1. Integrating Mental Health into Advanced Primary Care – Why and How Neil Korsen, MD, MS Medical Director Mental Health Integration Program MaineHealth

2. Outline Background – Why Integration? Screening for common mental health conditions Improving access to and communication with mental health specialists Building an integrated team

3. Why Integration?  1 in 4 people seeking primary health care services have a significant mental health condition. Spitzer, JAMA 1999; Kessler, Arch Gen Psych 2005  >50% of people treated for depression receive all treatment in primary care. Katon, Arch Gen Psych 1996  Only 41% with mental health conditions receive any treatment Wang, Lane, Olfsen et al; Arch Gen Psych, 2005  Management of common chronic illnesses often includes a need for changes in behaviors (e.g., diet & exercise).  People’s life problems and stresses affect their health and their health care.

4. Behavioral Health in PCMH  Behavioral health is integral to overall health as mind and body are inseparable. –Patient Centered Primary Care Collaborative  Most people with poor mental health are cared for in primary care settings, despite many barriers. Efforts to provide everyone a medical home will require the inclusion of mental health care if it is to succeed in improving care and reducing costs. –Petterson et al, American Family Physician 2008

5. Access Standardized Screening & Assessment Care Management Support for Behavioral Change Mental Health Treatment & Consultation Patient Centered Medical Home mental/behavioral health components Community Resources e.g., NAMI Specialty Mental Health

6. Integrated Care – MHI Program Involvement PCMH Pilot Sites PCMH/MHI Collaborative Sites MHI Collaborative Participants MHI Mental Health Partners

7. Behavioral-Physical Integration  Participate in baseline assessment of current behavioral- physical health integration capacity  Take steps to make improvement(s), e.g.,  Implement a system to routinely conduct a standard assessment for depression (e.g., PHQ-9) in patients with chronic illness  Incorporate a behavioral health clinician into the practice to assist with chronic condition management  Co-locate behavioral health services within the practice

8. LevelAttributes Minimal Collaboration ISeparate site & systems Minimal communication Basic Collaboration from a distance IIActive referral linkages Some regular communication Maximized off-site Collaboration IIAEfficient and effective access to specialty mental health. Strong consultative relationships. Links to community resources and providers. Coordinated treatment. Basic Collaboration on site IIIShared site; separate systems Regular communication Collaborative Care partly integrated IVShared site; some shared systems Coordinated treatment plans Regular communication Fully Integrated System VShared site, vision, systems Shared treatment plans Regular team meetings Further modified from Doherty, McDaniel, and Baird - 1996 Levels of Integration

9. Screening for Common Mental Health Conditions

10. 1. Emotional/ behavioral health needs (e.g., stress, depression, anxiety, substance abuse) … are not assessed (in this site) 1 … are occasionally assessed; screening/ assessment protocols are not standardized or are nonexistent 2 3 4 … screening/assessment is integrated into care on a pilot basis; assessment results are documented prior to treatment 5 6 7 … screening/ assessment tools are integrated into practice pathways to routinely assess MH/BH/PC needs of all patients; standardized screening/assessment protocols are used and documented. 8 9 10 Screening and Assessment

11. Addresses under-recognition of common mental health conditions Change ideas: –Choose a high risk population one or more conditions for screening (depression, anxiety, substance use) –Implement a process to routinely screen to use screening results

12. Which condition(s)? Depression – recommended by US Preventive Services Task Force (USPSTF) to screen adults and adolescents Anxiety disorders - not recommended by USPSTF, but a common co-morbidity with depression Substance use – recommended by USPSTF for adults

13. Which Population(s) to Screen? Health maintenance visits Chronic illnesses –COPD –CVD –Diabetes Other high risk populations –Chronic pain –Children with home or school behavior problems –People who have been hospitalized

14. Developing a Screening Process Identify population to be screened Identify condition(s) to screen for Develop processes to get screening done –Assign roles to members of practice team Develop processes to take action for those who screen positive

16. PHQ-9 1.A validated tool for screening and diagnosing depression and for following response to treatment 2.Scoring parallels DSM-IV diagnosis for Major and Minor Depression 3.Can be administered in ‘interview’ style or completed by patient

18. Screening for Depression: The first two questions of the PHQ-9 have been validated as a sensitive way to screen for depression –96% of people with depression will say yes to one of those two questions. –Consider an answer of ‘2’ or ‘3’ on either of those questions a positive screen. –Administer the full PHQ-9 only to those who screen positive

19. Scoring the PHQ-9 Add columns vertically for the first 9 questions then tally across the bottom of the page Total score from 0 to 27 10 th question is a “Function Score” indicating to what degree the depression symptoms have made it difficult for the patient to function in their everyday life The degree of functional difficulty can help you decide whether to start active treatment in people with mild symptoms.

20. Guideline for Using the PHQ-9 for Initial Management Score/ Symptom Level Treatment 0-4 No depression Consider other diagnoses 5-9 Mild  Consider other diagnoses  If diagnosis is depression, watchful waiting is appropriate initial management 10-14 Moderate  Consider watchful waiting  If active treatment is needed, medication or psychotherapy is equally effective 15-19 Moderately Severe  Active treatment with medication or psychotherapy is recommended  Medication or psychotherapy is equally effective 20-27 Severe  Medication treatment is recommended  For many people, psychotherapy is useful as an additional treatment  People with severe symptoms often benefit from consultation with a psychiatrist

21. What is Watchful Waiting? It is estimated that a third of people with symptoms at this level will recover without treatment. Watchful waiting means you are seeing the patient about once a month and monitoring their PHQ-9 score, but not starting active treatment. Self-care activities such as exercise or relaxation are usually a component of watchful waiting. If the patient’s symptoms have not resolved after 2-3 months, active treatment ought to be considered.

