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All in the Family
1. All in the Family: The Benefits and Challenges of Collaborative Health Care Models Peter S. Martin, MD, MPHMarilyn Griffin, MD Catherine Krasnik, MD, PhD 62nd Institute on Psychiatric Services October 15, 2010
2. Disclosure Statement Drs. Martin, Griffin, and Krasnik are all APA Public Psychiatry Fellows, sponsored by Bristol Myers-Squibb
3. Workshop Objectives Describe the current system of health care and how this leads to difficulties in integrating primary care with mental health needs. Identify models of integrative health care and discuss the similarities and differences that exist between these models. Distinguish between the integrative models when applied to adult versus pediatric populations. Discuss how the overall health care models between the United States and Canada lend unique benefits and challenges to the integration of health care.
5. Collaborative Care: Where It Is, Where It’s Been, and Where It Can Go Peter S. Martin, MD, MPH Child and Adolescent Psychiatry Fellow University of Rochester
6. Outline Review of current coordination Discussion of collaboration versus integration Review of different collaborative care models Highlight the medical home model and examine how it can be utilized in mental health
8. Why Change the Current System? Heavy burden Mental health and physical health interwoven Large treatment gap for mental disorders Primary care settings could offer enhanced access for mental health services Reduced stigma Cost-effective for treating common disorders (?) Good outcomes when integration occurs (?) Funk, M. and G. Ivbijaro, eds. Integrating Mental Health into Primary Care: A Global Perspective.
9. Why Change the Current System? Poor outcomes Aggravated players Wasted time Poor compensation for work already being done Improve screening to encourage primary prevention
17. Levels of Integration BASIC On-site CLOSE Fully Integrated MINIMAL BASIC at a Distance CLOSE Partly Integrated Collaboration Continuum Doherty, W. The Why’s and Levels of Collaborative Family Health Care.
19. The Four Quadrant Clinical Integration Model Quadrant II ↑ BH ↓ PH Quadrant IV ↑ BH ↑ PH Behavioral Health Risk/Status Quadrant III ↓ BH ↑ PH Quadrant I ↓ BH ↓ PH Physical Health Risk/Status Mauer, B. Behavioral health/primary care integration: The four-quadrant model and evidence-based practices
20. The Four Quadrant Clinical Integration Model Quadrant II ↑ BH ↓ PH Quadrant IV ↑ BH ↑ PH Behavioral Health Risk/Status Quadrant III ↓ BH ↑ PH Quadrant I ↓ BH ↓ PH Physical Health Risk/Status Mauer, B. Behavioral health/primary care integration: The four-quadrant model and evidence-based practices
21. The Four Quadrant Clinical Integration Model Quadrant II ↑ BH ↓ PH Quadrant IV ↑ BH ↑ PH Behavioral Health Risk/Status Quadrant III ↓ BH ↑ PH Quadrant I ↓ BH ↓ PH Physical Health Risk/Status Mauer, B. Behavioral health/primary care integration: The four-quadrant model and evidence-based practices
22. The Four Quadrant Clinical Integration Model Quadrant II ↑ BH ↓ PH Quadrant IV ↑ BH ↑ PH Behavioral Health Risk/Status Quadrant III ↓ BH ↑ PH Quadrant I ↓ BH ↓ PH Physical Health Risk/Status Mauer, B. Behavioral health/primary care integration: The four-quadrant model and evidence-based practices
37. Create a primary care communication approach that assures coordinated service planningMauer, B. Behavioral health/primary care integration: The four-quadrant model and evidence-based practices
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40. Assure case management (housing, community supports)
42. Collaborate at high level with healthcare system teamMauer, B. Behavioral health/primary care integration: The four-quadrant model and evidence-based practices
43. Where does the medical home model fit with different collaborative care approaches?
44. Background of Medical Home Concept 1967: The American Academy of Pediatrics (AAP) introduced the medical home concept Referring to a central location for archiving a child’s medical record 2002: AAP policy statement expanded the medical home concept to include these operational characteristics: Accessible, Continuous, Comprehensive, Family-centered, Coordinated, Compassionate, Culturally effective care 2004: The American Academy of Family Physicians (AAFP) developed own model for improving patient care called the “medical home” 2006: The American College of Physicians (ACP) developed own model for improving patient care called the “advanced medical home” 2007: The ACP, AAFP, AAP, and AOA release the Joint Principles of the Patient-Centered Medical Home National Center for Medical Home Implementation
45. Joint Principles of the Patient-Centered Medical Home Personal physician Physician directed medical practice Whole person orientation Care is coordinated and/or integrated Enhanced access Quality and Safety Payment National Center for Medical Home Implementation
46. NCQA Standards Access and communication Patient tracking and registry functions Care management Patient self-management support Electronic prescribing Test tracking Referral tracking Performance reporting and improvement Advanced electronic communications West Virginia Bureau for Public Health. Medical Home NCQA Standards.
47. Mauer, B. Behavioral health/primary care integration and the person-centered healthcare home.
48. Quadrant I Psychiatric Consultation Mauer, B. Behavioral health/primary care integration and the person-centered healthcare home.
49. Quadrant III Psychiatric Consultation Mauer, B. Behavioral health/primary care integration and the person-centered healthcare home.
50. Quadrant II Outstationed medical nurse practitioner/ physician at behavioral health site Mauer, B. Behavioral health/primary care integration and the person-centered healthcare home.
51. Quadrant IV • Outstationed medical nurse practitioner/ physician at behavioral health site • Nurse care manager at behavioral health site Mauer, B. Behavioral health/primary care integration and the person-centered healthcare home.
52. “Mental Health Home” Not necessarily a new service Can take existing services and coordinate with a core set of principles Enhanced care and coordination of care Integration of primary and preventative services Use of evidence-based practices and continuous quality improvement Adoption of recovery principles Family and community outreach Smith, TE and Sederer, LI. A new kind of homelessness for individuals with serious mental illness? The need for a “mental health home.”`
53. Differences from existing other medical home models Primary coordinator may not be a physician Psychiatry is not typically seen as a primary care discipline Enhanced care Targets those with SPMI Emphasizes a focused, chronic-care disease management model Ideal: Co-location and integration of primary and behavioral health care Smith, TE and Sederer, LI. A new kind of homelessness for individuals with serious mental illness? The need for a “mental health home.”`
54. Potential Pitfalls Who is the coordinator – physician vs. NP/PA vs. another care coordinator Is the PCP the best coordinator in all cases – maybe instead specialist Difficult for small practices to take on extra workload Difficulty with getting families involved (easier to do with children vs. adults) Homer, CJ et al. Medical home 2009: What it is, where we were, and where we are today.
55. Remaining Challenges Financing Policy and regulation Workforce Information sharing Need for greater research relating to the costs, cost offsets and health outcomes of patient-centered healthcare home models for the population with serious mental illnesses. Mauer, B. Behavioral health/primary care integration and the person-centered healthcare home
56. Take Home Points Large continuum of care No one-size-fits-all model Flexibility is required Challenging work Economics cannot be ignored Patient-centered focus should not be lost
57. Pilot Projects of Interest Cherokee Health Systems (Tennessee) Depression Improvement Across Minnesota-Offering a New Direction (DIAMOND) (Minnesota) Intermountain Healthcare (Utah and Idaho) The U.S. Air Force Behavioral Health Optimization Project (Nationwide) Buncombe County Health Center (North Carolina) South Cove Community Health Center (SCCHC) (Boston) PRISM-E (Primary Care Research in Substance Abuse and Mental Health for the Elderly) IMPACT (Improving Mood: Promoting Access to Collaborative Treatment) PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial) RESPECT-D (Reengineering Systems for Primary Care Treatment of Depression)
58. Suggested Resources Collins, C et al. Evolving models of behavioral health integration in primary care. Milbank Memorial Fund. 2010. http://www.milbank.org/reports/10430EvolvingCare/EvolvingCare.pdf Mauer, B. Behavioral health/primary care integration and the person-centered healthcare home. National Council for Community Behavioral Healthcare. 2009. Pautler, K., and M.-A. Gagne. 2005. Annotated Bibliography of Collaborative Mental Health Care. Mississauga, ON: Canadian Collaborative Mental Health Initiative. http://www.ccmhi.ca/en/products/documents/03_AnnotatedBibliography_EN.pdf Smith, TE and Sederer, LI. A new kind of homelessness for individuals with serious mental illness? The need for a “mental health home.” Psychiatric Services. 2009;60:528–533. http://ps.psychiatryonline.org/cgi/reprint/60/4/528
59. Additional ResourcesMedical Home National Center for Medical Home Implementation http://www.medicalhomeinfo.org/ Center for Medical Home Improvement http://www.medicalhomeimprovement.org/ NCQA http://www.ncqa.org/tabid/631/Default.aspx
60. Hopeful Outcome Quadrant II ↑ BH ↓ PH Quadrant IV ↑ BH ↑ PH Quadrant III ↓ BH ↑ PH Quadrant I ↓ BH ↓ PH
61. Children Are Not Small Adults:Collaborative health care from the Child and Adolescent Psychiatry and Pediatric Perspective Marilyn Griffin, MD, PGY 5 Triple Board Program University of Pittsburgh Medical Center Western Psychiatric Institute and Clinic 2009-2011 APA Public Psychiatry Fellow APA IPS October 15, 2010
62. Outline The need for collaborative care in the Pediatric setting The medical home – revisited Child and Family Counseling Center Other models Moving forward
63. Kids have needs too… ≈ 1 in 5 children in US with diagnosable mental health disorder ≈ 80% if mentally ill children are not identified or treated Suicide is the 3rd leading cause death in 10-24 yo Pediatric mental health problems often identified at primary care visits Comorbidity and complex interactions between mental and physical health
64. The children are our future Opportunity to create patient and family centered system in a familiar setting Mental Illness is the 2nd leading cause of disability and premature mortality in the U.S. Burden of untreated mental illness on various systems of care
65. The children are our future, cont. Source: Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities (2009 pg 246). Adapted from Eisenberg and Neighbors (2007).
