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Bi-Directional Physical and Behavioral Health Integration:
Improving Care for Patients
Jurgen Unutzer, MD Jeff Hummel, MD
Healthier Washington Practice Transformation Support Hub
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• An investment of Healthier Washington managed by the Washington State Department of Health
• Helps practices successfully move to whole-person, patient-centered care
The Healthier Washington Practice Transformation Support Hub
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• Three separate contracts, funded by DOH
• Qualis Health provides Practice Coaches and Regional Connectors programs
• Web Resource Portal offered through partnership with UW Department of Family Medicine Primary Care Innovation Lab
The Hub: A Four-year, State Innovation Model (SIM) Testing Grant
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Help Providers to:
• Integrate physical and behavioral health
• Move from volume-based to value-based care
• Improve population health through clinical and community linkages
Hub Goals
Triple Aim
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• Connect practices to the best fit resources and TA
• Personalized practice assessments, education, and tools
• Support for bi-directional physical and behavioral health integration
• Finding and coordinating community-based linkages
The Hub: What Do You Need to Support Practice Transformation Efforts?
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• Webinars and group
learnings on practice
transformation and best
practices
• Links to a Web Resource
Portal with references, tools,
and up-to-date information
• Help understanding models
and available options
Education, Tools and Resources
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Integrated Behavioral Health Care: Moving Towards Whole Person Care
Jürgen Unützer, MD, MPH, MA Chair, Department of Psychiatry & Behavioral Sciences Director, AIMS Center (Advancing Integrated Mental Health Solutions) University of Washington
Healthier Washington Practice Transformation Support Hub January 10, 2017
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Mental Illness and Substance Abuse
• Nearly 25 % of all health related disability – More than diabetes, heart disease, or cancer
• For employers: – Absenteeism, presenteeism, high costs
• For governments: – Homelessness, involvement with the criminal justice
system; high health care cost • One suicide every 13 minutes
– In WA State alone: 2 – 3 suicides / day – More than homicides or motor vehicle accidents
• No family goes untouched
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Morbidity and Mortality Associated with Severe Mental Illness (SMI)
• Suicide and injury account for about 30-40% of
excess mortality • 60% of premature deaths in persons with
schizophrenia are due to preventable (and costly) medical conditions with 20+ years of life lost
URL:http://www.cdc.gov/pcd/issues/2006/apr/05_0180.htm
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Behavioral Health Care in WA State
CMHC ~140,000
Primary Care ~300,000
No Formal Treatment ~ 550,000
Acute Care Psychiatric Hospitals
~800
State Hospitals ~1,000
Population ~ 7 Million
Adults w/ MH Dx
~ 1 Million
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THE STATE OF MENTAL HEALTH IN AMERICA
Source: Parity or Disparity: The State of Mental Health in America (2015), Mental Health America
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Behavioral Health Workforce Shortage – Psychologists (PhD, PsyD)
– Psychiatrists (MD, DO) – Psychiatric Nurses / Nurse Practitioners (RN, ARNP) – Social Workers (MSW, LCSW) – Counselors (LFMT, LPC, MHC, CADAC, CACC)
• But – More than half of WA counties don’t have a single practicing
psychiatrist or psychologist • Doctoral level providers are concentrated in a few urban areas • Most practicing psychiatrists are within 10 years of retirement age
– Most counties have shortages of prescribing providers – Challenges with recruitment and retention of all types of behavioral
health providers
• Bottom line: – We have a major workforce shortage now and we won’t keep up
with growing demand due to population growth.
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Quality of Care
• ~ 30 million people receive a prescription for a psychotropic medication each year (most in primary care) but only 1 in 4 improve.
• Patients with serious mental illness die 10 – 20 years earlier, in large part due to poor medical care.
“Of course you feel great. These things are loaded with antidepressants.”
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Mental Health and Medical Disorders are tightly linked • Katon Slide
e.g., Depression & Diabetes
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Whole Person Care: Patient Centered
Social
Services
Housing Vocational
Rehab
Alcohol & Substance
Abuse Treatment
Mental Health Care
Medical Care
Silos or “Cylinders of Excellence?” “don’t you guys talk to each other?”
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Task Sharing and “Integrated Care”
Hospital
Community Mental Health
Care
Collaborative Care
Behavioral Health Consultant
Primary Care Provider
Community-Based Services & Supports
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Not All Integration Efforts are Effective
Approaches that don’t work: • Screening without adequate treatment • Referral to specialty care without close coordination
and follow-up • Co-located behavioral health specialists without
systematic tracking of outcomes or evidence-based treatments
Patients ‘fall through the cracks’ or stay on ineffective treatment for too long.
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Integrated care: models vs principles • No one approach fits all
– Arguing about the best integration model is a bit like arguing about the best religion.
• Evidence-based models have to be adapted to local settings in order to be successful.
