Bi-Directional Physical and Behavioral Health Integration:

Improving Care for Patients

Jurgen Unutzer, MD Jeff Hummel, MD

Healthier Washington Practice Transformation Support Hub

• An investment of Healthier Washington managed by the Washington State Department of Health

• Helps practices successfully move to whole-person, patient-centered care

The Healthier Washington Practice Transformation Support Hub

• Three separate contracts, funded by DOH

• Qualis Health provides Practice Coaches and Regional Connectors programs

• Web Resource Portal offered through partnership with UW Department of Family Medicine Primary Care Innovation Lab

The Hub: A Four-year, State Innovation Model (SIM) Testing Grant

Help Providers to:

• Integrate physical and behavioral health

• Move from volume-based to value-based care

• Improve population health through clinical and community linkages

Hub Goals

Triple Aim

• Connect practices to the best fit resources and TA

• Personalized practice assessments, education, and tools

• Support for bi-directional physical and behavioral health integration

• Finding and coordinating community-based linkages

The Hub: What Do You Need to Support Practice Transformation Efforts?

• Webinars and group

learnings on practice

transformation and best

practices

• Links to a Web Resource

Portal with references, tools,

and up-to-date information

• Help understanding models

and available options

Education, Tools and Resources

Integrated Behavioral Health Care: Moving Towards Whole Person Care

Jürgen Unützer, MD, MPH, MA Chair, Department of Psychiatry & Behavioral Sciences Director, AIMS Center (Advancing Integrated Mental Health Solutions) University of Washington

Healthier Washington Practice Transformation Support Hub January 10, 2017

Mental Illness and Substance Abuse

• Nearly 25 % of all health related disability – More than diabetes, heart disease, or cancer

• For employers: – Absenteeism, presenteeism, high costs

• For governments: – Homelessness, involvement with the criminal justice

system; high health care cost • One suicide every 13 minutes

– In WA State alone: 2 – 3 suicides / day – More than homicides or motor vehicle accidents

• No family goes untouched

Morbidity and Mortality Associated with Severe Mental Illness (SMI)

• Suicide and injury account for about 30-40% of

excess mortality • 60% of premature deaths in persons with

schizophrenia are due to preventable (and costly) medical conditions with 20+ years of life lost

URL:http://www.cdc.gov/pcd/issues/2006/apr/05_0180.htm

Behavioral Health Care in WA State

CMHC ~140,000

Primary Care ~300,000

No Formal Treatment ~ 550,000

Acute Care Psychiatric Hospitals

~800

State Hospitals ~1,000

Population ~ 7 Million

Adults w/ MH Dx

~ 1 Million

THE STATE OF MENTAL HEALTH IN AMERICA

Source: Parity or Disparity: The State of Mental Health in America (2015), Mental Health America

Behavioral Health Workforce Shortage – Psychologists (PhD, PsyD)

– Psychiatrists (MD, DO) – Psychiatric Nurses / Nurse Practitioners (RN, ARNP) – Social Workers (MSW, LCSW) – Counselors (LFMT, LPC, MHC, CADAC, CACC)

• But – More than half of WA counties don’t have a single practicing

psychiatrist or psychologist • Doctoral level providers are concentrated in a few urban areas • Most practicing psychiatrists are within 10 years of retirement age

– Most counties have shortages of prescribing providers – Challenges with recruitment and retention of all types of behavioral

health providers

• Bottom line: – We have a major workforce shortage now and we won’t keep up

with growing demand due to population growth.

Quality of Care

• ~ 30 million people receive a prescription for a psychotropic medication each year (most in primary care) but only 1 in 4 improve.

• Patients with serious mental illness die 10 – 20 years earlier, in large part due to poor medical care.

“Of course you feel great. These things are loaded with antidepressants.”

Mental Health and Medical Disorders are tightly linked • Katon Slide

e.g., Depression & Diabetes

Whole Person Care: Patient Centered

Social

Services

Housing Vocational

Rehab

Alcohol & Substance

Abuse Treatment

Mental Health Care

Medical Care

Silos or “Cylinders of Excellence?” “don’t you guys talk to each other?”

Task Sharing and “Integrated Care”

Hospital

Community Mental Health

Care

Collaborative Care

Behavioral Health Consultant

Primary Care Provider

Community-Based Services & Supports

Not All Integration Efforts are Effective

Approaches that don’t work: • Screening without adequate treatment • Referral to specialty care without close coordination

and follow-up • Co-located behavioral health specialists without

systematic tracking of outcomes or evidence-based treatments

Patients ‘fall through the cracks’ or stay on ineffective treatment for too long.

