1. Michael Mabanglo, LCSW, PhD
Behavioral Health Integration Complex Care Initiative
BEHAVIORAL HEALTH INTEGRATED COMPLEX CARE INITIATIVE MEASUREMENT BASED CARE (MBC)
Jaesu Han, MD
Michael Mabanglo, LCSW, PhD

2. How do we know if we are helping?
Because a patient tells us so? Because we have a gut feeling? I just really know my patient? None of these are things to consider but…

3. What is MBC? Use of standardized evidenced based measures
rating scale, physical exam measure or lab value to diagnosis a health condition
track response to an intervention

4. Why do MBC?
Primary Care Providers underdiagnose and undertreat depressed patients (Sheehan,2004)
BH Clinicians fail to accurately identify which of their clients are likely to deteriorate in the course of treatment (Hannan et al.,2005)

5. Why do MBC?
Providers are prompted to action by operationalized decision points until patients are at goal
Patients are more attuned to their condition and empowers them in discussions with providers
Adapted from John Fortney, PHD, (aims.uw.edu)

6. What qualities make a health condition optimal for MBC?
The health condition has:
a measure that can be easily measured and tracked
a significant impact on quality of life or mortality
Is there an effective treatment(s)
Marc:
Have the What MBC is
Add the why MBC? Marc to forward AIMS slide(s)

7. A Day in the Life of an Integrated Complex Care Team

8. Scene 1 Pleasant Valley Primary Care Center
7:45 am: the Nurse Care Manager finds the PCP who is seeing an ICCI patient that morning
Spell out that interaction is a way to use the Registry Data to sharpen team conversations regarding patient care

9. PRC/MRC Clt/Pt BHC/NCM/ CC/PN PCP
Core BHICCI
Primary Care Site
Adapted from AIMS Center, UW
BHICCI Team
PCP

10. PRC/MRC Clt/Pt BHC/NCM/ CC/PN PCP
Core BHICCI
Primary Care Site
Adapted from AIMS Center, UW
PCP
Listen for:
Succinct patient summary
Specific questions/recommendations to PCP

11. Primary Care based ICCI Team
55 y/o woman with Diabetes, Hypertension, Obesity and Depression
Feedback:
Set up Slide b/c so small
Before conversation, Go over info. Staff should have this slide as a handout
Invite audience participating and ask what do you notice about this data? From your perspective how might you contribute to the conversation? What might you say to the PCP?
Demonstrate a PCP/NCM collaborative conversation
Patient is on PCP Schedule that morning. CM is touching base with PCP.
MDD: initially poorly controlled MDD, started SSRI and started weekly sessions with BHS on 8/24/16. By 10/7/16 (6 weeks later), PHQ dropped by 6 points and essentially in remission by 11/24/16 (12 weeks later).
Hypertension: initially elevated BP on 8/24/16, turned out wasn’t taking BP meds due to side effects. Switched to different BP med and BP improved on follow-up on 9/1/16 (one week later).
DM: initially elevated HgA1c, turned out patient was not taking metformin regularly and eating habits were poor due to MDD. Didn’t want to start another medication but agreed to taking metformin regularly. On 10/7/16 (6 weeks later), taking metformin regularly and lost a few pounds, mood better, wants to continue current plan.
On 11/24/16 (12 weeks later), HgA1c minimally improved. Added a second oral medication in addition to metformin.
Today’s visit:
She was supposed to get a HgA1c before the appt but didn’t get it, remind the PCP to get POC HgA1c
NCM also offers to work with patient on further lifestyle changes

12. Depression: Diabetes: Hypertension:
Recheck PHQ-9 monthly until remission
Diabetes:
Recheck HbA1c every 3 months
Hypertension:
BP can be rechecked within 1 day of intervention

13. Scene 2 Pleasant Valley Behavioral Health Center
Joining a SCR in progress…
Call out that Leslie and Emily will present a more in-depth demonstration of Systematic Care Review later this afternoon
We just want to briefly show the various ways how MBC is used.

14. BHC/NCM/ Clt/Pt MRC CC/PN Psychiatrist PCP Listen for:
BHICCI Team
Core BHICCI
BH Site
Adapted from AIMS Center, UW
PCP
Listen for:
Prep work done by NCM
Collaborative relationship with MRC
Make clear to the audience why we are giving a different diagrams: Sites have different looks base on kind of site and staffing

15. Mental Health based ICC Team
45 y/o man with Bipolar Disorder, Hypertension, Diabetes
Flagged for SCR
SCR Meeting with MPC: new referral for poorly controlled HTN and DM.
Poorly controlled DM II despite metformin and glipizide, considering a third medication for DM
Poorly controlled HTN despite 3 agents
Gained 50 pounds in past year
Turns out on 9/1/15, patient was in depressed phase of bipolar disorder and olanzapine was added to his Lithium by outside psychiatrist.
Today’s visit
In SCR, olanzapine is likely cause of increased weight and subsequent worsening of HTN and DM
How would the CM or PPC convey this concern to outside psychiatrist?

16. NCM Prep SCR relationship Identifying info
Brief review of pertinent medical records
Outreach status
SCR relationship
Collaborative with equal input
Deliberate planning

17. THANK YOU!