• There are important principles that need to be followed in order to reach the Triple Aim: Value = Reach * Effectiveness / Cost
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Principles for Evidence-Based Integration in Behavioral Health and Primary Care
Population-Based A defined group of clients is tracked in a registry so that no one “falls through the cracks.”
Measurement-Based Treatment to Target Measurable treatment goals clearly defined and tracked for every patient. Treatments are actively changed until clinical goals are achieved.
Team-Based and Person-Centered Primary care and behavioral health providers collaborate effectively, using shared care plans.
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Collaborative Care Team Approach
PCP
Patient BH Care Manager
Psychiatric Consultant
Rest of Primary Care Team
Core Program
Additional Clinic Resources
New Roles
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Research: Collaborative Care Doubles Effectiveness of Care for Depression
Perc
enta
ge (%
) Im
prov
ed
Participating Organizations
50 % or greater improvement in depression at 12 months
Unützer et al., JAMA 2002; Psych Clinics North America 2004
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Wall Street Journal, Sept 2013
Return on investment for collaborative depression care: $ 6.50 for each $ 1.00 spent
Unutzer et al, Am J Managed Care, 2008.
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> 80 Randomized Clinical Trials: Better care experience
- Access to care - Client & provider satisfaction
Better health outcomes - Less depression - Less physical pain - Better functioning - Better quality of life - Lower mortality
Lower health care costs
“The triple aim of health care reform.”
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Not All Collaborative Care Teams Look Alike Providence SW team includes pharmacists in review
for diabetes med management
Patient
Care Manager
Primary Care Provider
Consulting Psychiatrist
Pharmacist
Legend
Frequent
Interaction
Less Frequent
Interaction
Case Review Participants
New Roles
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Telemedicine-based Integrated Care: What does the evidence tell us? Practice-Based IC (CC) • Practice-based care
includes both in-person and telephone-based interventions
• Over 80 randomized, controlled trials
• 2 meta-analyses
Telemedicine-Based IC (CC) • May include limited in-person
interactions, but mostly through phone or other virtual interventions
• 8 published trials with positive results
• 4 of the trials in rural Arkansas CHCs or VA clinics in rural areas
• 4 of the trials used exclusively off-site care managers and psychiatrists
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Missouri CMHC Healthcare Homes • Patient Population:
– Adults with Severe Mental Illness
• Staffing Model for Integration: – Primary Care Consultants – Primary Care RN Care Managers
• Annual + Metabolic Screening • Diabetes Education and Treatment • Pay for Performance
– Half of Quality Performance Measures are Medical – Half of Medication Adherence Measures are Medical
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Translating Research into Practice
“It is one thing to say with the prophet Amos, ‘Let justice roll down like mighty waters,’ and quite another to work out the irrigation system.”
-- William Sloane Coffin, Social activist and clergyman
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HEDIS Depression Metrics Already Driving Value Based Purchasing
Depression Screening & Follow-up Based on NQF# 0418
Depression Remission or Response Measured by PHQ9 or PHQA Remission: PHQ9 score of less than 5 Response: 50% improvement over
first elevated PHQ9 within 5 – 7 months of first elevated
PHQ9
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How Did the NCQA arrive at an expectation of remission or response to
depression treatment by 5 to 7 months?
Influenced by two recent studies: MHIP 2009-2010 evaluation P4P drives treatment to target and improves
clinical outcomes
Mayo Clinic System large retrospective study
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Active Treatment to Target Drives Early Improvement In recent retrospective study (2008 – 2013) of over 7,000 patients:
– Time to depression remission was 86 days for patients in Mayo Clinic collaborative care
– Time to remission in usual care was 614 days
Time to Remission for Depression with Collaborative Care Management in Primary Care http://www.ncbi.nlm.nih.gov/pubmed/26769872
J AM Board Fam Med 2016 Jan-Feb
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Effective integration requires practice change.
