Transcript Slide 1

Collaborative Care in Primary Care and
Behavioral Health: Are We at the Tipping Point?
Henry Chung, M.D.
Vice President and Chief Medical Officer
Care Management Company of Montefiore Medical Center
And
Clinical Associate Professor of Psychiatry
New York University School of Medicine
Agenda
 Why does Integration Matter for the Health of Our
Patients?
 Is Integrated Care the Same as Collaborative Care?
 What are the key ingredients of Collaborative Care?
 Quality Outcomes and Measurement
 Health Homes and ACO’s – the Promised Land?
Health and Behavioral Health Challenges
 Basic medical and behavioral health services must be available in all clinical
settings –most people with behavioral health disorders are seen in medical
settings NOT specialty settings
 Specialty behavioral health settings must have excellent access to medical
services - most people with severe and persistent mental illness or severe
addiction have excess morbidity and mortality due to premature CV disease
 All health settings must have care coordination capability in the appropriate
continuum depending on case mix and severity – episodic point of care
treatment is INEFFECTIVE resulting in major gaps in treatment; in high cost
complex safety net patients, medical and behavioral health readmissions
are a HUGE excess cost to the system
 Care management for patients with multiple disorders as well as specialty
care management must be used in a stepped care manner – locus of
patient care and costs should be accounted for in the segmentation process
Primary Care and Behavioral Health
Integration Models (Mechanic D)
 Enhanced screening, treatment and referral - Trained
primary care providers screen, identify, treat and /or refer
to mental health specialists (usually off site) for treatment
 Co-location of services –behavioral health clinicians
provide consultation and/or short term treatment
 Systematic integration with shared protocols, health
information, and quality metrics and outcomes
Key Principles of Depression Integration in
Primary Care
 Training of PCP to Screen and Diagnose
 Starting Treatment (almost always medication)
 Patient Education
 Follow Up and Stepped Care
 Easy Access to Specialty Care
 BUT?
What are the Limitations?
 Organizational Commitment
 Cultural Tailoring necessary
 Payment Alignment Problems
 Sustainability Problems
 “Quest for Cost Offset!”
 Working Through the Cultural Values of Primary Care
and Behavioral Health
Landmark Randomized Controlled Trials in
Depression
 IMPACT – Older Adults and Depression
 RESPECT-D – Primary Care Patients and Depression
 ? PRISMe – Older adults with depression in primary
care or at-risk drinking randomized to collaborative
care vs enhanced specialty care
Why PRISM-E?
 RCT for geriatric patients presenting in primary care
settings (VA, FQHC, academic) with depression
randomized to Integrated care or enhanced specialty care
with more realistic resource allocations (ie limited!)
 Rationale : assess real world outcomes with greater
generalizability for integrated care compared to improved
specialty mental health; ie no algorithms, no treat to target
interventions
 Main hypotheses: Improved Engagement in Integrated
Settings; Equivalent 6 month outcomes;
PRISM-E Enhanced Specialty Mental Health
Model Requirements
 Appointment available within 2-4 weeks of PCP dx of
depression/ at risk alcohol
 Licensed MH/SA professionals with some indication of
geriatric expertise
 Coordinated followup contacts with PCP and patient if they
missed first visit
 Concrete services incl transport if necessary
 Availability of urgent and emergency appointments
Engagement and treatment of depression
in PRISM-E
71%
80
70
49%
60
50
37%
29%
40
30
20
10
0
Integrated Care
Specialty
Engaged
N=599
Response
N=621
PRISM-E Outcomes for Hazardous Drinking
 Very high refusal rates in PC settings, except for VA PC
settings
 Higher engagement in PC than in specialty settings
 No difference in outcomes at 3 or 6 months
 Patients with both depression and SA did slightly better in
specialty settings (but very small sample)
Don Berwick
Institute for Healthcare Improvement
“TRYING HARDER WILL NOT WORK.
CHANGING SYSTEMS
OF CARE WILL.”
What is Collaborative Care?
