Transcript Massachusetts Consortium on Depression in Primary Care

Robert Wood Johnson
Foundation: Depression in
Primary Care Initiative:
National Meeting, Amelia
Island FL
Massachusetts Consortium on
Depression in Primary Care (MCDPC)
Demonstration
February 16, 2006
Challenges for Medicaid Plans
Thanks to: UMMS Team
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Linda Weinreb, MD, PI
Carole Upshur, EdD, Co-PI
Gail Sawosik, MBA, Project Coordinator
Deborah-Ruth Mockrin, LICSW, Care Manager
Judith Savageau, MPH, Data analyst
Ken Fletcher, PhD, Data analyst
Dan O’Donnell, MD, MPH, Primary Care Consultant
Sandy Blount, PhD, MH Integration Consultant
Heidi Vermette, MD, (former Consulting Psychiatrist)
Dan Kirsch, MD, Consulting Psychiatrist
Elizabeth de la Rosa, Bilingual Care Manager
Lorna Chiasson, DFMCH Administrative Staff
Jianying Zhang, MS, CHPR Statistician for MassHealth claims data
Ann Lawthers, ScD, CHPR research staff for MassHealth claims data
MassHealth Team
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Annette Hanson, MD (former Medical Director), Co-PI
Michael Norton, MSW, MassHealth Behavioral Health
Programs, Co-PI
Louise Bannister, RN, JD, Director PCC Plan
Phyllis Peters, MBA, Deputy Assistant Secretary, Acute
and Ambulatory Services
Fran Slate, MS, Contract Manager, MCO Plan
Kate Staunton Rennie, MPA, Deputy Director, PCC Plan
Kate Willrich Nordahl, MS, Director MCO Plan Ron
Steingard, MD, Medical Director
Collaborating Health
Plans
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Massachusetts Behavioral Health
Partnership
PCC Plan
Boston Medical Center HealthNet Plan
Neighborhood Health Plan
Network Health
Issues for MCDPC
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Plans had different arrangements around behavioral
health—carve in, carve out, FFS, capitated; and these
evolved during the demonstration time
Significant investment of plans collaborating was made
possible by RWJF grant (e.g. monthly meetings); likely
not sustainable
Major state budget and plan changes required staff
time unrelated to the demonstration project
Significant leadership turnover, Medicaid office
reorganizations, and need to defend a federal suit on
children’s mental health during time of depression
demonstration
Enrollments and over all risk (e.g. disabled members)
shifted among plans during implementation period
Challenges to behavioral
health integration found
in MassHealth Plans
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Failure of network administrators or plan behavioral health directors
to appreciate the extent of patient access difficulties and difficulties
for PCPs trying to access BH care on behalf of patients
Limited availability of urgent care appointments in behavioral
health resulting in crisis care, ER visits
Up to 50% of patients don’t show up for BH appointments without
follow up support
Patients ‘on paper’ were connected to behavioral health but not in
fact
Behavioral health rules about compliance push patients out (e.g. if
miss certain number of appointments, they will no longer be served)
Behavioral health providers, like primary care, don’t have chronic
illness or patient management system in place
Both PCPs and behavioral health providers acknowledged there
were no systems for communicating with each other; time
investment to do this and lack of financial support for that time an
issue as well as lack of guidelines, protocols, expectations
PCPs want
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Sense that they can get patients connected to
behavioral health without undue wait time (applies to
both MassHealth and commercial payers)
Medication consultation on short notice/real time—
phone or email ‘curbside consult’ without need to wait
for patient referral process
Ability to make referral appointments for patients like
other specialties
All payers need to be on same page about
reimbursement for depression treatment
Needs to be way to work with same team of care
manager, psychiatrists, therapists to address patient
needs—difficult to develop multiple relationships
Intervention tried
Care Manager role
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CM or PCP office staff able to fax or call in appointment for patient; if BH provider
prefers patient to call, CM is notified if call takes place
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Information communicated back and forth from practice to BH provider by CM
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CM conducts routine follow-up; connects patient to plan based social case
management, transportation, community resources
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CM monitors all health care needs and keeps PCP informed
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CM collects data and follow up PHQ-9 scores
Systems changes in behavioral health:
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Urgent visits (within 2-3 days) available
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Some providers allocated priority BH slots to high volume primary care sites
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Regular intake and initiation of therapy within two weeks
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Psychiatry medication consultation within 1-2 weeks
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Patient asked to sign HIPAA release for CM and PCP practice
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BH providers have` information from PCP to assist with patient assessment
Sustainable solution
across plans
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Preferred providers convened along with PCP practice
representatives from each plan
Lists of contact information, including ‘inside lines’ and what to
do to reach clinician (either PCP or BH provider for patient) in an
emergency distributed for practices and BH agencies
PCP practices identify an appointment liaison
Preferred providers agree to accept appointments from PCP
practice, not just directly from patient
PCP practices agree to provide PHQ score and other information
to the BH provider at time of referral for an appointment
BH providers agree to communicate to PCP practices if patient
kept the appointment
BH providers agree to improve communication with PCP
practices about patient progress (with appropriate consent)
Remaining challenges
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How to set this process up across the state
Define and continue role of BH network mangers to
link to PCPs
Maintaining communication and connections
between PCPs and BH providers with staff turnover
Addressing shortages of specific services, e.g.
bilingual therapists, and psychiatrists
Sustaining learning from this project into the future
with potential changes in contracting language, new
vendors etc. that result in leadership changes
Issues specific to
Medicaid plans
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Lack of continuity of insurance coverage-patients in and out of
coverage in frequent cycles due to both administrative and patient
factors
Rates paid to providers—both BH and PCP
Biases by providers vis a vis Medicaid
Hard to reach consumers (transient, lose of phones etc.)
More diverse racially/ethnically/linguistically
More psychosocial challenges that medical care can’t address
(food security, housing problems, disabilities, etc.)
Less resources for self-management
Less community-based support resources: cost and other barriers