mpca integrating healthcare presentation
DESCRIPTION
TRANSCRIPT
Jeff CapobiancoJune 22, 2009
Overview of Presentation1. How do we define Integrated Health
Care?
2. Why now?
3. What does a successful model look like?
4. What are some basic elements of Integrated Health Care?
“Integrated Health Care”
One of latest “buzz words” in health care
There can be confusion about the concept:How do you define Integrated Health Care?What does a successful model look like?
Most agree it’s a desirable goal
Many not be sure how to get there
Defining Integrated Health CareIntegrated Health Care = health care
services combining the best of conventional & complementary health care. Mosby's Dictionary of Complementary & Alternative Medicine. (2005)
Integrated Health Care = basic model for interdisciplinary health care that includes many health care providers, with the specific professions represented on any team varying according to the needs of patients served. Amer. Psychological Asso's Presidential Task Force on Integrative Health Care for an Aging Population (2008).
Defining Integrated Health Care
“An ideal system is integrated; for (people) entering a confusing array of services, there is no wrong door. All entry points lead to coordinated care.”
Michigan Mental Health Task Force October, 2004
President's New Freedom Commission on Mental Health (2000)
Why now? “Research demonstrates that mental health is key to
overall physical health. Therefore, improving services for individuals with mental illness requires close attention to how mental health care and general medical care interact. While mental health and physical health are clearly connected, a chasm exists between the mental health and general health care systems in financing and practice”.
Prevalence of Psychiatric Disorders in Low-income Primary Care Patients
35% of low-income patients with a psychiatric diagnosis saw their PCP in the past 3 months
90% of patients preferred integrated care
Based on findings, authors argue for system change
Source: Mauksch LB, et. Al. Mental Illness, Functional Impairment, and Patient Preferences for CollaborativeCare in an Uninsured, Primary Care Population. The Journal of Family Practice, 50(1):41-47, 2001.
At Least One Psychiatric Dx 51% 28%
Mood Disorder 33% 16%
Anxiety Disorder 36% 11%
Alcohol Abuse 17% 7%
Eating Disorder 10% 7%
Low-Income PatientsDisorder
General PC Population*
Morbidity and Mortality RatesPeople with serious mental illness are dying nearly three
decades earlier (on average) than general populationSuicide and injury account for about 30-40% of excess
mortality; 60% of premature deaths in persons with schizophrenia due to “natural causes”
High prevalence of obesity, diabetes and cardiovascular disease
Newer medications for bipolar disorder and schizophrenia can exacerbate metabolic risksBH Providers less likely to screen and monitor regularly
J Parks, D Svendsen, P Singer, ME Foti National Association of State Mental Health www.nasmhpd.org (October 2006)
Preventable Causes of Morbidity & Mortality Impact of medications
Lack of access to healthcare
Higher rates of modifiable risk factors: Smoking Alcohol consumption Poor nutrition / obesity Lack of exercise “Unsafe” sexual behavior IV drug use Residence in group care facilities and homeless shelters
Vulnerability due to higher rates of: Homelessness Victimization / trauma Unemployment Poverty Incarceration Social isolation
American Association of State and Territorial Health Officials (2005)
Why now?Nearly 44 million Americans (26% of the
population) experience a mental health problem annually
Only 5% of those suffering from a mental health problem receive treatment from a mental health professional
Mental Health Weekly 1997 and Mountain View Consulting Group, Inc.
Why now?70-80% of all psychotropic medications are
prescribed within primary care settings
About ½ the time, mental health problems go undetected in primary care settings
Even when diagnosed, these problems tend to be under-treatedMH outcomes in primary care patients only
slightly better than spontaneous recovery
Summarizing: Why now?People are Untreated/Under-treated
Over-utilize medical services:Visit physician twice as often as those receiving
appropriate careSeek treatment in emergency rooms when in crisisPeople with persistent depression have annual
adjusted medical costs 70% higher than those without depression
Summarizing: Why now?Reduces the stigma of mental health by normalizing
treatment to a primary care setting
For those individuals who do not meet SPMI criteria, primary care can competently provide mental health care coordination/care
Integration of the care provides improved access to mental health and primary health with a single door entry
Provides the public mental health system a relationship with the community of primary health and allows for sound “exit strategies”
Potential for improved health care options by bringing together a fragmented system of care
Care Integra Behavioral Healthcare Solutions
What does IH Care it look like?“Reunification in practice of mind and body”
Health care model in which physical health and mental health clinicians partner to manage the treatment of mental health disorders in the person’s medical home/primary center of care.
