integrated care: where’s this going? why?

IBHP Grantee ConvocationSacramento, CA

September 12, 2008

Frank deGruy

Integrated Combining dissimilar things into a coherent

whole that has meaning and value

Behavioral Health Mental disorders Substance use problems Health behavior change

Mental Health Services Research NIMH AHRQ RWJ MacArthur

Substance Use and Criminality Quality Improvement Clinical Decisionmaking and EBM PBRNs

Basic Design Issues Efficacy to effectiveness

Heterogeneous study samples Usual Care control groups Multilevel interventions Multilevel and mixed methods evaluations

Stepped Care Multistep interventions

QI “Research” PBRN methods

Economic analyses Direct and Indirect Costs Cost Offset Cost Effectiveness Cost Benefit

Chronic Disease Management Registry Self management Care manager Care protocol Objective outcome measurement

Prevalence and nature of the problems Depression & impairment, then the others Comorbidity Adequacy of treatment Health behavior change

Nature of primary care practices Patients are reluctant to fragment care Practices are overwhelmed: competing

demands Systemic nature of practice Easier to change than to sustain

Nature of the partners Strange environment, different assumptions Different work styles Not used well Teamwork: new layer of overhead

Nature of supporting systems Commodification of clinicians and practices Carveouts More difficult to change Different priorities, incentives (incentives!)

What is it? Probable defining context Behavioral/mental health integration at

risk for marginalization Mandate for MH resources to serve

multiple purposes Learn DM, Asthma, CAD literature Comorbidity

System Issues Carveouts Reimbursement rules & productivity

incentives Benefits design

How to deal with carveouts Who pays for care managers? Specialty

consultants? Who “owns” them? Where do they live?

Pilot Mentality Running assessment Midcourse corrections Emphasis on teamwork Vertical Integration