Among Adolescents                         
NQF 2597: Substance Use Screening and Intervention Composite 
NQF 2152: Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling
NQF 0028: Preventive Care & Screening: Tobacco Use: Screening and Cessation Intervention       
TCPI 01:  Comprehensive Health and Life Plan     
TCPI 02:  Referral of At-Risk Patients
TCPI 03:  Medication Management

4. Who Gets Mental Health Treatment?
Wang et al., 2005

5. No Treatment
Primary Care Provider
Mental Health Provider

6. Mental Health in Primary Care Settings
Hospital
CMHC Specialty Care
Collaborative Care Brief Behavioral Interventions
Primary Care Patient Self-Management
COORDINATION

7. Patient-Centered Collaborative Care Team
New Roles
Primary Care Provider
Psychiatric Consultant
Care Manager
( MSW, RN, PhD)
Patient
© University of Washington
Part 2

8. Behavioral Health Services Available
Assessment and treatment planning by team
Indirect case-reviews by psychiatric consultant
Tele-video assessment as needed by psychiatric consultant
Care Planning
Patient tracking of all active patients by care manager
Relapse prevention planning by care manager
Facilitated referral to specialty mental health by care manager
Care Management
Primary care provider prescribes medications
Medication Prescribing
Psychosocial support delivered by care manager
Brief behavioral interventions delivered by care manager
Psychotherapy Intervention

9. Doubles Effectiveness of Care for Depression
2. Key Components of Integrated Care_Unutzer
Doubles Effectiveness of Care for Depression
50 % or greater improvement in depression at 12 months %
Participating Organizations
Unützer et al., JAMA 2002; Psych Clin North America 2004

10. IMPACT Care Benefits Diverse Populations
50 % or greater improvement in depression at 12 months
Arean et al. Medical Care, 2005

11. Collaborative Care Effective for Asian-American Populations
Three groups compared:
Asians at Community health center that focuses on Asians (culturally sensitive clinic)
General community health centers
Matched population of whites treated at the same general community clinics
Implementation study of collaborative care for 345 participants
primary care visits with depression care managers, PCP prescribing, psychiatric consultation
depression severity (PHQ9) tracked at baseline and 16 weeks
RESULT: After adjustment for differences in baseline demographic characteristics, all three groups had similar treatment process and depression outcomes
 Asian patients served at the culturally sensitive clinic (N=129) were less likely than Asians (N=72) and whites (N=144) treated in general community health clinics to be prescribed psychotropic medications
CONCLUSION:
Collaborative care effective way to treat depression in Asian American populations
More Asian American served when collaborative care delivered in culturally sensitive clinics
Ratzliff et al. Psychiatr Serv. 2013

12. State-wide Collaborative Care program Safety-net practices/FQHCs
Mental Health Improvement Program (MHIP)
Behavioral Health Improvement Program (BHIP)
Our Practice
State-wide Collaborative Care program
Safety-net practices/FQHCs
Started in 2008
>50,000 patients served to date
UW primary care clinics- now 19
Mixed payer population
Started in 2011
4660 indirect/ 8717 direct patient assessments to date
Part 2

13. Variable number of PCPs ~3-20 0.2 FTE psychiatric consultant
Mental Health Improvement Program (MHIP) Team
Behavioral Health Improvement Program (BHIP) Team
Our Practice
FTE care manager
Variable number of PCPs ~3-20
0.2 FTE psychiatric consultant
1.0 FTE care manager
~ 5.0 FTE PCPs
0.2 FTE psychiatric consultant
Part 2

14. What is performance?
Process Outcomes
Close follow-up (Minimum 2 contacts/month)
Regular use of behavioral health measures (PHQ-9)
Psychiatric consultation if patient not improved
Clinical Outcomes
PHQ-9 (depression measure for screening and tracking)
GAD-7 (anxiety measure for screening and tracking)

15. PHQ-9: Scale 0 to 27 (increasing severity)
Over the last 2 weeks, how many days have you been bothered by any of the following problems?
Not at All
Several Days
More than Half the Days
Nearly Every
Day
1. Little interest or pleasure in doing things 1 2 3
2. Feeling down, depressed or hopeless
3. Trouble falling asleep, staying asleep or sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself – or that you are a failure or have let yourself or your family down.
7. Trouble concentrating on things, such as reading the newspaper or watching television
8. Moving or speaking so slowly that other people could have noticed. Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual.
9. Thoughts that you would be better off dead or of hurting yourself in some way.
If you checked off any problem on this questionnaire so far, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
Not difficult at all
Somewhat difficult
Very Difficult
Extremely difficult

16. High Performance Areas: MHIP
Initial results from pilot showing taking a long time for patients to show improvement in depression
Pay for performance on process measures
Complete initial assessment
Meet with psychiatric consultant weekly and obtain indirect assessments on all patients not improving
Half of caseload had to receive 2 contacts per month
Population management target = 50% of patients show improvement on PHQ-9
Part 3 and 4