Includes a single treatment plan focused on what the person needs
Moves away from a disease-focused system to a person-centered system
Approaches to Health IntegrationPlace primary care within the public mental health
system
Place mental health services within the primary care setting
Place health promotion and disease management programs within the mental health system
Place health promotion and disease management programming in the primary care setting
Coordinated Community Care ProgramsPartnerships between several community
partners in a common goal to address wellness
Targets prevention, early intervention, and targeted disease intervention
Primary mission of host site may not be health care- however wellness focus expands mission
Integration Template
Function
Minimal
Collaboration
Basic Collaboration from a Distance
Basic Collaboration On-
Site
Close Collaboration/
Partly Integrated
Fully Integrated Doherty, McDaniel & Baird (1995)
-Separate systems -Separate facilities -Communication is rare -Little appreciation of each other’s culture “Nobody knows my name” Who are you?
-Separate systems -Separate facilities -Periodic focused communication; most written -View each other as outside resources -Little understanding of each others’ culture or sharing of influence “I help your consumers”
-Separate systems -Same facilities -Regular commun., occasionally face-to-face -Some appreciation of each others role and general sense of large picture -Mental Health usually has more influence “I am your consultant’
-Some shared systems -Same facilities -Face-to-Face consultation; coordinated treatment plans -Basic appreciation of each others role and cultures -Collaborative routines difficult; time &operation barriers -Influence sharing “We are a team in the care of consumers”
-Shared systems and facilities in seamless bio-psychosocial web -Consumers & providers have same expectations of system(s) -In-depth appreciation of roles and culture -Collaborative routines are regular and smooth -Conscious influence sharing based on situation and expertise “Together we teach others how to be a team in care of consumers and design a care system
Continuum of Integration
MH/Primary Care Integration Options
Function
Minimal
Collaboration
Basic Collaboration
from a Distance
Basic Collaboration On-
Site
Close Collaboration/
Partly Integrated
Fully Integrated/Merged THE CONSUMER and STAFF PERSPECTIVE/EXPERIENCE
Access Two front doors; consumers go to separate sites and organizations for services
Two front doors; cross system conversations on individual cases with signed releases of information
Separate reception, but accessible at same site; easier collaboration at time of service
Same reception; some joint service provided with two providers with some overlap
One reception area where appointments are scheduled; usually one health record, one visit to address all needs; integrated provider model
Services Separate and distinct services and treatment plans; two physicians prescribing
Separate and distinct services with occasional sharing of treatment plans for Q4 consumers
Two physicians prescribing with consultation; two treatment plans but routine sharing on individual plans, probably in all quadrants;
Q1 and Q3 one physician prescribing, with consultation; Q2 & 4 two physicians prescribing some treatment plan integration, but not consistently with all consumers
One treatment plan with all consumers, one site for all services; ongoing consultation and involvement in services; one physician prescribing for Q1, 2, 3, and some 4; two physicians for some Q4: one set of lab work
Funding Separate systems and funding sources, no sharing of resources
Separate funding systems; both may contribute to one project
Separate funding, but sharing of some on-site expenses
Separate funding with shared on-site expenses, shared staffing costs and infrastructure
Integrated funding, with resources shared across needs; maximization of billing and support staff; potential new flexibility
Governance Separate systems with little of no collaboration; consumer is left to navigate the chasm
Two governing Boards; line staff work together on individual cases
Two governing Boards with Executive Director collaboration on services for groups of consumers, probably Q4
Two governing Boards that meet together periodically to discuss mutual issues
One Board with equal representation from each partner
EBP Individual EBP’s implemented in each system;
Two providers, some sharing of information but responsibility for care cited in one clinic or the other
Some sharing of EBP’s around high utilizers (Q4) ; some sharing of knowledge across disciplines
Sharing of EBP’s across systems; joint monitoring of health conditions for more quadrants
EBP’s like PHQ9; IDDT, diabetes management; cardiac care provider across populations in all quadrants