Collaborative (Chronic) Care Model
 Effective chronic illness care requires a re-organization
of the health care system to manage chronic or
recurring illnesses more effectively
 Application of evidence at point of care
 Patient activation to promote effective selfmanagement and patient-provider collaboration
 Systematic outreach to ensure appropriate
monitoring and follow-up care
Care Management/Coordination
 Holistic and coordinated approach for conditions often
put into separate silos in the delivery system
 Offers flexibility in patient-centric treatment modalities
and settings sensitive to cultural and economic barriers
to treatment
 Supports adherence through self- management and
active care coordination for multiple chronic illnesses
Self Management
 Goal directed patient behaviors that enhance clinical &
functional outcomes:
 Medication management and adherence
 Psychotherapy previewing and adherence
 Self-monitoring of symptoms, treatment status
 Managing effects of illness on social role function
 Reducing health risks (alcohol misuse, smoking)
 Preventive maintenance (e.g., exercise, screening
check-ups)
 Working with health care professionals
Why is the model effective?
 Organizing Framework for Team Based Care
 Peer Based Learning with clinical application (rapid
piloting)
 Patient Centered Care Coordination as a Foundational
Concept = Population Based Health
 QI principles tied to Specific Measures = Accountable Care
 Ability to Incorporate Latest Evidence Base into The Model
 Patient Self Management = Empowerment
 Sustainability is paramount
SBIRT for Alcohol
Components
SBIRT
Screening
Brief strategy to identify at-risk population
Brief
Intervention
One or more discussions with clinician (10-15 min each):
1.Assessment & feedback on drinking
2.Advice, goal setting, agree on plan
3. Follow-up contact
Referral to Specialty
Treatment
Patients with more severe problems require more than a brief
intervention
Copyright © 2011 The National Center on Addiction and Substance Abuse at Columbia University
SBI for Alcohol in Primary Care
Effectiveness and Cost-Effectiveness
Most effective intervention for alcohol problems based
on clinical trials research
Solberg et al. (2008):
 SBI for alcohol ranked among top of 25 USPSTFrecommended screening practices based on
effectiveness and cost-effectiveness
 Similar in ranking to screening for hypertension or
colorectal cancer
Copyright © 2011 The National Center on Addiction and Substance Abuse at Columbia University
Life-Years Saved, Costs, And Savings From 20
Evidence-Based Clinical Preventive Services (2006 Dollars)
Life-years saved per 10,000
people per year of intervention
Medical cost of service
per person per year
Medical savings of
service per person per
year
Annual net medical
costs per person per
year
Childhood immunizations
1,233.1
$306
$573
−$267
Influenza immunization
23.8
28
20
8
Pneumococcal immunization
6.4
46
113
−67
Discuss daily aspirin use
63.0
21
87
−66
Smoking cessation advice
and assistance
97.5
10
50
−40
Alcohol screening and
brief counseling
7.0
9
20
−11
Breast cancer screening
45.0
64
3
61
Cholesterol screening
27.8
128
24
104
Colorectal cancer screening
40.8
46
31
15
Depression screening
0.0
42
0
42
Hypertension screening
10.7
79
50
29
Clinical preventive service
•Source Authors’ analyses; sources for data used in each model are available from the authors.
•Health Affairs
September 2010 29:9
Other Promising Collaborative Care Models in
the Arsenal
 GAD and Panic Disorder
 Bipolar Disorder
 PTSD
 Opioid Abuse and Dependence using Buprenorphine
 Others?
Behavioral Health and Measurement: A Quality
Imperative
 Why Measurement?
