Integrating Behavioral Health and Primary Care. Overview

Transcription

1 Integrating Behavioral Health and Primary Care Department of Family Medicine & Public Health Sciences Overview 1) Healthcare system & spending 2) Why behavioral health? 3) Patient-Centered Medical Home 4) Integration 5) WSU Training & pilot data 6) Unanswered Qs 1 2

2 Healthcare System 44 Million Americans w/out healthcare Skyrocketing healthcare costs 75% of healthcare costs chronic illness PC in the US is not comprehensive, coordinated, accessible, or continuous Fragmented dual health system 3 Spending in US 2 4

3 2011 Healthcare Spending 19% 33% Primary care 4-7% 5 Top 20 Diagnoses in PC (2010) 1. HTN 2. Hyperlipidemia 3. DM 4. Back pain 5. Anxiety 6. Obesity 7. Allergic rhinitis 8. Reflux esophagitis 9. COPD/Respiratory 10. Hypothyroidism 11. Visual refractive errors 12. Osteoarthritis 13. Fibromyalgia 14. Malaise and fatigue 15. Joint pain 16. Acute laryngopharyngitis 17. Acute maxillary sinusitis 18. Major depressive disorder 19. Acute bronchitis 20. Asthma 3 7

4 Why Behavioral Health? 84% of common physical complaints have no identifiable organic etiology 80% of people with behavioral health (BH) disorders will see a PCP yearly 50% of BH disorders are treated in PC 59% of psychiatric prescriptions are written by PCPs 30-50% of Pts referred by PCPs to BH specialists don t follow through Is anybody out there??? Psychotherapy : the least frequently used intervention for depression in PC 8 Why Behavioral Health? Saves lives: When primary care practices used a care manager (MSW, RN, or ψ) to help treat depression in older adults, Pts were 24% less likely to die compared with TAU (BMJ, 2013). Compliance: 20% Pts with DM2 and CVD suffer from depression. They re less likely to make lifestyle changes and adhere to medication regimens (Arch Gen Psych, 2013). Medical $: Depression increases medical $ by 50-70%. When nurse care managers monitored Pts with depression and DM2 or CVD Pts had lower mean outpatient costs of $594 per person 114 more depression-free days compared with Pts who received usual care (Arch Gen Psych). Including mental health services in primary care practices may even reduce physician burnout. 4 9

5 Healthcare System Affordable Care Act (2010) 1. Better health of the population 2. Better patient care (quality, access, reliability) 3. Reduce costs 10 Patient Centered Medical Home 5 11

6 Evidence for the Effectiveness of PCMH PCMH Pilot (JAMA; ) 32 practices in Penn/29 comparison practices No cost or utilization reductions PCMH Impact on Cost & Quality (PC-PCC; ) Peer-reviewed journals (N=14) State program evaluations (N=7) Industry publication (N=7) 12 New Evidence Peer-reviewed: 6/10 reductions in cost 12/13 reductions in at least 1 utilization measure State reports (non peer-reviewed) 7/7 reductions in cost 6/7 at least one utilization measure Industry (non peer-reviewed) 4/7 reductions in cost 6/7 at least one utilization measure 6 13

7 PCMH Specialist Mental Health PCP and Patient Hospital PT/OT Lab Dietitian 15 Integration Definition: The care that results from a practice team of PC and BH clinicians, working together with Pts and families, using a systematic and costeffective approach to provide patient-centered care for a defined population. This care may address mental health, substance abuse conditions, health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stress-related physical symptoms, ineffective patterns of health care utilization. 7 16

8 Agency for Healthcare Research & Quality (AHRQ) Elements of integrate behavioral health Mental health care Substance abuse care Health behavior change Life stressors and crises Stress-related physical symptoms Ineffective patterns of healthcare utilization Teaching bio-psycho-social model 17 Inter-professional Training -Practicum/Internship- Primary Care Health Psychology UMass PC Postdoc MSU PC Postdoc 8 18

9 WSU Family Medicine IJPM 2013 Clinic huddle Shadowing Pull-ins, warm hand-offs Co-counseling Shared precepting Feedback to PCPs (assessment, intervention) Lectures Video-observation & feedback Home visits Research 19 What Happens? Doctoral students & Family Medicine Residents Family Medicine (2013) Assessment Behavioral Intervention Lifestyle Chronic Dis Management Freq % Freq % Freq % PCP 148/ / / Psych 65/ / /550 5 Both 227/ / / Total 440/ / /