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UW RESOURCES
The University of Washington offers many educational and consultation resources that are available to Washington State providers
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AIMS Center staff and faculty have trained over 6,000 providers in more than 1,000 clinics in evidence-based integration strategies, including collaborative care
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UW Integrated Care Psychiatry Training Program (ICTP) Will Complement Support Hub
Current IC training for:
– 107 practicing psychiatrists
– 70 Psychiatry residents (Seattle & Spokane)
New IC Psychiatry fellowship program:
– 5 fellows
Next steps Currently reaches 16 counties:
– expand reach to all counties
– Train, place, and support consulting psychiatrists
Include nurse practitioners and other prescribing providers
Future Common core curriculum for behavioral health providers:
– EB Treatments – Team-based care – BH care
management – Technology
Train & support trainers across state
UW Psychiatry & Behavioral Sciences
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UW Psychiatry & Addictions Case Conference (UW PACC) Series Telehealth resource support for providers who care for patients with behavioral health conditions
New attendees always welcome! Thursdays 12:00-1:30pm PST Email [email protected] to register Every PACC session includes a 20-minute educational presentation by UW psychiatrists followed by in-depth case consultations for community providers
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Summary • Mental illness & substance use:
– Major drivers of disability & cost • Fewer than half of those in need have access to effective
care. • Current care is often not effective:
– More of the same may not get us where we need to go • Effective integration of behavioral health care and primary
care: – Better access to care – Better health outcomes – Lower costs
The Triple Aim of Healthcare Reform
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Bi-directional Integration Strategies
Primary Care Settings New Team Roles:
BH Care Managers On-site BH Specialists Psychiatric Consultants
Measurement-Based Screening & Follow-up (e.g., PHQ9, GAD-7)
Screening & brief intervention for substance use disorders (SBIT)
Measurement-Based Treatment to Target
Behavioral Health Settings New Team Roles:
Primary Care Consultants Primary Care RN Care Managers
Metabolic Screening Routine Preventive Care Cardiovascular and Diabetes
Care (BP, A1C) Measurement-Based
Treatment to Target
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Principles for Evidence-Based Integration in Behavioral Health and Primary Care
Population-Based A defined group of clients is tracked in a registry so that no one “falls through the cracks.”
Measurement-Based Treatment to Target Measurable treatment goals clearly defined and tracked for every patient. Treatments are actively changed until clinical goals are achieved.
Team-Based and Person-Centered Primary care and behavioral health providers collaborate effectively, using shared care plans.
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Bi-Directional Physical and Behavioral Health Integration: Improving Care for Patients
Jeff Hummel, MD, MPH
January 10, 2017
Integrated Behavioral Health: What does it mean on a day-to
day-basis?
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Objectives
• From the primary care clinician’s perspective what does integrated behavioral health look like?
• How does it meet the needs of the primary care team and my patients?
• If integration is bi-directional what does primary care need to be prepared to do in return?
• If this isn’t a “one-size-fits-all” program, what options are there for how this might work?
© Qualis Health, 2016
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Primary Care and Behavioral Health • Behavioral health issues are common and
primary care handles a lot of them really well • Enthusiasm & skills of clinicians vary • There is tremendous variation in severity in most
behavioral health issues • Patients with Behavioral Health issues:
– Frequently require a high degree of skill/experience – Generally take more time for emotional support – Unstable social support systems
• Net effect: a tendency to avoid if possible © Qualis Health, 2016
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When the problem is too big, integrated care means
• Being able to say, “I can help you,” without committing to a 45-minute conversation
• Having a clear efficient pathway for quickly getting the patient connected to a skilled behavioral health professional team
• Reducing barriers to clinicians eliciting, identifying, or defining a behavioral health issue during a primary care visit
© Qualis Health, 2016
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When a problem is not too big integrated care means
• Having evidence-based structure and tools for common behavioral health conditions
• On-going conversation with experts on best practices for common problems and the boundaries with complex problem
• Real-time access to a consultant when one reaches a limit, or the situation changes © Qualis Health, 2016
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What Does Primary Care do in Return?
• Provide consultative services to BH clinicians on common medical issues – Accept phone calls for clinical guidance – Accept referrals from BH Agency – Develop a structured relationship for
communication with referring BH clinicians • Participate in bi-directional teaching and
case sharing
© Qualis Health, 2016
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Options for What it Might Look Like
• Referral agreement & standardized process • Designated BH clinician to provide
consultation services to PC clinicians • Designated PC clinician to provide
consultation services to BH clinicians • PC team member present in BH agency • BH team member present in PC Clinic • Participate in monthly case conferences
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Summary • Primary care is less stressful and more enjoyable
when behavioral health is a formal or informal member of the team
• Patient experience is better care when primary care and behavioral health work together
• The opportunity for applying population health strategies for behavioral health issues, e.g. depression, is enhanced with integrated care
• Over all costs go down with behavioral health integration because self-management of chronic illness is easier when behavioral health is well managed
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Learn More
Resources available at: http://www.safetynetmedicalhome.org/change-
concepts/organized-evidence-based-care/behavioral-health
Jeff Hummel, MD, MPH
e-mail: [email protected]
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• Let us know how we can help you:
• Contact the Help Desk for resources, questions, and to be added to our mailing list
• Talk to us about assessing your practice
• Find out how you can enroll in on-site technical assistance
The Hub: Offering a Menu of Services to Support Practice Transformation Efforts
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Questions and Discussion
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For More Information Hub Help Desk: (206) 288-2540 or (800) 949-7536 ext. 2540 or by email [email protected].
Healthier Washington Practice Transformation Support Hub Web sites: http://bit.ly/2e0PpmF
www.QualisHealth.org/hub
Coming in early 2017: Transformation training links and tools on the Hub Resource Portal website
The project described was supported by Funding Opportunity Number CMS-1G1-14-001 from the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.