Integrated Behavioral Health within the Medical Home

Transcription

1 Integrated Behavioral Health within the Medical Home Measurement-based care, Treatment to target, Accountable care: a statewide t P4P program Jürgen Unützer, MD, MPH, MA

2 Jürgen Unützer, MD, MPH, MA Disclosures Employment: University of Washington Professor & Vice Chair, Dept. of Psychiatry y Chief of Psychiatry, University of Washington Medical Center Director, Division of Integrated Care and Public Health Director, AIMS Center: Advancing Integrated Mental Health Solutions Adjunct Professor, School of Public Health: Health Services Grant funding (current & recent) National Institute t of Health (NIMH, NIDA, AHRQ, NLM) Department of Defense (Henry M. Jackson Foundation) American Federation for Aging Research (AFAR) John A. Hartford Foundation Alaska Mental Health Trust Authority George Foundation American Red Cross (RAND) California HealthCare Foundation Robert Wood Johnson Foundation Hogg Foundation for Mental Health Contracts (current & recent) Community Health Plan of Washington, Public Health of Seattle & King County Washington State Healthcare Authority California Institute of Mental Health Los Angeles County Department of Mental Health, Santa Clara County, Ventura County Healthelink, Independent Health, NAVOS Institute for Clinical Systems Improvement (ICSI) Mathematica / Center for Healthcare Strategies Consultant (current & recent) AARP Services Incorporated (ASI) National Council of Community Behavioral Health Care (NCCBH) RAND Corporation Group Health Research Institute Advisor (current & recent) Carter Center Mental Health Program World Health Organization

3 University of Washington 20 f R h d P ti 20 years of Research and Practice in Integrated Mental Health Care

4 Example: Depression 1/10 see psychiatrist 5/10 receive treatment in primary care ~ 30 Million with an antidepressant Rx but ONLY 20 % improve.

5 Building more effective care models.

6 Health Care Reform: Moving towards coordinated / integrated care. Un-managed Coordinated Care Patient Centered Fee for Service Fee For Service Inpatient focus O/P clinic care Low Reimbursement Poor Access and Quality Little oversight No organized networks Focus on paying claims Little Medical Management Accountable Care Organized care delivery Aligned incentives i Linked by HIT Integrated Provider Networks Focus on cost avoidance and quality performance PC Medical Home Care management Transparent Performance Management Paul McGann, MD. Acting CMO; CMS. 2/25/2011 Integrated Health Patient Care Centered Personalized Health Care Productive and informed interactions between Patient and Provider Cost and Quality Transparency Accessible Health Care Choices Aligned Incentives for wellness Multiple integrated network and community resources Aligned reimbursement/care management outcomes Rapid deployment of best practices Patient t and provider interaction ti Information focus Aligned self care management E-health capable 6

7 IMPACT Team Care Model (Patient t Centered Medical Home for Behavioral Health) Primary Care Practice with Mental Health Care Manager Outcome Measures Treatment Protocols Population Registry Psychiatric Consultation

8 IMPACT Study ,801 depressed adults in primary care randomly assigned to usual care or IMPACT collaborative care and followed for 24 months 18 primary care clinics 8 health care organizations in 5 states Diverse health care systems (FFS, HMO, VA) 450 primary care providers Urban and semi-rural settings Funding John A. Hartford Foundation, California HealthCare Foundation, Robert Wood Johnson Foundation, Hogg Foundation

9 IMPACT doubles effectiveness of care for depression 50 % or greater improvement in depression at 12 months % 70 Usual Care IMPACT Participating Organizations Unützer et al., JAMA 2002; Psych Clin NA 2004

10 IMPACT improves physical function SF-12 Physical Function Component Summary Score (PCS-12) P<0.01 P< P<0.01 P= Usual Care IMPACT Baseline 3 mos 6 mos 12 mos Callahan et al., JAGS 2005; 53:

11 IMPACT reduces health care costs ROI: $ saved d/$1i invested Cost Category 4-year Intervention Usual care costs group cost group cost in in $ in $ $ Difference in $ IMPACT program cost Outpatient mental health costs Savings Pharmacy costs 7,284 6,942 7, Other outpatient costs 14,306 14, , Inpatient medical costs 8,452 7,179 9, Inpatient mental health / substance abuse costs Total health care cost 31,082 29,422 32,785 -$3363 Unützer et al., Am J Managed Care 2008.

