integrating mental health into advanced primary care – why and how
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Integrating Mental Health into Advanced Primary Care – Why and
HowNeil Korsen, MD, MS
Medical DirectorMental 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
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
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 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
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 systemsCoordinated treatment plans
Regular communication
Fully Integrated System
V Shared site, vision, systemsShared treatment plansRegular team meetings
Further modified from Doherty, McDaniel, and Baird - 1996
Levels of Integration
Screening for Common Mental Health Conditions
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
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. 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
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)
Not at all
Several days
More than half the days
Nearly every day
1. Little interest or pleasure in doing things 0 1 2 3
2. Feeling down, depressed, or hopeless 0 1 2 3
3. Trouble falling/staying asleep, sleeping too much 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
Add Columns: _____ + _____ + _____
(Healthcare professional: For interpretation TOTAL: of TOTAL, please refer to back of page)
_______
Not difficult at all _______
Somewhat difficult _______
Very difficult _______
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?
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 Treatment
0-4No depression
Consider other diagnoses
5-9Mild
Consider other diagnosesIf diagnosis is depression, watchful waiting is appropriate initial management
10-14Moderate
Consider watchful waitingIf active treatment is needed, medication or psychotherapy is equally effective
15-19Moderately Severe
Active treatment with medication or psychotherapy is recommendedMedication or psychotherapy is equally effective
20-27Severe
Medication treatment is recommended For many people, psychotherapy is useful as an additional treatmentPeople 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
PHQ-9 - Change from last score, measured monthly
TreatmentResponse
Treatment Plan
Drop of 5 or more points each month
Good Antidepressant &/or PsychotherapyNo 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.
Interpreting Follow Up Scores
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
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 care5 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
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
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 skills5 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
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 HealthSpecialist
Diagnose, Treat
Care Manager Follow up,
Family Adherence Patient Education
Primary Care Clinician Support Staff
Screen, Diagnose, Treat
PsychiatristOr APRN
Consult, Train
NAMI Community
Resources,Family Support
Patient and Family
Team Effectiveness Model
Mission
Goals
Processes/Procedures
Interpersonal Relationships
Roles
Cul
ture
– P
rim
ary
Car
e Culture – M
ental Health
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 canArthur 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, cartwc@mainehealth.org, 662-3529
Neil Korsen, MD MS, korsen@mainehealth.org, 662-6881
Mary Jean Mork, LCSW, morkm@mmc.org, 662-2490
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