Lessons on the Integration of Medicine and Psychiatry

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1 Lessons on the Integration of Medicine and Psychiatry Edward Post, MD, PhD Associate Professor of Internal Medicine, University of Michigan VA Health Services Research & Development Center of Excellence, Ann Arbor MI Views expressed in this presentation are those of the presenter and do not necessarily reflect positions or policies of the University or VA. Outline Approach to Mental Health [MH] Integration and Medical Homes Successes and Challenges to Date Issues in the Wider Health Care System Common Directions Going Forward Q & A Primary Care-Mental Health Integration [PC-MHI] in VA Two PC-MHI components: Care management Co-located collaborative care Blended programs link these complementary components as appropriate Focus primarily on common mental health conditions: Depressive and anxiety disorders Alcohol misuse and abuse PTSD screening/assessment Health Behavior Coordinators implement health psychology programs along with Health Promotion/Disease Prevention Program Managers 3 1

2 Principles of Integrated Care in Patient-Centered Medical Homes Open or advanced access (temporal and spatial integration) Problem-focused assessment and treatment: tend to what the patient wants tended to On-site clinicians in primary care Stepped care Measurement-based care Care management Referral management when needed What is Co-located Collaborative Care? Co-located Collaborative Care is provided by mental health specialists who work in the Primary Care clinic setting and work collaboratively to support primary care providers. Services provided may include curb-side consultation, focused assessment, joint treatment planning, expertise in psychopharmacology, brief therapy, and complex behavioral health interventions. BHPs are clinicians on the integrated care team who deliver and coordinate patient care directly in the primary care setting. Behavioral Health Provider (BHP) as it may include any licensed professional staff with mental health expertise working within primary care. This includes psychiatrists, licensed social workers, psychologists, and nurses. The primary role of all BHPs is to support the primary care plan that the patient and PCP have developed and to care for mental health disorders such as depression, alcohol misuse, or anxiety. What is Care Management? Care Management provides evidence-based and algorithm driven treatment protocols for the treatment of commonly occurring disorders in primary care, including depression and anxiety. Care Management involves a behavioral health provider (RN, Social Work, Psychologist) providing treatment in collaboration with the Primary Care Provider and most often under the supervision of a prescribing mental health provider. Care management delivers a packageof disease-specific services, not excluding: Evaluation and triage, usually telephone-based Algorithmic, protocol-based treatment support Patient activation, education for self-management Telephone follow-up including on-going assessment and monitoring of adherence to medication, treatment plan, behavioral activation, problem solving 2

3 Primary Care Based Mental Health Assessment and Triage Models Education of primary care providers on best practices Guidelines, CME events, seminars, etc. Support for the primary care provider Collaborative care Technological assists Enhancement of referral mechanisms Co-located care Specialty services Evidence Base for Integrated MH Improved identification Improved identification of depression, psychiatric comorbidities and substance misuse (Oslin et al., 2006) Improved identification of depression (Watts et al., 2007) Improved access Increased rates of treatment (Alexopoulos et al., 2009; Watts et al., 2007; Bartels et al., 2004; Hedrick et al., 2003; Liu et al. 2003; Unützer et al., 2002) Reduced wait times (Pomerantz et al., 2008) Evidence Base for Integrated MH Improved engagement and adherence Improved engagement in mental health treatment (Zanjani et al., 2008) Improved engagement and adherence in treatment for depression and at-risk alcohol use (Bartels et al., 2004) Greater antidepressant adherence (Hunkeler et al., 2006; Katon et al., 1999, 2002) Improved no-show rates (Pomerantz et al., 2008; Zanjani et al., 2008; Guck et al., 2007) Higher quality care Increased probability of receiving guideline-concordant treatment (Watts et al., 2007; Roy-Byrne et al., 2001) Higher patient perceptions of quality of care (Katon et al., 1999) 3

