integrating primary care and behavioral health: lessons from a ground view to 1,000 feet integrating...
TRANSCRIPT
Integrating Primary Care and Behavioral Health:
Lessons From a Ground View to 1,000 Feet
Integrating Behavioral Health Project September 11, 2008
Larry Mauksch, M.Ed
Department of Family Medicine
University of Washington
Principles for success in practice change
• Build relationships through experiential team
training on clinical and operational topics
• Have regular huddles and meetings
• Create team ownership of change, challenges,
and successes
• Find out what is important to patients in life, in
problem focus, in treatment, and in relationships
Principles for success in practice change
• Figure out what to change first, don’t change
everything at once, be patient but persistent
• Do not let staff turnover cause system decay
• Track Progress: patient, team, system, cost
• Create back-up systems to optimize clinical
success:
– multidisciplinary transdisciplinary
Principles for success in practice change
• Conserve resources and intensify care for patients with greater complexity (stepped care)
• CELEBRATE SUCCESS!!!
DepressionObesity
Substance abuse Diabetes
Family
Person
Biopsychosocial patient centered care
Primary Care Provider
Patient
PsychiatricConsult or Tx
Self Management
Group
Care Management
Beh HealthConsult or Tx
Shared Space
Hallway Updates and
consults
3-way meetings
Financial IncentiveTo Work Together
Integrated Information System:
Electronic Medical RecordProvider communicationPatient tracking for f/u
Organizational Features Promoting
Integration
Leadership Shared Mission / Vision
Team TrainingOngoing Training
Primary Care Provider
Patient
Self Management
Group
Case Management
PsychiatricConsult or Tx
Beh HealthConsult or Tx
Marillac Clinic Background
• Primary care clinic: – medical, dental, mental health, optical
• Only serves people:– at or below 200% Fed poverty guidelines– uninsured (no Medicaid or Medicare)
• Grand Junction, Colorado – 2004 population of Mesa Country = 127,000
• Private, non profit, not an FQHC• In 2004: 9700 visits from 3100 patients
Prevalence : Marillac-500 Vs PHQ-3000
0% 10% 20% 30% 40% 50% 60%
Prob Alcohol Abuse
Binge Eating Dis
Other Depression
Bulimia
Other Anxiety Disorder
Panic Dis
Major Depression
Any Diagnosis
PHQ-3000 Marillac 500
Patient Health Concerns at Appointmentn = 500
0
5
10
15
20
25
30
35
Problems with mood
HypertensionAnxiety stressSkin concern
Tobacco dependence
HeadachesSinusitisDiabetes
Back Disorders
Medication refill / check
Percent
Patient Written Concerns (%) Elicited by Provider (%)
Marilllac Utilization: Top 10 Provider Diagnoses6783 visits: 6/1/98 - 5/22/99
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
DEP HTN SIN TOB ANX FHM NIDD Brnch SrTh ETOH
Top 10 Diagnostic Pairs at Marillac 27% of 3036 Multiple Prob Visits 6/1/98 -
0.00% 1.00% 2.00% 3.00% 4.00% 5.00% 6.00% 7.00%
HTN-Tob
FHM-HTN
Sin-Tob
Dep-FHM
Obes-HTN
Dep-ETOH
Dep-Tob
NIDD-HTN
Dep-HTN
Dep-Anx
Collaborative Care: Phases of Integration at Marillac
• Preliminary work (1994-1996)- Therapist leaves at 6 mo
• Phase 1 (1997-1998) Building a conceptual and physical
commitment in the clinic and community
• Phase 2 (summer, 1998 - summer, 1999) Intensive training
• Phase 3 (spring 1999 – spring 2002) Building the Marillac system
and design of interagency model
• Phase 4 (2002-2006) Quality improvement within Marillac and
across agencies
• Phase 5 (2006…) Decay, retraining and transformation towards a medical home
Principles of change• Lasting collaboration requires an educational
and training process that builds relationships between disciplines• A new culture
• Meaningful and sustainable changes in service require change in system design• Chronic care model: Information systems, provider training,
promotion of self management, expert consultation and decision support, community involvement
Essential Ingredient:Organizational / Structural
• Strong board and executive director support• Providers co-located for better communication• Combined medical record (paper going to EHR)
with full access to MH and PC providers• Inter-agency collaboration
– Funding– Shared training– Inter-agency communication and referral systems
PsychologistFamily
Therapist
& Psychiatrist
Addictions
CounselorCase
Manager
MedicalExam
Rooms
MedicalExam
RoomsMedical
Provider
StationsMedicalExam
Rooms
MedicalExam
Rooms
MedicalExam
Rooms
Medical
Assistant
Stations
MedicalExam
Rooms
MedicalExam
Rooms
MedicalExam
Rooms
Reception Front Office
Physical Layout
Bathroom
Essential Ingredients: Clinical
• Staff and interdisciplinary team training Clinicians and staff
Clinicians and staff from community agencies
• Patient tracking and follow-up
Assessment of population needs and quality of
care
Clinical training
• Didactic topics (evidenced based)• Patient and family centered communication skills
• Primary care counseling skills
• Collaborative care communication skills
• Experiential approaches• Shadowing
• Regular interdisciplinary case conferences
Collaborative Tips: Behavioral Health Provider
• Adherence– Monitor dose– Monitor side effects– Monitor beliefs– Assess symptoms
• Consult with MD/PA/NP– Medication – Successes– Obstacles
• Share therapeutic info– Family, cultural issues– Strategies
• Monitor overall health quality of life– Note physical
symptoms– Health maintenance– Chronic illness mgmt– Chronic illness beliefs
Collaborative Tips: Medical/Nursing Provider
• Share concerns about adherence with MHP
• Share psychosocial information about patient and family
• Encourage participation in psychotherapy
• Assess patient beliefs about psychotherapy
• Ask what psychotherapeutic goals you can support– Communication skills– Cognitive changes– Behavioral changes– Emotional awareness
• Share concerns about other health care issues
Collaborative Tips: Care Manager
• Monitor the gaps-- “interstitial thinking”
• Track patients using systems “owned” by the team.
