Transcript Presentation Title - Maine Quality Counts

Integrating Mental Health into
Advanced Primary Care – Why and
How
Neil Korsen, MD, MS
Medical Director
Mental Health Integration Program
MaineHealth
Outline
• Background – Why Integration?
• Screening for common mental health
conditions
• Improving access to and communication
with mental health specialists
• Building an integrated team
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.
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
Patient Centered Medical Home
mental/behavioral health components
Standardized
Screening &
Assessment
Support for
Behavioral
Change
Mental Health
Treatment &
Consultation
Specialty
Mental Health
Care Management
Community Resources
e.g., NAMI
Integrated Care – MHI Program Involvement
PCMH Pilot Sites
PCMH/MHI Collaborative Sites
MHI Collaborative Participants
MHI Mental Health Partners
Behavioral-Physical Integration
 Participate in baseline assessment of current behavioralphysical 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
Levels of Integration
Level
Attributes
Minimal
Collaboration
I
Separate site & systems
Minimal communication
Basic Collaboration
from a distance
II
Active referral linkages
Some regular communication
Maximized off-site
Collaboration
IIA
Efficient and effective access to specialty
mental health. Strong consultative
relationships. Links to community resources
and providers. Coordinated treatment.
Basic Collaboration
on site
III
Shared site; separate systems
Regular communication
Collaborative Care
partly integrated
IV
Shared site; some shared systems
Coordinated treatment plans
Regular communication
Fully Integrated
System
V
Shared site, vision, systems
Shared treatment plans
Regular team meetings
Further modified from Doherty, McDaniel, and Baird - 1996
Screening for Common Mental
Health Conditions
Screening and Assessment
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
… 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.
5
8
6
7
9
10
Screening and Assessment
• 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
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
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
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
PHQ-9
1.
2.
3.
A validated tool for screening and diagnosing
depression and for following response to
treatment
Scoring parallels DSM-IV diagnosis for Major and
Minor Depression
Can be administered in ‘interview’ style or
completed by patient
PATIENT QUESTIONNAIRE (PHQ-9)
Name:
Date:
Over the last 2 weeks, how often have you been bothered by any of the following problems? (use “
”
to indicate your answer)
More
Nearly
Several
Not at all
than half
every
days
the days
day
1. Little interest or pleasure in doing things
0
1
2
3
2. Feeling down, depressed, or hopeless
0
1
2
3
0
1
2
3
4. Feeling tired or having little energy
0
1
2
3
5. Poor appetite or overeating
0
1
2
3
6. Feeling bad about yourself – or that you are a failure
or have let yourself or your family down
0
1
2
3
7. Trouble concentrating on things, such as reading the
newspaper or watching television
0
1
2
3
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
0
1
2
3
9. Thoughts that you would be better off dead, or of
hurting yourself in some way.
0
1
2
3
_____ +
_____ +
_____
3. Trouble falling/staying asleep, sleeping too much
Add Columns:
(Healthcare professional: For interpretation
of TOTAL, please refer to back of page)
TOTAL:
_______
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
_______
Patient Health Questionnaire (PHQ) Copyright© 1999 Pfizer Inc. All rights reserved. Reproduced with
permission. PRIME-MD ® is a trademark of Pfizer Inc.
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
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
• 10th 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.
Guideline for Using the PHQ-9 for Initial Management
Score/
Symptom Level
0-4
No depression
5-9
Mild
10-14
Moderate
Treatment
Consider other diagnoses
Consider other diagnoses
If diagnosis is depression, watchful waiting is
appropriate initial management
Consider watchful waiting
If active treatment is needed, medication or
psychotherapy is equally effective
Active treatment with medication or psychotherapy is
15-19
Moderately Severe 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
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.
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
Interpreting Follow Up Scores
PHQ-9 - Change from last
score, measured monthly
Treatment
Response
Treatment Plan
Drop of 5 or more points
each month
Good
Antidepressant &/or Psychotherapy
No treatment change needed.
Follow-up in 4 weeks.
Drop of 2-4 points each
month
Fair
Antidepressant:
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
Poor
Antidepressant: 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.
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
Improving Access and
Communication
Mental health referrals
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
• 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
Building an Integrated Team
Integrated Team Function
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
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
Team Roles in Integrated
Primary Care
Mental Health
Specialist
Diagnose, Treat
Primary Care Clinician
Support Staff
Screen, Diagnose,
Treat
Care Manager
Follow up,
Family Adherence
Patient Education
Patient and
Family
Psychiatrist
Or APRN
Consult, Train
NAMI
Community
Resources,
Family
Support
Team Effectiveness Model
Mission
Goals
Roles
Processes/Procedures
Interpersonal Relationships
Beckhard, R. Optimizing Team-Building Efforts. Contemporary Journal of Business, Summer 1972.
Mental Health Specialist in
Primary Care:
How about those
differences?
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?
Start where you are
Use what you’ve got
Do what you can
Arthur Ashe
Resources:
Websites




www.integratedprimarycare.com – National clearinghouse site for information on
integrated care out of U Mass.
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.ibhp.org - Integrated Behavioral Health Project. Good general information
on integrated care site out of California.
www.pcpcc.net - Patient Centered Primary Care Collaborative. National
resource devoted to developing and advancing the patient centered medical
home.
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.
Contact info:
 Cynthia Cartwright, MT RN MSEd,
[email protected], 662-3529
 Neil Korsen, MD MS, [email protected],
662-6881
 Mary Jean Mork, LCSW, [email protected],
662-2490