10 Education Extras! Encounters (N = 347) Psychosocial Case Conceptualization Communication Advice Emotional Debriefing Positive Feedback Medication Consultation/ Discussion 175/347 10/347 34/347 50/347 63/347 50% 3% 10% 14% 18% 21 Unanswered Question Is behavioral health integration necessary? Is it cost-effective? Artificial vs. real integration Reimbursement for behavioral health? PC Health Professions Workforce Primary Care Health psychology (APA, ABPP) Social work (NASW: health, alc/tobacco/other) Nursing (NP primary care) 10 22

11 Collaborative Practice Interprofessional Collaborative Practice American Association of Colleges of Nursing American Association of Colleges of Osteopathic Med American Association of Colleges of Pharmacy American Dental Education Association Association of American Medical Colleges Association of Schools of Public Health 23 Collaborative Practice Collaborative practice is the key to safe, high quality, accessible, patient-centered care. Goal: To prepare all health professions students for deliberately working together with the common goal of building a safer and better patient-centered and community/population oriented U.S. healthcare system How care is delivered is as important as what care is delivered 11 24

12 ACGME (2011) Multispecialty resident survey: Formal team training experiences with nonphysicians is significantly related to greater resident satisfaction with learning and training experiences, less depression, anxiety, and sleep problems, and fewer serious medical errors 25 Core Competencies 1) Values/ethics for interprofessional practice Respect the dignity and privacy of Pts while maintaining confidentiality in the delivery of team-based care 2) Roles/responsibilities Explain the roles and responsibilities of other care providers and how the team works together to provide care 3) Interprofessional communication Communicate consistently the importance of teamwork in patient-centered and community-focused care 4) Teams and teamwork Engage other health professionals appropriate to specific care situations in shared patient-centered problem solving 12 26

13 Key Areas Key areas integral to the future development of enhanced primary care and the PCMH: Integrating services both inside and outside primary care practices. Examples include integrating behavioral and oral health into PCMHs and integrating PCMHs into Accountable Care Organizations (ACO) and various community based organizations and services; Providing financial support for enhanced primary care that helps control the total cost of care while maintaining or improving quality for patients; Developing the primary care health professions workforce to embrace all members of the team, including the patient and their family/caregiver; Engaging patients, consumers, and the public particularly in PCMH transformation and quality improvement activity; and Embracing the potential of technology to support this model of care. 27 Example 1: Routine Visit Presenting problems: Just not feeling well Mrs B: age 49, BMI 42, HTN (145/95), DM2 (HA1c=9.2) PCP: Inquired about changes in health over the last 4 months? BH: Any life changes around that same time? Pt: 74 yr-old mother living with her after stroke. BH: PHQ-4=4 (depression/anxiety more than ½ the days); worsened in the last month ( Mother is more demanding and will only use a cane vs. walker ) Brief discussion of ambivalence & self-time / relaxation hand-out PCP: (1) reviewed meds, (2) referral specialist for home healthcare for mother, (3) BH assessment at follow-up 13 28

14 Example 2: ER Follow-up Presenting problems: ER Heart attack Mr A: age 27, single, truck driver PCP: Woke up at 3am with palpitations, feared heart attack, ER BH: Night before? Didn t sleep well the night before; drank & got high with new girl friend, hadn t smoked pot since high school, got a little paranoid PCP: Physical exam normal; no Hx psych or sub abuse; + family Hx BH: (Educ) The combination of sleep deprivation, alcohol/marijuana increased his anxiety, interfered with sleep, and resulted in panic : Education about panic; hand-out; info about BH services PCP: Follow-up 29 Example 3: ADHD? Presenting problems: Male: 22 yr old college senior Needs Adderall for studying PCP: No Hx of ADHD or LD in elementary, middle or HS Pt: Did so much better this semester using it to study BH: GPA? (Pt: 3.4) Sleep hygiene? (Pt: terrible) PCP: Needs a full evaluation before he ll prescribe medication 14 30