67. Medical Home – revisited, cont. 1967 AAP introduced the medical home concept 2002-2006 expanded definitions of medical home and creation of other models 2007 AAFP, AAP, ACP, AOA, developed: Joint Principles of the Patient-Centered Medical Home
68. Medical Home – revisited, cont. Unique opportunity to engage in services without stigma Appropriate level of care in familiar environment Benefit for patients and families by improving access to specialty care
70. Child and Family Counseling Center (CFCC) Based on medical home model Unmet behavioral health service need Provide evaluation and treatment: Mood disorders Anxiety disorders Attention-deficit and disruptive behavior disorders Adjustment disorders http://www.chp.edu/CHP/counseling
71. CFCC Partnership Children’s Community Pediatrics Children’s Hospital of Pittsburgh Western Psychiatric Institute and Clinic
72. CFCC: Children’s Community Pediatrics 110 Pediatricians Several mid-level providers 19 practices 28 offices 8 counties http://www.cc-peds.net/main/index.shtm
73. CFCC: Children’s Hospital of Pittsburgh Only children’s hospital serving Western PA Level 1 Pediatric Trauma Center One of 8 pediatric hospitals in US named to: U.S. News & World Report's Honor Roll of America’s “Best Children’s Hospitals” for 2010–2011 http://www.chp.edu/CHP/Home
74. CFCC: Western Psychiatric Institute and Clinic Largest psychiatric facility in Western PA Serves over 25,000 patients and families/yr Full continuum of services including 24 hour psychiatric emergency room Residency training site for Triple Board Program and Family Practice/Psychiatry Program http://www.upmc.com/HospitalsFacilities/Hospitals/wpic/Pages/default.aspx
75. CFCC Partnership Mission Statement “ …a collaborative effort between pediatricians, licensed clinical social workers, psychologists and psychiatrists to provide timely access to high-quality, empirically-supported behavioral health assessments, behavioral interventions , and psychiatric interventions to children and families in an integrated model of care provided within the pediatric primary care office.”
77. CFCC: 2007 Pilot Project BH specialist in 1 CCP office 2 days/week (therapist, child & adolescent psychiatrist) Referral indications and exclusions identified Clinical treatment protocol outlined Training sessions for all staff Centralized registration and billing Electronic Medical Records
96. Family supportReferral to Behavioral Health Therapist for assessment and possible treatment Pediatrician refers to Emergency Dept. or appropriate community agency Managed by the Pediatrician Non-behavioral concerns are not referred to behavioral provider: Custody Issues CYF/child welfare issues Learning/school evals Financial/housing, etc. If no symptoms resolution or specialized care required (bipolar disorder, psychosis, etc.) Referral to child psychiatrist Pediatrician refers to appropriate community agency Therapists/psychologist collaborate with psychiatrist and pediatrician G.Crum/A.Schlesinger 5-13-08
97. CFCC: Beyond the Pilot 2 Child and Adolescent Psychiatrists 2 Triple Board trained Physicians Therapists at 14 different locations Non CCP patients seen at central location (Pine Center, Wexford Office)
98. CFCC: Beyond the Pilot, cont. > 1500 patients seen since Aug 2008 Ave approx 600 visits/month Approx 10% no show rate 80% diagnoses = anxiety, depression, or ADHD Comorbidity Depressive & Anxiety d/o Anxiety d/o & ADHD
99. CFCC: Strategies for Success Buy in by all invested parties Monthly meetings Provide staff with appropriate tools/support Centralized billing
100. Communication is the key Office Managers Nurses Operations Scheduling Staff Front desk Triage Staff Families
101. Other models http://www.aap.org/mentalhealth/mh3co.html St. Cloud, MN: CentraCare Integrative Behavioral HealthCare Initiative Salt Lake City, UT: University Health Care Neurobehavior Healthy Outcomes Medical Excellence (HOME) Program
102. Moving forward: What’s next? Systemic changes Prevention Mental health screen Support for providers New methods of financing Health Care Reform Innovative educational method Health care provider training Workforce incentives
104. Systemic changes: Prevention, cont. Source: Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities (2009, pg 155).
105. “It is easier to build strong children than to repair broken men.” Frederick Douglass
106. Systemic changes: Prevention, cont. Community Transformation Grants: Sec 4201 Authorizes competitive grants for programs promoting health and prevention Community Health Workforce Grants: Sec 5313 Authorizes grants to positive health behaviors and outcomes http://www.thenationalcouncil.org/galleries/policy-file/HC%20Reform%20Bill%20Update-April%207.pdf
107.
108. Systemic changes: Mental Health Screen Component of routine care under 2010 health reform legislation Various free online resources www.teenscreen.org www.pediatricmedhome.org
109. Systemic change: Support for providers AAP Task Force on Mental Health AAP toolkit: http://www.aap.org/pcorss/demos/mht.html AAP IMPACT http://www.aap.org/mentalhealth
110. Financing: Health Reform Medicaid Medical Home Pilot: Sec 2703 authorizes up to $25 million to help states plan and implement projects Medicaid Accountable Care Organization Pilot Program: Sec 2706 Will allow pediatric providers to receive recognition & payment as ACOs http://www.thenationalcouncil.org/galleries/policy-file/HC%20Reform%20Bill%20Update-April%207.pdf
111. Financing: Health Reform, cont. Co-location of Primary and Specialty Care in Community-Based Behavioral Health: Sec 5604 Authorization of $50 million in grants for co-location of coordinated & integrated services http://www.thenationalcouncil.org/galleries/policy-file/HC%20Reform%20Bill%20Update-April%207.pdf
112. Innovative Educational Methods: Healthcare provider training Prevention training standards & programs Medical and graduate medical education curriculum changes Johns Hopkins Pediatric Residency Training Program
113. Innovative Educational Methods: Workforce incentives Training for behavioral health specialists: Sec 5306 HHS secretary to grant awards to improve training programs Loan Repayment for Pediatric Behavioral Health Specialists in Underserved Areas: Sec 5203 Authorizes funds for loan repayment if serve in underserved areas Educating Primary Care Providers About Behavioral Health: Sec 5405 Authorizes funds for Primary Care Extension Program http://www.thenationalcouncil.org/galleries/policy-file/HC%20Reform%20Bill%20Update-April%207.pdf
114. So what does this all mean? There is a huge need to provide comprehensive integrative collaborative care for the pediatric population Health homes facilitate an organized platform to deliver care Finances, communities and workforce are the foundations for health homes
116. INTEGRATING MENTAL HEALTH SERVICES INTO PRIMARY CARE: A Canadian Example Catherine Krasnik MD, PhD APA/BMS Public Psychiatry Fellow Department of Psychiatry and Behavioural Neurosciences McMaster University, Hamilton, ON, CANADA Ontario, Canada
117. Objectives The Canadian context Family Health Teams Why did our program start Integrating mental health services in primary care How better collaboration can assist with challenges facing our health care systems Redesigning systems to optimize benefits
118.
119. 10 Provinces and 3 Territories 9,900,000 sq. kms 33 million people Federal Government Provinces responsible for health care (13 health care delivery systems) Canada Health Act defined principles to guide the entire system (1964) -Universality, Portability, Publicly Administered, Comprehensive, Accessible Almost all health services are publicly funded (10.1% of GDP) Canada
120. What’s included in Canadian Medicare? Covers physician services and hospital-based care Emergency care available to everyone Wait times for specialty appointments and procedures Mental health care Preventive care Physicians paid to do prevention counseling (this varies by province) *drug coverage is not included unless you have third party insurance or are on social welfare *allied health professionals not included (e.g. psychologists, unless part of mental health clinic)
121. Role of Primary Care First point of contact with the health care system Often cradle to grave 81 % of population see their family physician annually Initiates referrals to specialists Comprehensive, integrated around the clock care Co-ordinates information about patients care Provides a variety of specialized services Average practice size – 2,200 7.5 - 10% have no family physician Common elements but also variation between provincial models
122. Home of Problem Based Learning Home of Evidence Based Medicine Melius est Urinam Facere quam Amovere!
123. Family Health Teams (FHTs) 171 FHTs funded in 4 waves across Ontario Various stages of implementation 31 more to be funded in next 12 months Currently involve over 25% of comprehensive care family physicians in Ontario 2-25 physicians (largest 130 – Hamilton FHT) Rostered populations - Funded by capitation Team based care
124. Family Health Teams Family Physician(s) Nurse Nurse Practitioner Social Worker/Mental Health Counsellor Dietitian Pharmacist Health Educator Family health care Emphasize health promotion and illness prevention Emphasize self-management Care co-ordination/system navigation Linked with other community and health services Mental health is a key part of the work of FHTs
125. Recognised the role primary care is already playing, often without support Why did our program start? Challenges in addressing mental health issues in primary care Problems in the relationships with mental health services
126. Poor communication between family medicine and mental health services Difficulty in accessing timely psychiatric consultation Recurrent problems between Mental Health and Primary Care Services Mental health service intake procedures cumbersome and inefficient General lack of support and respect for the FP as a mental health caregiver
127. Redesigning Systems of Care Better management and obtaining better outcomes require changes in the way systems of care are organized, both within and between systems.