Data Separate systems, often paper based, little if any sharing of data
Separate data sets, some discussion with each other of what data shares
Separate data sets; some collaboration on individual cases
Separate data sets, some collaboration around some individual cases; maybe some aggregate data sharing on population groups
Fully integrated, (electronic) health record with information available to all practitioners on need to know basis; data collection from one source
Basic Elements of Integration
Financial Structural
Clinical
Behavioral Health/Primary Care Integration
Financial Structural
Clinical
Behavioral Health/Primary Care Integration
Financial Structural
Clinical
Behavioral Health/Primary Care Integration
FinancingPublic sector financing is a major barrier
to achieving clinical integration in most settings
Financial or structural integration does not assure clinical integration Improving the health status of those we
serve requires all of us to come to the table and work within existing financing structures to find solutions rather than use financing as a way to delay discussions
FinancingThree fundamentals to successfully implementing
financing strategies are:
1.Think of the healthcare money in a community as a collaborative local resource
2.Generate the will to make it work within existing funding mechanisms
3.Be willing to advocate strongly with your state officials for the implementation of currently approved codes for services provided in integrated settings
(National Council Magazine, Winter 2009)
Clinical- Training & TrustMost primary care physicians receive little training in
psychiatry
Most psychiatric specialty training does not provide much training in primary care issues
Few have worked in a collaborative, integrated practice arrangement
Primary Care and Beh Health Clinicians can teach each other skills and in so doing create a more seamless system of care
Clinical-Health Education ActivitiesIn a recovery-oriented mental health system, physical
health care is as central to an individual's service plan as housing, job training, or education Bazelon Center Report (2004)
Implementing strategies and programming in order to address chronic conditions
Providing consumers with the resources and tools to better manage, treat or prevent complications with chronic health conditions
Programs address healthy lifestyles, healthy eating, physical activity and smoking cessation
ClinicalIdentify Clinical practice guidelines, care
protocols, chronic care models & disease management approaches that exist specifically for complex multi-morbidities common among individuals with SMI
Remember clinical integration requires financial and structural supports in order to be successful
Structural
Start by finding partners who share mission of serving safety net needs
Get champions, directors & boards speaking
Develop a strategic plan based on a “rolling start”
Develop contracts or MOU’s
Develop shared job descriptions and joint hiring
StructuralInvestigate where health information technology and data
exchange capabilities exist between providers
Target improving access, continuity, and coordination of medical care by focusing on the creation of a medical home where a complete health care profile is served in a seamless system of care
Culture Matters…Primary Care Docs
Language = patients10-15 minute blocksDeal one-on-one w/other
physicians Find it difficult to deal with
interdisciplinary team Medical records short,
concise summaries of the diagnosis, treatment and outcome
PsychiatristsLanguage = clients or
consumers45-60 minute sessions
Time with consumers considered sacrosanct
Behavioral health records are long and complex Contain goals and objectives Variety of provided services;
may be re-evaluated over time
Contain consumer input
Exciting Things to Expect!Financial Barriers
Not reimbursed for collaborative work Revenue silos Billing requirements; record-keeping regulations
Firewalls in communication systems
Legal landmines
Stigma and discrimination associated with mental health problems
Lack of resources Human (providers; staff) Funding Time/Space Interest Proper tools
Language and Cultural Differences
“Opportunity is missed by most people because it is dressed in overalls and looks like work”- Thomas Edison
Benefits of IntegrationImproved detection of physical and behavioral
health disordersSignificant increase in patients receiving
recommended care and positive clinical outcomeHigher levels of patient adherence to treatmentBetter clinical outcomes than by treatment in
either sector aloneImproved patient and provider satisfaction
Never Underestimate the Power of a Shared Vision
Children & Teen Resources Early Detection & Intervention for the Prevention of
Psychosis Program:
www.Preventmentalillnessmi.org
http://changemymind.com/
The Early Psychosis Initiative:
Early Psychosis: A Physician’s Guide (2000)
www.mheccu.ubc.ca/projects/EPI