22. How often should the PHQ be done for management of a patient with depression? Once a month until the patient reaches remission (score 0-4) or for the first 6 months of treatment Every 3 months after that while the patient is on active treatment Once a year for people with a history of depression who are no longer on active treatment

23. PHQ-9 - Change from last score, measured monthly Treatment Response Treatment Plan Drop of 5 or more points each month GoodAntidepressant &/or Psychotherapy No treatment change needed. Follow-up in 4 weeks. Drop of 2-4 points each month FairAntidepressant: May warrant an increase in dose. Psychotherapy: Probably no treatment change needed. Share PHQ-9 with psychotherapist. Drop of 1 point, no change or increase each month PoorAntidepressant: Increase dose or augment or switch; informal or formal psychiatric consult; add psychotherapy. Psychotherapy: 1. If depression-specific psychotherapy discuss with supervising psychiatrist, consider adding antidepressant. 2. For patients satisfied in other psychotherapy consider adding antidepressant. 3. For patients dissatisfied in other psychotherapy, review treatment options and preferences. Interpreting Follow Up Scores

24. Goals of Treatment Remission – score of 0-4 after an initial score of 10 or higher. Clinical response – score of less than 10 after an initial score of 10 or higher

25. Improving Access and Communication

26. 2. Coordination of referrals and specialists does not exist 1 is sporadic, lacking systematic follow-up, review or incorporation into the patient’s plan of care; little specialist contact with primary care team 2 3 4 occurs through teamwork & care management to recommend referrals appropriately; report on referrals sent to primary site; coordination with specialists in adjusting patients’ care plans; specialists contribute to planning for integrated care 5 6 7 is accomplished by having systems in place to refer, track incomplete referrals and follow-up with patient and/or specialist to integrate referral into care plan; includes specialists’ involvement in primary care team training and quality improvement 8 9 10 Mental health referrals

27. Improve communication & coordination with mental health specialists within or outside your practice Change ideas include: –ID mental health specialists who care for many of your patients and meet with them –Develop templates for communication, include patient consent –Improve tracking for patients referred for mental health care

28. Building an Integrated Team

29. 3. Patient care team for implementing integrated care does not exist 1 exists but has little cohesiveness among team members; not central to care delivery 2 3 4 well defined, ea. member has defined roles/responsibility; good communication & cohesiveness among members; members are cross-trained, have complementary skills 5 6 7 is a concept embraced, supported and rewarded by the senior leadership; “teamness” is part of the system culture; case conferences and team meetings are regularly scheduled 8 9 10 Integrated Team Function

30. Developing an Integrated Team Change ideas include: Regular team meetings Morning huddles to anticipate and plan for patient needs that day Use warm handoffs to onsite mental health staff

31. Team Roles in Integrated Primary Care Mental Health Specialist Diagnose, Treat Care Manager Follow up, Family Adherence Patient Education Primary Care Clinician Support Staff Screen, Diagnose, Treat Psychiatrist Or APRN Consult, Train NAMI Community Resources, Family Support Patient and Family

32. Team Effectiveness Model Mission Goals Processes/Procedures Interpersonal Relationships Roles Culture – Primary Care Culture – Mental Health Beckhard, R. Optimizing Team-Building Efforts. Contemporary Journal of Business, Summer 1972.

33. Mental Health Specialist in Primary Care: How about those differences?

34. The Questions for Integrated Care Settings –Who will be delivering the service? –What service will be delivered and what code will be used? –Who are the partners doing integration? –Where will the service be delivered? –What is the “facility”? Under what license? –Who will “employ” staff? –Who will do the billing? –How will the reimbursement work? Which insurance will be billed? What are the rules for that insurer?

35. Start where you are Use what you’ve got Do what you can Arthur Ashe

36. Resources: Websites  www.integratedprimarycare.com – National clearinghouse site for information on integrated care out of U Mass. www.integratedprimarycare.com  www.nationalcouncil.org - The unifying voice of America’s behavioral health organizations. Includes resources for providers and a link to the National Council’s journal. www.nationalcouncil.org  www.ibhp.org - Integrated Behavioral Health Project. Good general information on integrated care site out of California. www.ibhp.org  www.pcpcc.net - Patient Centered Primary Care Collaborative. National resource devoted to developing and advancing the patient centered medical home. www.pcpcc.net Books  Blount, A. ed.(1998). Integrated Primary Care: The Future of Medical and Mental Health Collaboration. New York: Norton  Hunter, L., Goodie, J., Oordt, M., & Dobmeyer, A. (2009). Integrated Behavioral Health in Primary Care. Washington, D.C: American Psychological Association  Robinson, P. & Reiter, J. (2006) Behavioral Consultation and Primary Care: a Guide to Integrating Services. New York: Springer Publications  Butler M, Kane RI, McAlpine D, Kathol, RG, Fu SS, Hagedorn H, Wilt TJ. Integration of Mental Health/Substance Abuse and Primary Care No. 173 (Prepared by the Minnesota Evidence-based Practice Center under Contract No. 290-02-009.) AHRQ Publication No. 09-E003. Rockville, MD. Agency for Healthcare Research and Quality. October 2008.

37. Contact info:  Cynthia Cartwright, MT RN MSEd, cartwc@mainehealth.org, 662-3529 cartwc@mainehealth.org  Neil Korsen, MD MS, korsen@mainehealth.org, 662-6881korsen@mainehealth.org  Mary Jean Mork, LCSW, morkm@mmc.org, 662-2490morkm@mmc.org