128. Redesigning Mental Health Systems of Care Three Steps: Rethinking the role of primary care within the system Looking at how mental health services can complement/support this role Redesigning systems of care to optimize the potential collaboration can offer
129. The potential role of Primary Care Early detection Initiation of treatment Monitoring and follow-up Co-ordination and continuity of care Referral and system navigation Family interventions
130. Redesigning Systems of Care Three Steps: Rethinking the role of primary care within the system Looking at how mental health services can complement/support this role Redesigning systems of care to optimize the potential collaboration can offer
131. Goals of better collaboration Improve access to care and reduce wait times Increase system capacity – use current resources differently / more efficiently Enhance the experience for the person receiving care Improve co-ordination of care
138. Initial Program Goals 1994 1. To increase accessibility to mental health care for primary care patients 2. To expand the range of mental health services delivered in primary care 3. To strengthen linkages between primary care and mental health / community programs. 4. To increase family physicians’ skills and comfort in handling mental health problems. 2010 1. To improve the mental health of the populations being served 2. To enhance the experience of seeking / receiving care 3. To improve system efficiencies
150. To assist the Psychiatrist Family physician prescribes Morning huddle Available to FP / counselor – but not patients - when out of the practice Funding by a sessional fee which also covers non-billable activities and paperwork (letters) Meet as a group 2 monthly
151. Role of Family Physician Remains involved Ongoing care More likely to investigate a problem Better supported in a shared care model Still sees the majority of mental health problems Increases the range of cases they can manage Prescribes
152. Specific skills the family physician can use Motivational Interviewing List of patients with a specific problem Meet to discuss cases Telephone backup Self-Help Manual PHQ – 9 (Patient Health Questionnaire)
153. Use of a Self-Help Manual Dan Bilsker – Simon Fraser University Anti-depressant skills workbook Positive coping with health conditions www.comh.ca/pchc/
162. Satisfaction Family Physician -With the counselor 90% -With the psychiatrist 90% -With the program 92% Psychiatrist 90% Counselor 92% CSQ 91% Average score on V.S.Q. was 4.5 / 5 Each item meets or exceeds AAGH benchmarks Provider Satisfaction Consumer Satisfaction
164. Benefits Primary Care Physician Mental Health System Ready access to MH services Access to underserviced areas Regular communication with Psychiatrist Feel supported; continuum of care More comfortable being seen in family practice; less stigma Shorter wait times Services used more efficiently Referrals triaged therefore more likely appropriate for services being requested Patient can be discharged earlier from inpatient and outpatient care knowing F/U is available Overall increase in system capacity Consumer
166. We had added an innovation to systemsthat weren’t always performing well – now we had to change the way the system functioned to support the innovation.
167. Redesigning Systems of Care Three Steps: Rethinking the role of primary care within the system Looking at how mental health services can complement/support this role Redesigning systems of care to optimize the potential collaboration can offer – changing processes of care
178. We would not be where we are today without the help of those from yesterday
179. AcknowledgementCollaborative Care: Where It Is, Where It’s Been, and Where It Can Go Dennis Bertram, MD, MPH, ScD Linda Pessar, MD Kim Griswold, MD, MPH Patricia Pastore, NP Cynthia Pristach, MD Seung-Kyoo Park, MD YogeshBakhai, MD Michael Scharf, MD All the APA Public Psychiatry Fellows and Leaders
180. AcknowledgementsChildren Are Not Small Adults: Collaborative health care from the Child and Adolescent Psychiatry and Pediatric Perspective Child and Family Counseling Center Abigail Schlesinger, MD Kenneth Thompson, MD Roberto Ortiz-Aguayo, MD Jennifer Dee Gretchen Crum, LCSW
181. AcknowledgementsIntegrating Health Services Into Primary Care: A Canadian Example Dr. Nick Kates Professor, Associate Member, Department of Family Medicine Director of Programs, Hamilton Family Health Teams Provincial Lead, QIIP (Quality Improvement and Innovation Partnership) Dr. Harriet MacMillan Professor, Psychiatry & Behavioural Neurosciences and Pediatrics David R. (Dan) Offord Chair in Child Studies Associate Member, Clinical Epidemiology & Biostatistics APA Fellowship Nancy Delanoche Dr. Jules Ranz
182. Acknowledgements All the fellows in the APA Public Psychiatry Fellowship Nancy Delonche Jules Ranz, MD
183. Bazelon Center for Mental Health Law. Accessed at http://www.bazelon.org/issues/healthreform/issuepapers/MedicalHomes.pdf Blount, A. Integrated Primary Care: Organizing the Evidence. Families, Systems, & Health. 2003;21(2):121–33. Collins, C et al. Evolving models of behavioral health integration in primary care. Milbank Memorial Fund. 2010. Doherty, W. The Why’s and Levels of Collaborative Family Health Care. Family Systems Medicine. 1995;13(3–4):275–81. Funk, M. and G. Ivbijaro, eds. Integrating Mental Health into Primary Care: A Global Perspective. Geneva, Switzerland: World Health Organization and London, UK: World Organization of Family Doctors. 2008. Homer, CJ et al. Medical home 2009: What it is, where we were, and where we are today. Pediatric Annals. 2009;38(9): 483-490,2009 Kirschner, N and Barr, M. Specialists/subspecialists and the patient-centered medical home. Chest. 2010;137(1):200-204. Mauer, B. Behavioral health/primary care integration: The four-quadrant model and evidence-based practices. National Council for Community Behavioral Healthcare. 2006. Mauer, B. Behavioral health/primary care integration and the person-centered healthcare home. National Council for Community Behavioral Healthcare. 2009. Oxman,TE; Dietrich, AJ and Schulberg, HC. The depression care manager and mental health specialist as collaborators within primary care. Am J Geriatr Psychiatry. 2003;11(5):507-16 . Parks, J and Pollack, D. Integrating behavioral health and primary care services: Opportunities and challenges for state mental health authorities. NASMHPD Medical Directors Council. 2005. West Virginia Bureau for Public Health. Medical Home NCQA Standards. Accessed at http://www.wvdiabetes.org/Portals/12/Medical%20Home%20and%20NCQA%20Standards%20(2009-06-24).pdf Images: http://www.spiegel.de/img/0,1020,899997,00.jpg http://gavindo.com/images/Partnership-Program-.jpg http://fellowshipofminds.files.wordpress.com/2010/04/medical-symbol-chrome.jpg http://upload.wikimedia.org/wikipedia/commons/b/b5/Greek_uc_psi.jpg ReferencesCollaborative Care: Where It Is, Where It’s Been, and Where It Can Go
184. ReferencesChildren Are Not Small Adults: Collaborative health care from the Child and Adolescent Psychiatry and Pediatric Perspective AACAP Committee on Health Care Access and Economics, AAP Task Force on Mental Health. Improving Mental Health Services in Primary Care. Pediatrics Volume 123, Number 4: 1248-1251, April 2009 American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Osteopathic Association. Joint Principles of the Patient-Centered Medical Home. Elk Grove Village, IL: American Academy of Pediatrics; 2007. Available at: http://www.medicalhomeinfo.org/Joint%20Statement.pdf. Goinik A, et al. Medical Homes for Children with Autism: A Physician Survey. Pediatrics Volume 123, Number 3: 966-971, March 2009 Horowitz L.M, Ballard ED, Pao M. Suicide screening in schools, primary care and emergency departments. Current Opinion in Pediatrics. 2009; 21 (5): 620-627 Lake, Raymond. How academic psychiatry can better prepare students for their future patients. Part I: the failure to recognize depression and risk for suicide in primary care; problem identification, responsibility, and solutions. Behav Med. 2008 Fall;34(3):95-100. Merikangas KR, He J, Burstein M, Swanson SA, Avenevoli S, Cui L, Benjet C, Georgiades K, Swendsen J. Lifetime Prevalence of Mental Disorders in U.S. Adolescents: Results from the National Comorbidity Survey Replication-adolescent Supplement (NCS-A). JAACAP . 2010; 49 (10): 980-989 O'Connell ME, Boat T, Warner KE. Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities. The National Academies Press 2009. Policy Statement- The Future of Pediatrics: Mental Health Competencies for Pediatric Primary Care. Committee on Psychosocial Aspects of Child and Family Health and Task Force on Mental Health. Pediatrics Volume 124, Number 1:410-417,July 2009 www.teenscreen.org www.thenationalcouncil.org
185. ReferencesIntegrating Health Services Into Primary Care: A Canadian Example Kates, N. Integrating Mental Health Services into Primary Care: The Hamilton FHT Mental Health Program. in Collaborative Medicine Case Studies. New York: 2008 pp. 71-82. Available at: www.springerlink.com/content/r8536r96x7h85780/ Kates, N. et al. Integrating mental health services within primary care: A Canadian Program. General Hospital Psychiatry Volume 19, Issue 5, September 1997, p 324-332. Kates, N. et al. Integrating mental health service into primary care: Lessons learnt. Families, Systems & HealthVolume 19, Issue 1, Spring 2001, p 5-12. Canadian Collaborative Mental Health Initiative (CCMHI), http://www.ccmhi.ca/en/index.html Kates, N. et al. Sharing Care: The Psychiatrist in the family physician’s office. Canadian Journal of Psychiatry Volume 42, November 1997. The Evolution of Collaborative Mental Health care: A Shared Vision for the Future. Prepared by the Collaborative Working Group of the Canadian Psychiatric Association and the College of Family Physicians of Canada on Shared Mental Health Care July 12th, 2010.