12 IMPACT: Summary - Less depression IMPACT more than doubles effectiveness of usual care - Less physical pain - Better functioning - Higher quality of life - Greater patient and provider satisfaction - Lower health care costs The Triple Aim Lower health care costs The Triple Aim I got my life back

13 Patient Centered Medical Home Peikes et al, Am J Manag Care 2012; 18(2): ) 116) 498 studies => 12 evaluations that meet criteria: practice innovation with >= 3/5 key PCMH components and quantitative study of triple aim outcomes. Only 6 evaluations produced d rigorous evidence on 1 or more outcomes Some favorable effects on all 3 triple aim outcomes: quality, cost, patient / provider experience Conclusion: PCMH is a promising innovation but rigorous quantitative evaluations and comprehensive implementation analyses are needed to assess effectiveness. IMPACT demonstrated effects in all 3 outcomes.

14 Taking effective models to scale

15 UW AIMS Center: 5,000 providers trained in > 600 primary care clinics Clinicians Tra ained ~ 600 clinics CMMI Innovation Grrant

16 Washington State Funded by State of Washington and Public Health Seattle & King County (PHSKC) Administered by Community Health Plan of Washington and PHSKC in partnership with the UW AIMS Center Initiated in 2008 in King & Pierce Counties & expanded to over 100 CHCs and 30 CMHCs state-wide in

17 Mental Health Integration Program g g > 25,000 clients served

18 Web-based Registry (CMTS ) Access from anywhere. Population-based. Keeps track of caseloads. Allows research on highly representative populations Structures clinical encounters. Prompts follow-up. Facilitates t consultation. ti

19 Washington State Senate Ways and Means, January 31, 2011

20 MHIP Community Health Centers (6 clinics; over 2,000 clients served) Population Mean baseline PHQ-9 depression score Follow- up (%) Mean number of care coordinator contacts % with psych iatric case-review consultation % with significant clinical improvement Disability Lifeline 16 / % 8 69% 43 % Uninsured 15 / % 8 59% 50 % Older Adults 15 / % 8 55% 43 % Vets & Family 15 / 27 92% 7 54% 53% High risk 15 /27 81% 7 50 % 60% mothers Data from Mental Health Integrated Tracking System (MHITS)

21 Quality Improvement through P4P Quality Improvement: pay-for-performance initiative introduced in % of clinic payments for services are contingent on meeting quality indicators 2 contacts / month Clinical improvement or psychiatric case consultation Medication reconciliation

22 P4P-based quality improvement cuts median time to depression treatment response in half. Estimated Cumulative Probablility Weeks Unutzer et al, AJPH, Before P4P After P4P

23 1.00 blility Kaplan-Meier Survival Curve by Enrolled After 2009 Time to 50% PHQ improvement Estimate ed Cumulat tivel Proba Log-rank test for equality of survivor functions, p< Weeks Before 2009, n=61 After 2009, n=592 Among Mom Population (African American, Asian, Latino & White) with baseline PHQ9>=10 (n=653)

24 Principles of Effective Integrated Behavioral Health Care Patient Centered Team Care / Collaborative Care Colocation is not Collaboration. Team members have to learn new skills. Population-Based Care Patients tracked in a registry: no one falls through the cracks. Measurement-Based Treatment to Target Treatments are actively changed until the clinical goals are achieved. Evidence-Based Care Treatments used are evidence-based. Accountable Care Providers are accountable and reimbursed for quality of care and clinical outcomes, not just the volume of care provided.

25 Thank you. Jurgen Unutzer, MD, MPH, MA James D. Ralston