 Improve individual outcomes by assisting in
treatment planning
 Group level outcomes can serve as benchmarks
and goals that can be used as critical information to
confirm or address effectiveness of service model
changes
 Creates a common language across disciplines and
providers to promote effective collaboration
Translating PHQ-9 Depression Scores into
Initial Planning
Score
Description
Actions
1-4
Community Norms
No further action
5-9
Mild Symptoms
Watchful waiting, periodic re-screening,
education, patient activation and
evaluation
10 – 14
Moderate Symptoms
Develop treatment plan, consider
counseling, education, assertive followup and evaluation, pharmacotherapy
15 – 19
Moderate -Severe
Immediate institution of treatment
including medication and/or counseling
≥ 20
Severe
Pharmacotherapy, counseling & referral
to mental health specialist
Using the PHQ-9 to Monitor & Adjust
Treatment at 4-6 Weeks
PHQ-9
Treatment Response
Drop of 5 points from baseline
Adequate
Drop of 2-4 points from
baseline
Drop of 1 point, no change or
increase
Possibly Inadequate
Inadequate
Treatment Plan
No treatment change needed
Follow-up in four weeks
May warrant an increase in
antidepressant dose
Increase dose; Augmentation;
Informal or formal psychiatric
consultation; Add
psychotherapy
APA NDLMI Psychiatry (Psychiatrist
and Non-Physician Co-Leader)
Depression Measurement Informed
Care Project
 PHQ9 was helpful in Tx decisions
 (n=6,096 Patient Contacts)
93%
 For contacts where PHQ9 was helpful, how did PHQ9
influence Tx? (n=5,578 Patient Contacts)
- Change Tx
- Confirm Tx
40%
60%
Impact of Measurement on Psychotherapy
Treatment Outcomes*
* Harmon, S. Cory, Lambert, Michael J., et al. (2007). Enhancing outcome for potential treatment failures: Therapist-client
feedback and clinical support tools. Psychotherapy Research, 17(4), 388
Health Homes and Accountable Care
Organizations
Defining the Medical Home
Superb
Access to
Care
Patient
Engagemen
t
in Care
Clinical
Information
Systems
• Patients can easily make appointments and
select the day and time.
• Waiting times are short.
• eMail and telephone consultations are
offered.
• Off-hour service is available.
• Patients have the option of being informed
and engaged partners in their care.
• Practices provide information on treatment
plans, preventative and follow-up care
reminders, access to medical records,
assistance with self-care, and counseling.
• These systems support high-quality care,
practice-based learning, and quality
improvement.
• Practices maintain patient registries; monitor
adherence to treatment; have easy access to
lab and test results; and receive reminders,
decision support, and information on
recommended treatments.
Care
Coordin
ation
Team
Care
Patient
Feedba
ck
• Specialist care is
coordinated, and
systems are in place to
prevent errors that
occur when multiple
physicians are
involved.
• •Integrated
and coordinated
team care depends on a free flow of
Follow-up
and support
communication among physicians, nurses, case managers and
is provided.
other
health professionals (including BH specialists).
• Duplication of tests and procedures is avoided.
• Patients routinely provide feedback to doctors; practices take
advantage of low-cost, internet-based patient surveys to learn from
patients and inform treatment plans.
•Publically
available
information
•Source: Health2 Resources 9.30.08
• Patients have accurate, standardized
information on physicians to help
them choose a practice that will meet
their needs.
•8
Health Homes Overview
Beneficiary criteria - At least two chronic conditions, one chronic
condition and at risk for another, or one serious and persistent
mental health condition. Chronic conditions include mental health
condition, substance abuse disorder, asthma, diabetes, heart
disease, being overweight (BMI over 25).
Designated Providers -Physicians, clinical group practices, rural
health clinics, community health centers, community mental health
centers, home health agencies; interdisciplinary health teams.
Payment - flexibility in designing the payment methodology including
structuring a tiered payment methodology that adjusts for severity of
illness and the “capabilities” of the designated provider.