186. Questions and Discussion Viewable slideshow: http://www.slideshare.net/collaborativecare/ all-in-the-family Downloadable PDF: http://sites.google.com/site/ collaborativecaremodels Contact Information: Peter Martin: peter_martin@urmc.rochester.edu Marilyn Griffin: griffinm3@upmc.edu Catherine Krasnik: krasnice@mcmaster.ca
Somatic Concerns: Those with SMI have a high rate of somatic co-morbidities. There is a large overlap between morbidity found in psychiatric and physical conditions. They often do not receive ongoing medical care, and the care they do receive is often sporadic and at the late stages of disease. To further this problem, when those with SMI are a part of the mental health system, somatic co-morbidities are often unrecognized. Worse still, the majority of these diseases are preventable somatic problems. In an inpatient setting, it was found that nearly sixty percent had active medical disorders, the most common being hypertension, epilepsy, organic brain syndrome, diabetes, and hepatitis. It is estimated that nearly eighty percent of outpatient visits in a mental health setting have some unexplained somatic complaint as part of the visit.7 Also, the majority of people with mental disorders have at least one somatic medical problem, seen most commonly in one study as poor eyesight (most likely due to diabetes mellitus), dental problems, and hypertension. One study demonstrated that seventy-four percent of those screened had one or more chronic health conditions, with fifty percent treated for two or more conditions. In addition, if feeling sick the majority would go to either an urgent care center or emergency department, with only twenty percent going to a “regular doctor.”20 In the same study, while fifty percent had a regular doctor, only fifty percent of these consisted of primary care physician (the rest consisting of either psychiatrists or they were unsure). Eighty-seven percent of patients had a new diagnosis or treatment when linked with a primary care physician. The high rate of somatic co-morbidities may cause or exacerbate psychiatric symptoms, thereby implicating that they may be involved in the causal pathway.3,26 The problem is complicated in that atypical presentations of common somatic problems are common in this population, with changes in vision being the most predictive of medical illness. It is estimated that those with mental illness have four times the mortality of those without.20 When looking at standardized mortality ratios, it is evident that those patients with psychiatric disorders have an excess mortality from both natural and unnatural causes, and this was especially true for those with substance abuse problems.3
**Informal commentsOutcomes – look at increased risk of death, comorbidities, overall poor quality of life- Individuals with serious physical health problems often have co-morbid mental health problems, and nearly half of those with any mentaldisorder meet the criteria for two or more disorders, with severity strongly linked to co-morbidity (Kessler et al. 2005) [Evolving Care]- Those with SMI die 25 years earlier (2006, eight-state report by Colton and Manderscheid documented that individuals with the most serious mental illnesses will die twenty-five years earlier than the average American) [Evolving Care]- Robinson and Reiter (2007), as many as 70 percent of primary care visits stem from psychosocial issues [Evolving Care]
Canadian Collaborative Mental Health Initiative (CCMHI): “There are almost as many ways of ‘doing’ collaborative mental health care as there are people writing about it”Do we talk about viewpoint of practitioner? Patient? Other?
Traditional collaborative/integration models: really focused on just the main providers, may not really incorporate the pt needs, but at least is a good starting to point to think of where to place those who deliver the services
COORDINATED • Routine screening for behavioral health problems conducted in primary care setting• Referral relationship between primary care and behavioral health settings • Routine exchange of information between both treatment settings to bridge cultural differences • Primary care provider to deliver behavioral health interventions using brief algorithms• Connections made between the patient and resources in the community
CO- LOCATED• Medical services and behavioral health services located in the same facility • Referral process for medical cases to be seen by behavioral specialists• Enhanced informal communication between the primary care provider and the behavioral health provider due to proximity• Consultation between the behavioral health and medical providers to increase the skills of both groups• Increase in the level and quality of behavioral health services offered• Significant reduction of “no-shows” for behavioral health treatmentShared care:1) Washtenaw Community Health Organization (Michigan): The Washtenaw Community Health Organization is a partnership between the county public mental health system and the University of Michigan Health System. The partnership allows for pooling of funds across systems and shared risk. Mental health clinicians from the community mental health center are out-stationed to primary care practices to provide direct treatment. A psychiatrist provides consultation to local public health clinics. The project has added a reverse co-location initiative (see discussion of Practice Model 5) by having a nurse practitioner visit community mental health clinics to provide primary care as well as to coordinate with the patient’s physician if there is one.2) VHA: One model uses a nurse care manager to provide telephone monitoring to individuals with depression and referral to specialty care when needed. The other model uses a software-based assessment to determine three interventions: watchful waiting, treatment by the primary physician, and referral to specialty care.
CO- LOCATED• Medical services and behavioral health services located in the same facility • Referral process for medical cases to be seen by behavioral specialists• Enhanced informal communication between the primary care provider and the behavioral health provider due to proximity• Consultation between the behavioral health and medical providers to increase the skills of both groups• Increase in the level and quality of behavioral health services offered• Significant reduction of “no-shows” for behavioral health treatmentShared care in reverse:1)Health and Education Services (HES) (Massachussets): a nonprofit, fullservice mental health organization in the North Shorearea. HES is focused on improving the physical health care of its Latino population. A Spanish-speaking nurse practitioner, who has expertise in both primary care and psychiatry, regularly visits three clinics. The nurse is available on a walkin basis to see patients with a range of medical issues.2) Horizon Health Services (NY): Horizon Health Services is a provider of comprehensive substance dependence and mental health services in Buffalo. Three of Horizon’s sites have medical units, where patients are offered an appointment if they do not have a primary care physician. The medical staff includes a family physician, registered nurse, nurse practitioner, LPNs, and HIV counselors.
INTEGRATED• Medical services and behavioral health services located either in the same facility or in separate locations• One treatment plan with behavioral and medical elements• Typically, a team working together to deliver care, using a prearranged protocol• Teams composed of a physician and one or more of the following:physician’s assistant, nurse practitioner, nurse, case manager, family advocate, behavioral health therapist • Use of a database to track the care of patients who are screened into behavioral health servicesPrimary care psychiatrist:1) MIPS clinic (NY): Clinic located at Strong Ties in Rochester for those with SPMITypically not much focus on primary care psychiatrist – few providers, and still have multiple difficulties, including boundaries (“we don’t hug in psych”)
Those with low to moderate severity of mental health disorders but a higher level of medical co-morbidity would be best benefit from an integrated approach where mental health is incorporated into a primary care clinic
Those with low to moderate severity of mental health disorders but a higher level of medical co-morbidity would be best benefit from an integrated approach where mental health is incorporated into a primary care clinic
What is typically thought of as “primary care”Remember: primary care may be more useful to reach certain populations -> elderly typically are the ones presenting to PCP, and cultural barriers more likely to be seen by PCP
Those with severe mental illness would benefit most from a primary care clinic located within behavioral health, and within the Four Quadrants model would be found in either Quadrant II or IV
Low BH-low physical health complexity/risk, served in primary care with BH staff on site; very low/low individuals served by the PCP, with the BH staff serving those with slightly elevated health or BH risk. The physician may serve low-need patients; with on-site behavioral health staff serving those with low-to-moderate behavioral health needs- Served in primary care settingEx – Pt with moderate alcohol abuse and fibromyalgiaPCP Better collaboration: create patient registry to track referalsBH –Also: brief treatment services to the patient, referral to community and educational resources, and health risk educationSpecifically: individual or group services, use of cognitive behavioral therapy, psycho-education, brief SA intervention, and limited case managementMust be competent in both MH and SA assessment and service planning EBP:- NATIONAL GUIDELINE CLEARINGHOUSE • Disease/Condition Specific Guidelines HRSA (Health Resources and Services Administration )• Chronic Care Model For Depression • Chronic Care Model For Diabetes, Asthma, Cardiovascular, Other Conditions (screening/prevention) Ex 1: National Institute on Alcohol Abuse and Alcoholism (Nationwide)The National Institute on Alcohol Abuse and Alcoholism’s brief intervention model has been sponsored in seventeen states. SBI (screening and brief intervention) for substance abuse in health care settings includes: (1) use of a screening instrument to identify the problem; (2) brief intervention, including motivational discussion and cognitive-behavioral strategies; and (3) arrangements for follow-up care if needed. The approach may be used by a primary care physician, nurse practitioner, or other trained medical staff. Typically, only a few hours of training are needed to deliver the interventions successfully. Ex 2: Family med residencies require psychosocial componentSo: many FM clinics have psychologists or social workers present to assist Ex 3:
Low BH-high physical health complexity/risk, served in the primary care/medical specialty system with BH staff on site in primary or medical specialty care, coordinating with all medical care providers including disease managers. Served in primary care settingsEx – Pt with moderate depression and uncontrolled DMPCP - provides primary care services, works with medical specialty providers and disease managers (e.g. diabetes, asthma) to manage the physical health issues of the individualUses standard BH screening tools and practice guidelines to serve most individuals in the primary care practice and tracking/registry system focuses referrals of a subset of the population to the BH clinician. BH – provide formal/informal consultation and triageAlso: brief treatment services to the patient, referral to community and educational resources, and health risk educationSpecifically: individual or group services, use of cognitive behavioral therapy, psycho-education, brief SA intervention, and limited case managementMust be competent in both MH and SA assessment and service planning -***More specific to Quad III: May also serve as a health educator regarding lifestyle and chronic health conditions found in the general public (diabetes, asthma) or conditions found in at-risk populations (Hepatitis C, HIV) - Include: patient education, activity planning; prompting; skill assessment; skill building; and, mutual support. - Also serve as a physician extender, supporting efficient use of physician time by problem solving with acute or chronic patients, as well as working with patients on medication compliance issues. Specialty healthcare and disease management programs could also integrate depression screening into a wide array of self management and rehabilitation programs (think depression in cardiovascular or diabetes populations) EBP:- NATIONAL GUIDELINE CLEARINGHOUSE • Disease/Condition Specific Guidelines HRSA (Health Resources and Services Administration )• Chronic Care Model For Depression • Chronic Care Model For Diabetes, Asthma, Cardiovascular, Other Conditions (screening/prevention)
High BH-low physical health complexity/risk, served in a specialty BH system that coordinates with the PCP. -Served in both primary care and specialty mental health settings* When mental health needs stable -> mental health care transitioned to primary careWhere most public sector BH occursIdeally: mental health care typically short term, transition to PCPEx – Pt with bipolar d/o and chronic painPCP – provides primary care services and collaborates with the specialty BH providers to assure coordinated care for individuals BH - provide BH assessmentArrange for or deliver specialty BH services, Assure case management related to housing and other community supportsAssure that the consumer has access to health careCreate a primary care communication approach (e.g., e-mail, v-mail, face to face) that assures coordinated service planning, especially in regard to medication management***Specific standard of practice should be adopted that defines the methods and frequency of communication with PCPs EBP:NATIONAL GUIDELINE CLEARINGHOUSE • Disease/Condition Specific Guidelines SAMHSA • Illness Management And Recovery • Medication Management Approaches In Psychiatry • Assertive Community Treatment • Family Psychoeducation• Supported Employment • Integrated Dual Disorders Treatment HRSA (Health Resources and Services Administration)• Chronic Care Model For Depression • Chronic Care Model For Diabetes, Asthma, Cardiovascular, Other Conditions (screening/prevention)
High BH-high physical health complexity/risk, served in both the specialty BH and primary care/medical specialty systems; in addition to the BH case manager, there may be a disease manager, in which case the two managers work at a high level of coordination with one another and other members of the team. -Served in primary care and specialty mental health settingsEx – Pt with schizophrenia and metabolic syndrome; hep CCharacteristics of pop:• lower medication adherence• higher incidence of co-occurring chronic medical conditions• high incidence of co-occurring alcohol and drug abuse problems• lack of a stable medical home• more complex medical plans-> Therefore: Strongest need for collaborationPCP – works with medical specialty providers and disease managers (e.g. diabetes, asthma) to manage the physical health issues of the individual, while collaborating with the BH system in the planning and delivery of BH clinical and support servicesPsychiatric consultation is a key element in these most complex situations. BH: provide BH assessment, arrange for or deliver specialty BH services, assure case management related to housing and other community supports, and collaborate at a high level with the healthcare system team. - The BH clinician must be competent in both MH and SA assessment and service planning- ***Some settings: BH services may be integrated with specialty provider teams (for example, Kaiser has BH clinicians in OB/GYN working with substance abusing pregnant women). With the extension of disease management programs into Medicaid health plans, there is the likelihood of coordinating with disease managers in addition to healthcare providers. The BH clinician and disease manager should assure they are not duplicating tasks, but working together to support the needs of the consumer. A specific standard of practice should be adopted that defines the methods and frequency of communication Ex:Cherokee Health Systems (Tennessee): Originally a community mental health center that expanded to become a federally qualified health center (FQHC). The program provides integrated behavioral health and primary care at twenty-two sites. In addition to comprehensiveprimary care, specialized services for persons with serious mental illness are available, including case management, day programs, and substance abuse services. Cherokee receives a Medicaid capitated rate for providing both medical and mental health services. Case managers work with adults and children with serious mental illness, as well as patients with chronic physical health problems. Cherokee is an effective model for underserved areas, where there is a lack of providers. As an FQHC, it is able to access special federal financial support. Co-location of services enables Cherokee providers to collaborate informally. Cherokee uses an integrated paper medical record. Treatment teammeetings are held monthly for patients with complex mental and physical health needs, and sometimes primary care and behavioral health staff see patients together. Cherokee also uses the brief interventions that are described in the next section in the primary care behavioral health model.
Personal physician- Each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care Physician directed medical practice- The personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients Whole person orientationThe personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals. Includes care for all stages of life; acute care; chronic care; preventive services; and end of life careCare is coordinated and/or integratedAcross all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (e.g., family, public and private community-based services) Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner Enhanced access- Care is available through systems such as open scheduling, expanded hours and new options for communication between patients, their personal physician, and practice staffQuality and safety Practices advocate for their patients to support the attainment of optimal, patient-centered outcomes that are defined by a care planning process driven by a compassionate, robust partnership between physicians, patients, and the patient’s family Evidence-based medicine and clinical decision-support tools guide decision making Physicians in the practice accept accountability for continuous quality improvement through voluntary engagement in performance measurement and improvement Patients actively participate in decision-making and feedback is sought to ensure patients’ expectations are being met Information technology is utilized appropriately to support optimal patient care, performance measurement, patient education, and enhanced communication Practices go through a voluntary recognition process by an appropriate non-governmental entity to demonstrate that they have the capabilities to provide patient centered services consistent with the medical home model Patients and families participate in quality improvement activities at the practice levelPayment: recognizes the added value provided to patients who have a PC-MH and based on the following framework Reflect the value of physician and non-physician staff patient-centered care management work that falls outside of the face-to-face visit Pay for services associated with coordination of care both within a given practice and between consultants, ancillary providers, and community resources Support adoption and use of health information technology for quality improvement Support provision of enhanced communication access such as secure e-mail and telephone consultation Recognize the value of physician work associated with remote monitoring of clinical data using technology Allow for separate fee-for-service payments for face-to-face visits. Payments for care management services that fall outside of the face-to-face visit, as described above, should not result in a reduction in the payments for face-to-face visits Recognize case mix differences in the patient population being treated within the practice Allow physicians to share in savings from reduced hospitalizations associated with physician-guided care management in the office setting Allow for additional payments for achieving measurable and continuous quality improvements **Medicaid: those with this insurance typically have more instability, more likely to utilize ED services; majority of those on this have multiple chronic conditions with wide psychosocial needs **Funding for IT will help push PCMH
NCQA – National Committee for Quality Assurance I want to emphasize here that in order to truly be a medical home, it is a rigorous process, not simply picking up the idea and hopefully going with it. This is one of the defining features of the medical home model and one of the reasons that not only government agencies but insurers have also jumped on board with the concept – everyone likes “numbers”
The Model: Person Centered Healthcare Home: a primary care team that includes a behavioral health consultant/care manager, psychiatric consultant, screening for behavioral health concerns, and stepped care.The Providers: Psychiatric consultation is structured to support both the primary care provider and the behavioral health consultant/care manager, with a focus on treatment planning for individuals who are not showing improvement.- The behavioral health consultant is connected to the specialty behavioral health system, and able to effectivelysupport stepped care to specialty behavioral health services.- In smaller primary care practices, the behavioral health consultant provides behavioral health services, including interventions focused on assisting individuals with management of their behavioral health and health issues, as well as care management tracking. In larger primary care practices, the behavioral health consultant may be supportedby a paraprofessional who is delegated some of the care management tracking activities.
The Model: Person Centered Healthcare Home: a primary care team that includes a behavioral health consultant/care manager, psychiatric consultant, screening for behavioral health concerns, stepped care, and access to specialty medical/surgical consultation and care management.The Providers: primary care provider collaborates with medical/surgical specialty providers and care managers
The Model: Person Centered Healthcare Home: primary care capacity in a behavioral health setting, including medical nurse practitioner/primary care physician, wellness programming, screening for health status concerns, and stepped care to a full-scope healthcare home. Access to the array of specialty behavioral health services designed to support recovery.The Providers: The primary care physician assures the full-scope healthcare home either through practicing on site or supervision of the nurse practitioner, consultation with behavioral health provider and stepped care.- Standard health screening (e.g., glucose, lipids, blood pressure, weight/BMI) and preventive services will beprovided. Wellness programs (e.g., nutrition, smoking cessation, physical activities) are available as primary as well as secondary preventive interventions, incorporating recovery principles and peer leadership and support.