4 Evidence Base for Integrated MH Better clinical and functional outcomes Improved short and long term clinical (remission; symptom reduction) and functional outcomes compared to standard care for depression (Alexopoulos et al., 2009; Gilbody et al., 2006; Hunkeler et al., 2006; Katon et al., 2002; Unützer et al., 2002; Roy-Byrne et al., 2001; Katon et al., 1999) Similar remission rates and symptom reduction for depression compared to enhanced specialty referral (Krahn et al., 2006) Decrease in at-risk alcohol use comparable to enhanced specialty referral (Oslin et al., 2006) More rapid clinical response (Alexopoulos et al., 2009; Hedrick et al., 2003) Higher fidelity to integrated care model resulted in better patient response and remission rates (Oxman et al., 2006) Increased patient satisfaction (Pomerantz et al., 2008; Hunkeler et al., 2006; Chen et al., 2006; Areán et al., 2002; Unützer et al., 2002) Findings from VA Program Evaluation and Studies of PC-MHI Early implementation was associated with increased prevalence of MH diagnoses in PC patients. Zivin K et al., Medical Care. 48(9): Similar rates of specialty MH clinic initiation and diagnoses at sites with versus without PC-MHI services. Pfeiffer PN et al., Psychiatric Services. 62(4): PC-MHI has increasingly served younger patients and those not already receiving VHA MH services. Johnson-Lawrence et al., Psychiatric Services. 63: Findings from VA Program Evaluation and Studies of PC-MHI (cont.) Among PC patients who received a specialty MH encounter, those with a PC-MHI encounter in the prior 3 months were had a 1.37 times greater likelihood of receiving a second specialty MH appointment. Wray et al., Psychol Serv Med Settings. 19(1): Receipt of same-day PC-MHI on the day of a positive depression screen is associated with greater initiation of antidepressant and psychotherapy treatment within 12 weeks. Szymanski et al., J Gen Intern Med. 28: Receipt of same-day PC-MHI on day of first VHA encounter, when that occurred in PC setting and included a MH diagnosis, is associated with greater likelihood of subsequent MH encounter. Bohnert et al., General Hospital Psychiatry. 35:

5 Mental Health Services in the Medical Home the Patient Centered Medical Home will not reach its full potential without adequately addressing patients mental health needs. Doing so, however, will likely shift responsibility for the delivery of much mental health care from the mental health sector into primary care. Croghan TW, Brown JD. Integrating Mental Health Treatment Into the Patient Centered Medical Home. AHRQ Publication No EF. Rockville, MD: Agency for Healthcare Research and Quality. June Contribution to Premature Mortality in the United States Behavioral patterns 40% Genetic predisposition 30% Social circumstances 15% Health care 10% Environmental exposure 5% Schroeder N Engl J Med

6 Improving Depression Care: Quality Improvement Models UPBEAT PROSPECT Study IMPACT Study PRISME Study (Depression, anxiety, or alcohol) TIDES (Telephone) Behavioral Health Laboratory (BHL) White River Model (Co-located care) TEAMcare DIAMOND Initiative 3CM / RESPECT / RESPECT-Mil Defining Collaborative Chronic Care Models Goal: Evidence-based, anticipatory, continuous, collaborative care CCM Elements: Practice redesign Patient self-management support Expert systems (on-site, guidelines) Information systems Community linkages Leadership / organizational commitment Wagner & Von Korff 1996&1997; Coleman 2009 Practice Redesign Scheduling Work Roles Follow-Up CCM Elements Evidence-Based, Planned Care via: Patient Education Self-Mgmt. Beh l Change Collaboration Shared Decision- Making Expert Systems Provider Education Decision Support Specialty Consultation Information Mgmt. Registries Reminders Outcome Tracking Feedback Care Plans Community Linkages Additional Resources Peer-Based Support Key Concepts: Anticipatory, Population-Based, Partnered (after Wagner 1996, Von Korff 1997; Bodenheimer 2002) 6

7 Issues Across the US Health Care System Economics Payment systems Accountable care organizations Team-based Care Multidisciplinary Interdisciplinary Technology and Culture Integration and Serious Mental Illness Integrated Care: Why Then? Why Now? Primary care is stillthe de facto mental health care setting in the United States. PRESENT AND FUTURE Most people referred to mental health either do not show up or do not engage in care. UNLIKELY TO CHANGE Only so much time in the internist or family practitioner s [PCP s] day. CLINICIAN S DAY Comorbidity impairs medical, social, societal outcomes. REALITY OF CHRONIC ILLNESS Integrated Mental Health Care is Just Health Care Identification Screening in primary care Pharmacy antidepressant initiation reports Patient request for treatment Assessment and triage to appropriate level of service Possible scenarios: Uncomplicated depression = PCP prescribes antidepressant, mental health care manager monitors, activates, and educates Diagnostic and/or pharmacologic question = co-located collaborative care provider curbside consultation Complicated depression = specialty mental health care Imminent risk of suicide = emergency department or 911 7

8 CCM at the Next Level: Design Issues and the Unique Value of Psychiatrists Patient cohort(s) upon which to focus Task flows Data systems (for both clinical and QI information) Registries Decision support Patient education (disease, self-mgmt.) Consultation Supervision Collaboration is Essential! Identify and determine the functional roles of all members of your medical home Work together to identify needs and develop processes for coordinating in-person care, telephonic follow-up and data-driven longitudinal care management Leverage data-driven, team-based care to reinvent a dynamic and satisfying workplace for a diverse set of professionals Questions 8

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