• Adapt communication to varying styles of behavioral health and primary care providers
• Track– Side effects– Adherence– Outcomes
• Facilitate – Referrals – Needed visits– Defining shared goals– Community
connections
Marillac Outcomes
A Proxy for Integration:Hallway consults
Averages in 2003 and 2004
• 1034 consults between primary care providers and case managers or mental health therapists
• 405 three way meetings between patients, behavioral health providers and primary care providers
Quality of Care Improvement
• Chart review comparison
– All charted mental illnesses
• 500 consecutive patients in 1999
• 500 consecutive patients in 2004
QI Acute Phase (120 days)
0
20
40
60
80
100
Seen ≥ 1 byPCP
Psych Rx Seen ≥ 3 forf/u
Met all 3criteria
1999 2004
QI Continuation Phase(9 months)
0
10
20
30
40
50
60
70
80
90
100
Seen ≥ 1 by PCP Psych Rx Seen ≥ 3 in f/u Met all 3 criteria
1999 2004
Stepped Care: 1999 vs 2004Overall MH contacts and PCP contacts
Total MH 1dxTotal MH2dxTotal MH 3+PCP 1 dxPCP 2dx PCP 3x
19992004
0
2
4
6
8
10
12
Primary Care Provider ContactsAcute phase (1st 120 days) 1999
(149)
2004
(111)
Patients with 1 mental health dx 3.2(75) 2.4(49)
Patients with 2 mental health dx 3.7(54) 3.6(43)
Patients with 3 mental health dx 3.7(20) 4.4(19)
Continuation phase (9 months post acute phase)
Patients in phase at start 36% 76%
Average number of visits 3.1 2.5
Stepped Care: 1999 vs 2004Team member MH contacts
CM 1 dxCM 2dxCM 3dx
Counsel 1dxCounsel 2dxCounsel3dxGroup 1 dxGroup 2 dxGroup 3 dxPsychMD 1dxPsychMD 2dxPsychMD 3dx
19990
0.5
1
1.5
2
2.5
3
3.5
1999
2004
1999 2004
Patients
Treated
Mean
Visits
Patients Treated
Mean Visits
P-value
Acute Care
149 3.16 111 4.81 .0001
Contin Care
139 3.76 193 4.88 .01
Number of Mental Health Contacts with Health Professionals in1999 and 2004
Essential Ingredients: Financial
• Commitment of core organizational resources
• Multi-organizational support
• Development of new financial resources
– Public and private grants
– State health programs
– New insurance relationships
– State policy changes
Donated FTE and Funding in Lieu of Decreased Uncompensated Care
• From Local hospitals
• Local mental health centers
1,000 Marillac Patient Hospital Admissions
0
10
20
30
40
50
60
CARDIOLOGY -Medical
PSYCH/DRUGABUSE - Medical
Grand Total
Jan-April 2003
Jan-April 2004
Psychiatry Inpatient Days January - April 2003 versus 2004
100% Marillac Medical Patients
0
20
40
60
80
100
120
140
160
Patient Days 2003 Patient Days 2004
Average Length of Stay:2003: 2.56 days2004: 2.68 Days
Psychiatry Charges: January - April 2003 versus 2004
100% Marillac Medical Patients
$0
$50,000
$100,000
$150,000
$200,000
$250,000
$300,000
$350,000
2003 2004
Research Team
Larry Mauksch, M.Ed*Stephen Hurd, Ph.D#Randall Reitz, Ph.D#Susie Tucker, Ed.D#Wayne Katon, MD†Joan Russo, Ph.D†
* University of Washington Department of Family Medicine
# Marillac Clinic, Grand Junction, Colorado
† University of Washington Department of Psychiatry and Behavioral Science
Marillac Papers• Mauksch, L. B., Tucker, S. M., Katon, W. J., Russo, J., Cameron, J.,
Walker, E., & Spitzer, R. Mental illness, functional impairment, and patient preferences for collaborative care in an uninsured, primary care population. J Fam Pract 2001, 50(1), 41-47.
• Cameron, J. and Mauksch, L. Collaborative Family Health Care in an Uninsured Primary Care Population: Stages of integration. Families, Systems and Health, 2002, 20(4) 343-363.
• Mauksch, LB. Katon, W., Russo, J., Tucker, S., Walker, E Cameron, J. The
content of a low income, uninsured primary care population: Including the
patient perspective. Journal of the American Board of Family Practice,
2003, 16,:278-289.
• Mauksch, L., Reitz, R., Tucker, S., Hurd, S., Russo, J., Katon,W. Improving
Quality of Care for Mental Illness in an Uninsured, Low Income Primary
Care Population, General Hospital Psychiatry, 2007, 29, 302-309
Remember• Build relationships through experiential team
training on clinical and operational topics
• Have regular huddles and meetings
• Create team ownership of change, challenges,
and successes
• Find out what is important to patients in life, in
problem focus, in treatment, and in relationships
More to Remember
• Figure out what to change first, don’t change
everything at once, be patient but persistent
• Do not let staff turnover cause system decay
• Track Progress: patient, team, system, cost
• Create back-up systems to optimize clinical
success:
– multidisciplinary transdisciplinary
Still more to remember
• Conserve resources and intensify care for patients with greater complexity (stepped care)
• CELEBRATE SUCCESS!!!