The Model: Person Centered Healthcare Home: primary care capacity in a behavioral health setting, including medical nurse practitioner/primary care physician, nurse care manager, wellness programming, screening/tracking for health status concerns, and stepped care to a full-scope healthcare home. Access to the array of specialty behavioral health services designed to support recovery and access to specialty medical/surgical consultation and care management.The Providers: primary care physician collaborates with medical/surgical specialty providers and external care managers- Nurse care management is added, along with focused goal setting and self management planning, to the standard health screening/ registry tracking (e.g., glucose, lipids, blood pressure, weight/BMI). Wellness programs (e.g., diabetes groups) are available as secondary and tertiary preventive interventions, incorporating recovery principles and peer leadership and support.
So how can psychiatrists fit in this model? Maybe taking some of the same principles from the PCMH and applying it with models already created (but not necessarily coordinated) in the mental health world.I see this as a great way to get the MH model off the ground in the world of psych, especially if practitioners are in a community that might be slower to change in other ways***Key caveat – my hope (at least) would not to make psychiatry yet again cut off from the rest of the medical world, but figuring out yet another model to help those who need it most. There are differences (whether anyone wants to openly admit to it) for those with SPMI, and as such there might need to be some tweaking of other systems to get people the care they need….and maybe even transition into “traditional” PCMH modelsSo you can see by examining these principles, and comparing them to what has already been discussed in regards to PCMH, that they are fairly similar and ultimately, I feel, have the same overall goal of improving the overall healthcare of our patient populationEnhanced access and coordination of care Priority access to services: new referrals, homeless, criminal justice contact *here’s a difference in particular specific to psych – more flexibility with scheduling Extensive case management: providers are involved with primary care team* Mental health home team takes responsibility for coordinating different services (ex. day treatment, intensive case management)* Also works with inpatient services * Incorporates different objectives and coordinates care and communication to make one unifying treatment plan* Can create critical mass for advocacy and supportIntegration of primary and preventative services- Often those in the public center do not receive the services they need - *have a 20% reduction in life span expectancy- Actively work along with PCP- Focus on wellness and primary careUse of evidence-based practices and continuous quality improvement *While difficult in psychiatry, especially in those with chronic conditions, it is still something to truly strive for Has dynamic continuous quality improvement team Attempt to engage staff and recipients to identify and adopt new practices Few people actually receive evidence-based practicesAdoption of recovery principles Participation and full participation of the recipient in all decision-making Attempts to provide/create choices for the recipient A single clinical care entity can help provide focus and clarityFamily and community outreach- Goes beyond individual treatment plans- Mental health home establishes identity aligned with community’s prevailing cultures Adopts a “customer is always right” attitude recipient and family are equal partners in decision making – *This is not to say that the patient always is right in regards to wanting x or y medication to treat something that is not appropriate; instead, helpful to have the attitude that what the patient wants will more likely actually get done, and to work with that
Psych = not primary care:- Psychiatrist in this model would not serve as the PCP would coordinate and communicate, and help with monitoring basic health indicators (i.e. BP, BMI, smoking status, even bloodwork)
Spectrum of management/co-management: PCP as primary manager, specialist as consultant Specialist as primary manager, PCP less involved PCP as co-manager with specialist****NEED care coordination for this to workSituations when co-management urgently needed Patients care “belongs” to no one Patients with multiple ED visits, preventable admissions, “bounce-backs” Patients who go to PCP for urgent visits, do not receive primary care from specialists Patients who miss multiple specialty appointmentsChallenges:- Coordination of public and private health insurance plans to avoid fragmentation and complexity- Policies that deny payment for more than one “entity” on the same day – even if different specialties Reimbursement – capitated/case rates in certain situations may be ideal, but may discourage providers from taking on difficult casesRisk-based reimbursement?Next steps:- Communicating key concepts to stakeholders Training clinical staff in the mental health home model Piloting initiatives with innovative providers Exploring and testing reimbursement strategies
TimeMoneyIncreased initial cost/per pt at clinic cost, but decreased system cost (less ED and inpt)Some increased administrative costs, but also might be offset by a decrease in other admin costsBiggest prob – too many different payers, no incentive to decrease system costsVisits per day limitsChanging paradigm of how psychiatrists practice (to be effective, do you necessarily always need large chunks of time?)Patient satisfaction?
Cherokee Health Systems (Tennessee): Originally a community mental health center that expanded to become a federally qualified health center (FQHC). The program provides integrated behavioral health and primary care at twenty-two sites. In addition to comprehensive primary care, specialized services for persons with serious mental illness are available, including case management, day programs, and substance abuse services. Cherokee receives a Medicaid capitated rate for providing both medical and mental health services. Case managers work with adults and children with serious mental illness, as well as patients with chronic physical health problems. Cherokee is an effective model for underserved areas, where there is a lack of providers. As an FQHC, it is able to access special federal financial support. Co-location of services enables Cherokee providers to collaborate informally. Cherokee uses an integrated paper medical record. Treatment team meetings are held monthly for patients with complex mental and physical health needs, and sometimes primary care and behavioral health staff see patients together. Cherokee also uses the brief interventions that are described in the next section in the primary care behavioral health model.Depression Improvement Across Minnesota-Offering a New Direction (DIAMOND): This groundbreaking project is a partnership of medical groups, health plans, the Department of Human Services, and employer groups. The Hartford Foundation’s IMPACT model is being used, featuring a care manager who provides ongoing assessment, a patient registry, use of self-management techniques, and the provision of psychiatric consultation. Patient outcomes are far superior to results seen under the usual care given currently to patients with depression in primary care. The project is applying the concept of a case rate payment for depression care. Minnesota health plans are paying a monthly PMPM to participating clinics for a bundle of services—including the care manager and consulting psychiatrist roles—under a single billing code.Intermountain Healthcare (Utah and Idaho): Intermountain Healthcare is a nonprofit system that includes outpatient clinics, hospitals, and health plans. Its Mental Health Integration project began with the RWJF depression initiative and has been expanded to include a focus on evidence-based treatment algorithms. The program serves both children and adults. After a comprehensive assessment, patients are assigned to low care, which is managed by a physician with support from a care manager, or moderate care, which includes the entire team (mental health clinician and psychiatric consultant). High-need patients are referred to specialty care—with tools to facilitate communication and follow-up with the mental health agency.The U.S. Air Force Behavioral Health Optimization Project: This project began by training several behavioral health clinicians in the primary care behavioral health model. Using a train-the-trainer approach, the project has trained dozens of behavioral health providers at Air Force health facilities around the country. The U.S. Navy and Army have now begun a similar training initiative.Buncombe County Health Center: This practice provides 85 percent of the safety-net care for low-income county residents. It is staffed by twelve physicians, physician assistants, and nurse practitioners, with three full-time co-located behavioral health clinicians. Clinicians work side by side with physicians. While a typical physician may see fifteen patients a day, a typical behavioral health clinician will see about ten patients. Behavioral health clinicians work out of medical examination rooms. One “behaviorist” is always on-call and available to immediately triage patients. The physicians and clinicians use the same waiting room and the same medical record. The behavioral health clinician makes specific, evidence based recommendations to the physician. Prompt feedback is given to the physician either verbally or in a chart note. The behavioral health clinician is a member of the primary care team and is viewed more as a primary care provider than as a specialty mental health therapist.South Cove Community Health Center (SCCHC) in Boston: This facility housed both a primary care clinic and behavioral health clinic, yet little interaction occurred between the two. Because of this, they developed a model in which training seminars were used to better instruct primary care providers about the integrated system and how to deal with the special cultural concerns of Chinese Americans. In this system, the primary care nurse functions as the primary “bridge” between the primary care team and the behavioral health clinic. Not only did this help facilitate referrals to the behavioral health clinic, but the intervention continued by providing a psychiatrist on-site to the primary care clinic. Using this intervention, there was an increase in the number of referrals to the behavioral health clinic (sixty percent) and the missed-appointment rate was improved (eighty-eight percent showed up to their appointments versus fifty-three before the intervention began). PRISM-E (Primary Care Research in Substance Abuse and Mental Health for the Elderly), created an integrated clinic where there were no distinct signs to differentiate the primary care provider from the mental health worker. The goals of this program were to decrease the level of stigma that people felt in regards to mental illness and to improve the logistical problems of transportation by allowing patients to go to one place for their physical and mental health needs. Interestingly, Oxman et al. stated that an integrated approach was superior to an enhanced referral model, yet the final results of the published by Krahn et al. suggest that in fact the enhanced referral model was superior to the integrated approach. However, this discrepancy is clarified when looking at the outcome measures; Oxman et al. utilized the number of people who ended up seeing a mental health professional, while Krahn et al. utilized symptom severity.IMPACT (Improving Mood: Promoting Access to Collaborative Treatment).10 Here, patients at a primary care clinic who may need the help of a mental health professional were seen by a case manager. Afterwards, there was a meeting that occurred weekly to discuss both new cases as well as those that needed treatment plan adjustments. In this model, there was a focus on creating a team approach between the primary care provider, the patient, and the specialists. As such, a personalized treatment plan was created for each patient that incorporated all aspects of their health. The case managers played a central role, as they provided active follow-up and monitored patient outcomes. In addition, there was a provision for increased stepped-up care if a patient required a more intensive mental health intervention. Using this approach, the authors found that forty-five percent of the patients involved had a fifty percent or greater reduction in their depressive symptoms, in comparison to nineteen percent in the usual care group.PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial): Here, a care manager (the equivalent of a case manager) was utilized to assist with adherence to antidepressant medication. Of the various trials that have looked at collaborative care, this one focused less on a consult-liaison service, as the primary care physician was chiefly the provider in charge, and more so on the benefits that a care manager can have on improving treatment outcomes. This is an important component of an integrative approach, especially for those with serious mental illness who are more likely to be non-adherent. In this study, it was found that symptom remission occurred earlier and to a greater extent.RESPECT-D (Reengineering Systems for Primary Care Treatment of Depression): The study was even less integrative than that seen in PROSPECT. Here the system was centrally-based, with no on-site management; rather, a phone system was utilized. With this approach, there was a more structured format to the screening of depression in the primary care setting. In addition, care managers had weekly phone-based supervision by a psychiatrist to follow-up with those cases identified in the clinic. A higher level of consultation was provided by the psychiatrist directly to the primary care physician if the situation warranted it. The overall model has been called the Three Component Model or 3CM. In this study, sixty percent were found to have a response or remission due to the intervention versus forty-seven percent for those with usual care
Good Afternoon, my name is Marilyn Griffin and I am a 5th year Triple Board Resident. For those of you who are unaware, Triple Board is a combined training in Adult Psych, Child and Adolescent Psych and General Pediatrics. In this portion of the workshop, I will focus on collaborative care from the child and adolescent psychiatry and general pediatrics perspective.
