integrated health - nhms nhms integrated care.pdf · posted by suzanne koven -a primary care doctor...
TRANSCRIPT
Integrated Health Matthew S. Duncan, MD Assistant Professor of Psychiatry Geisel School of Medicine at Dartmouth Dartmouth-Hitchcock Medical Center
SHOULD MENTAL
HEALTH BE A PRIMARY-CARE DOCTOR’S JOB?
POSTED BY SUZANNE KOVEN -a primary care doctor at Massachusetts
General Hospital in Boston Increasing Demand
Lack of Time
Lack of Training PCP’s
Medical Students
MH System/Insurance
PCMH Model
o HMS – Center for Primary Care MH staff in Primary Care
Teleconferencing
Ideal – on the spot, brief evaluation with PCP and Psychiatrist
OCTOBER 21, 2013
Collaborative/Integrated Care
(Heath et. al A Review and Proposed Standard Framework for Levels of Integrated Healthcare. SAMHSA-HRSA 2013)
Six Levels
Coordinated
Minimal Collaboration
Separate Facilities and Systems
No coordination and
communicate rarely
Basic Collaboration at
a Distance
Separate Facilities and Systems
Communication planned and
periodic
Co - located
Basic Collaboration on Site
Same facility but separate systems
Communicate regularly and
meet occasionally
Close Collaboration on Site with Some System Integration
Same facility and share some
systems
Communicate in person regularly
Integrated
Close Collaboration Approaching an
Integrated Practice
Shared space in same facility
Actively seek system solutions together and regular team meetings
Full Collaboration in a Transformed/Merged
Integrated Practice
Shared space in same facility
Resolved systems issues, function as one
team, communicate consistently at all levels
WHO
Psychiatrists:
5-30/100,000
Primary Care Physicians
100/100,000
Principles Policy
Fee for Service vs. Value Based HIPPA
Advocacy Training Limited and Doable Specialists
“New Yorkers to Find „No Wrong Door‟ to Public-Health Facilities” -
NY - Professional News October 21, 2013 Mark Moran
- 2005 – PHQ-9 screening
- 2007 – joining MH and substance abuse treatment
- 2007 - NY state agencies removed financial and regulatory barriers to integrated treatment
- provided funding to establish a Center for Excellence in Integrated Care
provide hands-on assistance in implementing best practices in at least half of the state’s 1,200 mental health and substance abuse treatment clinics.
- 2009, OMH required monitoring of cardiometabolic status and antipsychotic prescribing in all state-operated mental health facilities for adults, youth, and forensic populations.
- 2012 – IMPACT Model
Self-Assessment Interest/Goals
Triage sub-acute cases
Screen?
Care Coordination Social Work Behavioral Health
Treat Stabilization vs long-term Medications Counseling
Resources
Institution Support
Referral Network
External Virtual Team
Internal Team
Limited and Doable
Screening http://ibhp.org/uploads/file/IBHScreeningToolsRevFinal100313.pdf
Suicide: USPSTF/Annals of Internal Medicine – May 2013.
Unclear accuracy and no clear impact on outcomes
False Positives
Depression: 2010 Update of Previous USPSTF Recommendation In 2002, the USPSTF recommended:
screening adults for depression in clinical practices that have systems in place to assure accurate diagnosis, effective treatment, and follow-up.
The current recommendation:
staff-assisted depression care supports need to be in place. If such supports are not in place, the USPSTF does not recommend routine screening of adults.
IMPACT- Depression Care
PCP
Care Manager
Consulting Psychiatrist
Unutzer et al. JAMA 2002
Core Components
2 new processes Systematic diagnosis and outcomes tracking Stepped Care
2 new team members Care Manager Consulting Psychiatrist
Depression Care Model Usual
Pt’s therapist tells pt to tell PCP to start AD.
PCP reluctantly starts AD, arranges regular office visits
“crossed my fingers that the drug would be effective and wouldn’t cause side effects.”
IMPACT PHQ-9 Screening of all pt’s.
Immediate referral to a depression registry
Scheduled, frequent phone calls by depression care manager
Case- load supervision of DCM by Psychiatrist
1:1 Consultation if needed
Medications
- According to IMS Institute for Healthcare Informatics in 2009
Integrated Care
o Expand CM role o Systematize
Screening and Response Workflows
o Train, Educate, and Support
Key Components
Care Manager
Linkage
Support/Systems
LESSONS Advantages
Better Patient Care
Lower Healthcare costs
Less provider stress (if systems are in place)
Enhanced provider learning and confidence
Step toward a PCMH model
Cautions
Screening without Systems.
Systems without Training, Staffing and Specialist Support.
Ease of Access/PCMH can become CMHC.
Less can be More (but not optimal).
Trying to go Old School.