17. MHIP: Pay-for-performance cut in half the median time to achieve improvement in 50% of patients.
© University of Washington
AFTER P4P:
~ 26 week s to 50% of patients to improve
BEFORE P4P:
~68 week s to 50% of patients to improve
Unützer et al., 2012

18. BHIP: High Performance Areas
Population management target >50% of patients show improvement on PHQ-9
Estimated costs savings: defined as medical care cost savings per patient enrolled

19. BHIP: High Performance over 4 years
2012
2013
2014
2015
Number of Clinics 10 12 15
Number of Patients Enrolled
262
771
763
705
Average PHQ-9 at First Assessment
14.5
13.5
12.9
Indirect
Psychiatric Consultations
231
1505
1087
1417
Face-to-Face
320
2346
2394
3044
Percent of Patients Improved
81%
68%
64%
63%
Estimated Cost Savings
$340,000
$1,002,000
$991,900
$916,500

20. BHIP: High Performance Spread
Early success helped with implementation
Started with 5 clinics  now at 19 clinics
PCP satisfaction helped with spread
“I practiced for 16 years without it and I will never go back” primary care physician, UW Neighborhood Clinic
Part 3 and 4

21. Using Data to Manage Performance
Registry tool allows practice to track patient data and response to treatment
Visits
Indirect assessments
Graphs of measures
Clinic level data
Caseload number
Processes ( ex. Completed clinical assessment)
Outcomes (ex current number of patient with clincial improvement)

22. Behavioral Health Measurement-Based Treatment to Target
Part 5
Regular use of behavioral health measures to track response to treatment
Use of psychiatrists to help intensify treatment
Stepped care makes efficient use of behavioral health resources

23. Continuous Quality Improvement
Care
Manager 1
Manager 2
© University of Washington
Part 5
This example shows is summary data from a web-based registry which shows aggregate data from two different care manager caseloads, Care Manager 1 and Care Manager 2.
In this particular situation, the team was regularly reviewing the data and making observations. If you call your attention to the red box, both of these care managers were having a positive impact on their patient populations with respective improvement rates of 49% and 68%. Although both of these are good numbers, it is notable that Care Manager 2 was able to obtain higher improvement rates than Care Manager 1.
So the clinic manager sat down with these two care managers and looked at the data with them. One of the things that the clinic manager noticed was that Care Manager 2 was having almost twice as many follow-up contacts as Care Manager 1. This was a really important observation. In digging a little bit deeper, the clinic manager found that Care Manager 2 conducted a lot more phone contacts than Care Manager 1. One hypothesis was that the increased availability and frequency of engagement with the patients might be driving some of those higher outcomes. When the team reviewed this information and spoke to Care Manager 2, what they found was that every time Care Manager 2 had a cancellation or a no-show patient, she would pick up the phone and make 2-3 phone calls to patients that hadn’t come in. By doing this, she was getting in a lot more phone contacts with those patients that were falling through the cracks: she was able to deliver PHQ-9 screeners, and she was also able to engage patients in both coming back in and assessing how their treatment was going.
So a typical quality improvement effort that you might be able to implement when you see data like this is to train up Care Manager 1 to follow the same protocol, and then you could observe over time: is Care Manager 1 able to have more phone visits, and does that in fact drive better patient outcomes?
This example illustrates the commitment to regularly using data to look at the care delivered and commit to continuously looking for opportunities to improve it. This idea can be useful no matter what type of practice you are currently working in.

24. Data Workflow Individual Patient Records
Care Manger Caseload Registries
Clinic Level Summaries
Data Workflow

25. Critical to communicate a clear vision the ‘Why’ to everyone involved
Lessons Learned
Critical to communicate a clear vision
the ‘Why’ to everyone involved
IT infrastructure important
tools to support the registry, tracking of patients and metrics
Effective recruitment and training of care managers was essential
Operationally, it helped to have strong pilot sites
Part 6

26. Need and Demand
1500 patients PCP with 10% of the population with mental health needs
Insured Population  ~2% enrolled = patients
0.05FTE psychiatric consultant
0.5FTE care manager
Safety-Net Population  ~5% enrolled = patients
0.1FTE psychiatric consultant
1.0FTE care manager

27. Gather stakeholders and develop a vision
How to Get Started
Gather stakeholders and develop a vision
What are behavioral health needs?
What resources are available?
Establish clear goals to determine value
Define value broadly: patient and provider experience, PCP efficiency, etc…
How will you measure?
Map on to other organizational change
NCQA, PCMH, TCPI
Part 7

28. Questions?

29. Presenter Info
Anna Ratzliff, MD, PhD Telephone: Websites: APA-SAN - UW AIMS - UW ICTP -