I will elaborate on some of the themes of Peter’s presentation, discussing the need for collaborative care in the pediatric primary care setting Highlight the Child and Family Counseling Center, which is a collaboration between three systems in the city of Pittsburgh, briefly identify other models and discuss ways in which we can move forward to successfully create other programs which will provide quality comprehensive care to our patients.
The statistics are alarming. Almost one in five children have a diagnosable mental health disorder at any given time. And yes, psychosocial and mental health concerns are often mentioned during primary care appointments, but there are still approx 80% of kids with psychopathology who are not identified or treated.
Pediatricians have long established relationships with children and families and again are often the portals of entry to mental health systems. Therefore they are in unique positions to create a comprehensive health system in a familiar setting. The consequences of untreated mental health disorders have a domino effect. It is known that children and adolescents that are untreated have higher school absence rates, lower school performance, impaired relationships, higher rates of STDs, pregnancy, and substance abuse, limited to no employment opportunities, and poverty in adulthood.
Mental illness, whether untreated or treated, account for considerable costs to multiple systems of care, an estimate of over $200 billion annually. This is another take on the domino effect. Anindividual’s health problems, in turn, may lead to adverse consequences for others. In addition, health problems typically lead to increased costs secondary to reduced productivity and earnings and the increased use of social services such as child welfare and juvenile justice. As clichéish as it may sound, the children are our future and they deserve a place that not only identifies and treats pathology, but promotes physical and mental well being.
My colleague, Peter, has already outlined the chronological development of the medical home concept. Again, the AAP introduced this concept in 1967 and it’s meaning has transformed over the years with the most recent creation of Joint Principles of the Patient-Centered Medical Home
The medical home model provides children and families the opportunity to engage in mental health services within a familiar environment, decreasing the stigma. There are several other benefits of this model, especially improving access to care.
The Child and Family Counseling Center is a program in Pittsburgh based on the medical home model that was developed to provide an unmet need for behavioral health services within local pediatric offices.
There was a need to provide evaluation and treatment for common mood, anxiety, and behavioral disorders
Collaborative partnership was developed using consultative and co-location models of care between three systems, CCP, CHP and WPIC
CCP is a collective group of over 100 pediatricians and several mid level providers who deliver primary care services out of 28 offices which span 8 counties within the greater Pittsburgh area
CHP is a large level 1 trauma center serving Western PA. We have recently been named one of 8 of America’s Best Children’s Hospitals per US News and World Report.
And WPIC, is one of the largest psychiatric facilities in Western PA serving 25 thousand patients and families a year. It is the site of two combined residency programs, TB and FP/Psych
The initialmission of this collaboration was to provide access to quality, evidenced based behavioral health assessments, interventions and treatments in an integrated model within the pediatric primary care setting.
The key successful implementation of such care was bidirectional communication
In 2007 the CFCC pilot project was launched. Again using a consultative and co-location model, BH specialists were placed in the primary care office to provide evaluation, assessment and treatment of patients referred by their pediatrician. Referral guidelines and treatment protocols were established and adhered to by all providers. Training sessions were provided and consisted of topics ranging from the general nuts and bolts of the program to management of common parental BH questions via phone triage. The use of EMR helped to streamline registration, authorizations, billing and communication.
I know this is a busy slide, but I wanted to give you an idea of how the CFCC system works. Similar to the 4 quadrant model which Peter discussed, who and where the care is provided is determined by the severity of symptoms and degree of impairment. Mild symptoms and impairment of various disorders are managed by the pediatrician during routine office visits. Moderate to sever symptoms and impairment warrants a referral to a behavioral health therapist for assessment, diagnosis and appropriate treatment. Behavioral health therapist will then refer to the child psychiatrist if medication management is required. Lastly, the pediatrician will refer pts with immediate safety issues to the psychiatric ED or appropriate community agency.
The pilot was a success and the Child and Family Counseling Center now has 4 child and adolescent psychiatrist providers, 2 of which are triple board trained. Therapists are located at 14 different CCP locations. The center will also see patients who are referred from non Children’s Community Pediatric offices at the central location.
Since Aug of 2008, over 1500 patients have been seen since Aug 2008 with an average of approx 600 behavioral health visits/month and only a 10% no show rate. As with the national trends, 80% of the diagnoses seen are anxiety, depression or ADHD. And comorbidity does exist.
In speaking with the pioneers of the program, the strategies for the programs success included buy in by all parties. Everyone must see the value of integration including providers, staff, and most importantly patients and their families. BH manager attended monthly primary care meetingsand CAP facilitated BH training sessions. There is one expert responsible for completing eligibility requirements and billing for all participating practices. For example, once a patient encounter is closed, charges are dropped into an electronic work que that is processed by the expert.
The underlying theme of those strategies is communication… not included in this slide but important role players are other systems of care such as education, the child welfare system, and juvenile justice to name a few.
The AAP mental health website has a listing of various collobrative programs across the country. For example, in St. Cloud Minnesota, CentraCare Health System in partnership with BlueCross BlueShield of Minnesota and the Medica Health Foundation has launched programs integratingbehavioral health services and primary care in all of the primary care clinics throughout the health system, including pediatrics, family medicine, obstetrics and gynecology, and internal medicine. The initiative calls for mental health screening at all well visits across the age span, incorporating the use of electronic tablets and Web-based electronic platforms for screening.In Salt Lake City, UT The Neurobehavior HOME Program is a University of Utah-based, colocated specialty clinic that provide comprehensive health care to individuals with developmental disabilities. Care is provided by a multidiciplinary team including triple board trained physicians, CAPs, FPs, billing/coding specialist
So what’s next? How do we move forward?? We have to focus on systemic changes to current models of care, develop new methods of financing, and educating service providers
We have all been trained well on how to diagnosis and treat disease, however what would happen if we shift our focus to health promotion and prevention??
Research showing the likelihood that mental disorders in adults first emerge in childhood and adolescence highlights the need for a transition from the common focus on treatment to that of prevention and early interventions. The range of developmental stages in a childs life offers several opportunities for intervention. The authors of Preventing Mental, Emotional and Behavioral Disorders Among Young People: Progress and Possibilities, suggest an array of interventions designed to address differential risk and protective factors prominent in a particular developmental stage or the emergence of symptoms that tend to occur at different ages.
Such interventions can be integrated with routine health care and wellness promotion, as well as in schools, families, and communities. This would require the collaborative efforts of a multidisciplinary team including pediatricians, psychiatrists, educators and community based agencies to build strong children.
The new health reform includes provisions and federal funding to promote health and prevention. Specifically, these are 2 grants which will provide funding to programs that promote individual and community health and prevent the incidence of chronic disease, including programs to prevent or reduce the incidence of mental illness.
System change can be slow.. It took several years and the effort of tons of people for the development, passing and implementation of the New Health Reform. The APA is a major political advocate for mental health issues and recently sponsored an advocacy day where the Public Psychiatry and Minority Fellows had a day on the Hill.
In addition to prevention, providing mental health screenings has it’s place within the medical home. Mental health screening is recommended by the American Academy of Pediatrics and the U.S. Preventive Services Task Force. It is a required component of routine care for new plans under the 2010 health reform legislation. There are several free online resources and tool kits designed for mental health screening in the primary care setting
Efforts should be directed towards supporting established/practicing pediatricians to make systemic changes to current practice behaviors. The AAP Task Force on Mental health has created a clinician toolkit to help pediatricians address mental health concerns in the primary care setting. In addition, IMPACT- Improving mental health in primary care through access, collaboration and training provides a plethora of resources including teleconferences and webinars.
Now, how will we finance such collaborative efforts?? The new health reform offers some important funding resources for those who are interested in implementing collaborative projects. Millions of dollars have been set aside to assist states in planning and implementing Medicaid medical home projects. The Medicaid accountable care organization pilot program establishes a project that will allow qualified pediatric providers to receive recognition and payments under Medicaid as accountable care organizations
In addition, $50 million in grants will be authorized for coordinated and integrated services through the co-location of primary and specialty care in community-based mental and behavioral health settings.