•3
All Medicaid by Clinical Risk Groups (CY 2008)
Total
Member
Months
Pct Total
Pct of Total
Member
Member
Months Avg MM Months
Sum Total Claim
Expenditures
Pct of Total Claim
Expenditures
Total Claim
PMPM
Entire Medicaid by CRG
Recips
1) Healthy
2,891,590
26,366,511
53.65%
9.12
53.65%
$
6,256,508,376
14.30%
$
237
2) Maternity/Delivery
227,175
2,060,955
4.19%
9.07
4.19%
$
1,501,611,849
3.43%
$
729
3&4) Minor Conditions
333,807
3,656,225
7.44%
10.95
7.44%
$
1,801,754,388
4.12%
$
493
5) Single Chronic
741,860
7,915,447
16.10%
10.67
16.10%
$
8,925,736,961
20.40%
$
1,128
6) Pairs Chronic
628,772
7,132,396
14.51%
11.34
14.51%
$
16,778,912,692
38.34%
$
2,352
% of Memb
Mos
7) Triples Chronic
76,427
870,377
1.77%
11.39
1.77%
$
3,457,392,177
7.90%
$
3,972
16.28%
8) Malignancies
25,157
255,422
0.52%
10.15
0.52%
$
839,000,518
1.92%
$
3,285
9)Catastrophic
31,219
342,664
0.70%
10.98
0.70%
$
2,236,148,131
5.11%
$
6,526
10) HIV / AIDS
49,589
549,384
1.12%
11.08
1.12%
$
1,964,903,822
4.49%
$
3,577
5,005,596
49,149,381
100%
9.82
100.00%
$
43,761,968,915
100.00%
$
890
Total
Pairs & Triples
% of $
46.24%
•3
Primary Care Access Referral and Eval (PCARE)
Study - Proof of Concept for Health Home
 Goal: Improve quality of medical care for SPMI patients at
one CMHC
 Method: 12 month RCT of Patients in one CMHC
randomized to nursing care management (MI, coaching,
navigation, followup with appts) versus encouragement
and PCP list
 Demo: 85% of patients had schizophrenia, depression and
bipolar. 25% had co-occurring SA disorders. Most
common CMI were: HTN, arthritis, dental, diabetes.
PCARE Improvement in Medical Care
Druss, Von Esenwein, Am J Psychiatry 167:2, February 2010
Health Care Reform: ACOs
 The Accountable Care Act provides for a shared savings program:
 that promotes accountability for a patient population and
encourages investment in infrastructure and redesigned care
processes for high quality and efficient service delivery. Under
such program:
– groups of providers meeting pre-determined criteria may
work together to manage and coordinate care for Medicare
fee-for-service beneficiaries through an accountable care
organization (referred to in this section as an ‘ACO’); and
– ACOs that meet quality performance standards are eligible to
receive payments for shared savings
PCMH as Foundation for Accountable
Care Organizations
•ACOs are defined as a
group of providers that has
the legal structure to receive
and distribute incentive
payments to participating
providers.
•Source: Premier Healthcare Alliance
•38
ACO Quality Measures
 65 Quality Measures in 5 Domains in :
Patient/Caregiver Experience (7)
Care Coordination (12)
Patient Safety (2)
Preventive Health (9)
At Risk Pop/Frail Elderly in Chronic
Conditions (20)
 Specific Behavioral Health Measures: ONLY 1? HUH!?
So Are We at a Tipping Point? (Gladwell)
 Point at which a movement/event/intention becomes
inevitable, inescapable, when everything changes all at
once
 Transformation occurs through initial infection (idea) then
contagiousness (others latch on, tell others), little actions
having big effects (multiple pilot testing, things begin to
work, new application seems to work), change is often
sudden (then everybody gets it)
 Examples – flu epidemic, internet usage, Google.
NCDP © New York University
Key Ingredients to Reach a Tipping Point
1. Law of the Few
a. Connectors – People who know everyone and create
intersections and opportunities
b. Mavens – People who are credible information hounds
and validate ideas and methods
c. Salesmen – People who are able to use information and
people to spread idea to the skeptical
Case example: “The Midnight Ride of Paul Revere”
NCDP © New York University
Key Ingredients to Reach a Tipping Point
2. The Stickiness Factor
a. Memorable – evokes strong feelings
b. Minimal barriers to entry – can’t avoid seeing it or
seeing others do it – “why not me?”
c. “Cool” factor – in the know, the in crowd, identification
with status
d. Little things make a difference in making big changes,
example – PDSA’s
NCDP © New York University
So Are We There Yet?