The development of prevention training standards and training programs across disciplines including health, education, and social work are needed.An experiential mental health curriculum is being developed for residents in the Johns Hopkins pediatric residency training program. This program provides a 2-week experience where 3rd year residents work with mental health professionals during a 4-week required community and advocacy rotation . The objectives for the experience fall within the 6 core competencies of residency training.
We can not ignore the workforce shortage. The New health reform allows provisions for the improvement of behavioral health training, and funds for a Pediatric Specialty Loan Repayment Program for individuals who are employed in health professional shortage or medically underserved areas and provide pediatric medical subspecialty; pediatric surgical specialty; or child and adolescent mental and behavioral health services, which include substance abuse prevention and treatment services. Also there will be a program to educate primary care providers about preventive medicine; chronic disease management; mental and behavioral health services
So what does this all mean?? Kids need mental health services in addition to medical care. Health homes creates an organize platform to deliver care. Finances, communities and workforce are foundations for health home. There are various resources and funding opportunities available
ADD A BACKGROUND PICTURE
I’d like to thank my colleagues Peter & Marilyn for doing an excellent job exploring various models of collaborative care and how they might apply in specific settingsWhat I’m going to be talking to you about today is the Family Health Team which is analogous to the US medical home modelEssentially, the FHT involves integrating Psychiatric care into primary practiceFHTs have been operational in Ontario for 16 years (since 1994) and have been a huge component of Ontario’s health care reform over the past several yearsSince our program has been running for so long, we are now in a unique position to analyze data & outcomesSo what I’d like to focus the majority of my presentation on today is how our program works and the kinds of outcomes we’ve been achieving and what we’ve learned along the way in terms of redesigning systems in order to make them more efficient and to optimize care
Orient you geographically to CanadaPoint out Hamilton
I’d like to first take a quick minute to orient you to the CDN HC systemCanada is comprised of 10 provinces; 3 territoriesOver 9, 900 000 sq kmEstimated pop = 33 millionAs you may know, our HC model operates on a single payer system funded by the federal gov’tWho provides monies to provinces in the form of health tax transfersThe provinces are then responsible for determining priorities of their own health care needs and can spend the money in ways that are most relevant to their demographic so long as they abide by the 5 principles of the Canada Health ActWhich espouses:Universality: meaning available to all eligible residents of CanadaPortability: within the country and abroadComprehensiveness in its coverage of careAccessibility: without financial and other barriers That the care is publicly administeredUniversal coverage for medically necessary services provided on basis of need rather than ability to pay
Approximately 69 per cent of health care spending is publicly funded; the remainder consists of private health insurance spending (e.g. ambulance costs, prescription drug, dental, and vision plans) and out-of-pocket spending (e.g. both prescription and nonprescription drugs).Under most provincial and territorial laws, private insurers are restricted from offering coverage that duplicates that of the publicly funded plans, but they can compete in the supplementary coverage market. As well, each province and territory has an arm's-length workers' compensation agency, funded by employers, which provides services to workers who are injured on the job.
I’d like to also talk a little bit about the role of Primary Care in the Canadian Health Care SystemUnique position in that it is the first point of contact for children, adults, geriatric population
As Peter mentioned, there exist many models of collaborative care. The FHT involves bringing a Psychiatrist consultant into the Primary Care PracticePioneered by Dr. Nick Kates who is currently the provincial lead on Health Care Quality Improvement and Director of the Hamilton Family Health Team;1st program opened 16 yrs ago in 1994The FHT model has been so successful in Ontario that we now have over 170 FHTsFunded provincially by MOHLTC
The points I wanted to emphasize here are that the team is truly multidisciplinary, emphasis is on health promotion & illness preventionMental Health counselors are attached permanently to each practice, function to triage patients to FP vs. PSychiatristThe Psychiatric Consultant/Psychiatrist visits every 1-3 weeks depending on practice size and need. Work collaboratively with counselors and FP.
There has been a lot of discussion already on the merits and rationale of using collaborative care models and so I won’t spend a lot of time reiterating theseThe main reasons our program started1.2. People were falling through the cracks; mental health issues were not being detected (72% of people with Psych issues not identified)
Other challenges we encountered were:
Patients are usually seen within 2 weeks of being referred but URGENT cases can be seen immediately.Emphasis is on short-term care with individuals and families, thereby ensuring that the counselor remains accessible and eliminating lengthy waiting times for service.
Talk about HFHT pointsStaff ratiosPilot programs
Activities in each practice are coordinated by a Central Mgmt/Admin TeamThey receive funds in the form of transfer payments form the Ontario Ministry of Health and LTCresponsible for organization and allocation & flow of funds, recruitment and evaluationSets & monitors program standards & targets for ongoing quality improvement with regular feedback to all participantsEvaluation and quality assurance processes create a mechanism for local accountability
Counselor assists with referrals to community programs and mental health services (FPs complained took up too much of their time); Like in the US, represent first point of contactCounselor may also meet with visiting Psychiatrist to discuss cases for additional advice and support for cases they are managing.; Psychiatrist available by phone in event of crisisAll counselors in the program meet together monthly to discuss proposed changes in the program’s functioning or adjustments they might like to see, to learn about local resources or specific clinical issues and to provide each other with mutual support.
A Psychiatrist consultant visits each practice for half a day every 1-3 weeks, depending on the size of the practice and demand3 Major spheres of activity: direct case consultation with a limited degree of follow-up, indirect services (the patient is discussed or reviewed but not seen) and education.In addition to this there are NEW DEMANDS: in that the psychiatrist must be prepared to act as a true generalist; assess individuals of all ages with wide variety of problems/diagnosesBe able to conduct efficient, focused consultation & develop immediate mgmt plan and communicate this plan to the FP and PxNeeds to be familiar with common general medical conditions, non-psychotropic meds commonly prescribed by FPs and the potential effects each of these can have on the presentation & treatment of psychiatric disordersFamiliarity with mental health and community resources
Morning Huddle: Case discussion to optimize care
FP as GATEKEEPERSTILL SEES THE MAJORITY OF MENTAL HEALTH PROBLEMS with consultation
Acute patients to the ER and triaged accordingly
The program has established aComprehensive database which contains demographic, treatment and outcome data on every patient receiving mental health careNot only can individual episodes of care can be described, analyzed and costed, but by using a permanent unique identifier, the program can construct a longitudinal record for each person seen and monitor patterns of care and trends that are in use.
Demand for services has been high: 7094 referrals in total in 2007Patients are usually seen within 2 weeks of being referred but urgent cases can be seen immediately.Emphasis is on short-term care with individuals and families, thereby ensuring that the counselor remains accessible and eliminating lengthy waiting times for service.
Highest percentage of cases seen by counselors: depression followed by anxiety & family problemsAverage amt of hours provided by a counselor for each client per episode of care was 5.5h with 1 session per client involving another family memberSpent 58% of their time seeing patients, 12% charting and 12% in case-related discussions
61% of all referrals to the Psychiatrist were initiated by the FP; 39% by the counselor. (this varies among FHTs depending on counseling time)Most common reasons for referral: advice about meds (85%); clarification/confirmation of a diagnosis (66%); advice regarding therapy/mgmt (36%) or concerns about harm to self/others(9%) and advice about family/marital issues (9%)Average duration of consult was 49 min (range from 20 min to 3h for assessment of a child)20% of people seen had been discharged from a psychiatric service in the previous 6 months46% were experiencing their first episode of a psychiatric illness
96% of all individuals seen were considered to have a DSM-IV diagnosis, suggesting that referrals are being made appropriatelythe most frequent of which were mood and anxiety disorders14% adjustment9% phase of life or relationship problem26% of all patients were seen for at least one follow-up visitIn 77% of cases this follow-up appt was planned in advance to monitor progress or meet with other family membersThe other 23%: because of deterioration in patient’s condition, medication issues or side effects or a supervening crisis.
NOTE: Program started in 1994Perhaps one of the best indicators that our system is working is evidence that there has been a Reduction in referrals of FPs to outpatient clinics (60% decrease) and to inpatient care (10% decrease)
# of individuals referred for a general mental health assessment by each FP has increased 11-fold (from 5 -58 per year) since the inception of the program, while referrals from those FPs to outpatient clinics has decreased by more than 60%
From both a provider and consumer’s point of view, patients reported improvement in overall emotional and physical health as well as with chronic pain.
CONSUMER: improves the experience of seeking and receiving careMENTAL HEALTH SYSTEM: Care is better integrated; wait times reduced; more efficient use of resources leaving more complex cases requiring more specialized care to the outpatient clinics and inpatient unit
As was mentioned earlier, there is no one secret formula that will work for every program.Components of Success in a particular program usually consist of 2 or more of the following
There are many examples of how to improve the programRecruitment of child and geriatric psychiatrists to visit FHTs on a monthly basisEstablishing a case register of patients with a psychotic illness within each FHT; the register enables the family physician, counselor & Psychiatrist to review mgmt plans for these patients on a regular basis. It also allows the practice to “call back” everyone on the list so that they are seen at least annually. == Preventive careThe program is now looking at doing this for other at-risk groups. Eg. Older people living alone.
Overall, the FHT made mental health care more available + accessibleIncreased continuity of careProvided additional support for the family physicianOffered new opportunities for continuing educationLed to a reduced and more efficient use of other mental health services
From a consumer’s point of view, patients reported improvement in overall emotional and physical health