Integrated care: models vs principles • No one approach fits all

– Arguing about the best integration model is a bit like arguing about the best religion.

• Evidence-based models have to be adapted to local settings in order to be successful.

• There are important principles that need to be followed in order to reach the Triple Aim: Value = Reach * Effectiveness / Cost

Principles for Evidence-Based Integration in Behavioral Health and Primary Care

Population-Based A defined group of clients is tracked in a registry so that no one “falls through the cracks.”

Measurement-Based Treatment to Target Measurable treatment goals clearly defined and tracked for every patient. Treatments are actively changed until clinical goals are achieved.

Team-Based and Person-Centered Primary care and behavioral health providers collaborate effectively, using shared care plans.

Collaborative Care Team Approach

PCP

Patient BH Care Manager

Psychiatric Consultant

Rest of Primary Care Team

Core Program

Additional Clinic Resources

New Roles

Research: Collaborative Care Doubles Effectiveness of Care for Depression

Perc

enta

ge (%

) Im

prov

ed

Participating Organizations

50 % or greater improvement in depression at 12 months

Unützer et al., JAMA 2002; Psych Clinics North America 2004

Wall Street Journal, Sept 2013

Return on investment for collaborative depression care: $ 6.50 for each $ 1.00 spent

Unutzer et al, Am J Managed Care, 2008.

> 80 Randomized Clinical Trials: Better care experience

- Access to care - Client & provider satisfaction

Better health outcomes - Less depression - Less physical pain - Better functioning - Better quality of life - Lower mortality

Lower health care costs

“The triple aim of health care reform.”

Not All Collaborative Care Teams Look Alike Providence SW team includes pharmacists in review

for diabetes med management

Patient

Care Manager

Primary Care Provider

Consulting Psychiatrist

Pharmacist

Legend

Frequent

Interaction

Less Frequent

Interaction

Case Review Participants

New Roles

Telemedicine-based Integrated Care: What does the evidence tell us? Practice-Based IC (CC) • Practice-based care

includes both in-person and telephone-based interventions

• Over 80 randomized, controlled trials

• 2 meta-analyses

Telemedicine-Based IC (CC) • May include limited in-person

interactions, but mostly through phone or other virtual interventions

• 8 published trials with positive results

• 4 of the trials in rural Arkansas CHCs or VA clinics in rural areas

• 4 of the trials used exclusively off-site care managers and psychiatrists

Missouri CMHC Healthcare Homes • Patient Population:

– Adults with Severe Mental Illness

• Staffing Model for Integration: – Primary Care Consultants – Primary Care RN Care Managers

• Annual + Metabolic Screening • Diabetes Education and Treatment • Pay for Performance

– Half of Quality Performance Measures are Medical – Half of Medication Adherence Measures are Medical

Translating Research into Practice

“It is one thing to say with the prophet Amos, ‘Let justice roll down like mighty waters,’ and quite another to work out the irrigation system.”

-- William Sloane Coffin, Social activist and clergyman

HEDIS Depression Metrics Already Driving Value Based Purchasing

Depression Screening & Follow-up Based on NQF# 0418

Depression Remission or Response Measured by PHQ9 or PHQA Remission: PHQ9 score of less than 5 Response: 50% improvement over

first elevated PHQ9 within 5 – 7 months of first elevated

PHQ9

How Did the NCQA arrive at an expectation of remission or response to

depression treatment by 5 to 7 months?

Influenced by two recent studies: MHIP 2009-2010 evaluation P4P drives treatment to target and improves

clinical outcomes

Mayo Clinic System large retrospective study

Active Treatment to Target Drives Early Improvement In recent retrospective study (2008 – 2013) of over 7,000 patients:

– Time to depression remission was 86 days for patients in Mayo Clinic collaborative care

– Time to remission in usual care was 614 days

Time to Remission for Depression with Collaborative Care Management in Primary Care http://www.ncbi.nlm.nih.gov/pubmed/26769872

J AM Board Fam Med 2016 Jan-Feb

Effective integration requires practice change.

UW RESOURCES

The University of Washington offers many educational and consultation resources that are available to Washington State providers

AIMS Center staff and faculty have trained over 6,000 providers in more than 1,000 clinics in evidence-based integration strategies, including collaborative care

UW Integrated Care Psychiatry Training Program (ICTP) Will Complement Support Hub

Current IC training for:

– 107 practicing psychiatrists

– 70 Psychiatry residents (Seattle & Spokane)

New IC Psychiatry fellowship program:

– 5 fellows

Next steps Currently reaches 16 counties:

– expand reach to all counties

– Train, place, and support consulting psychiatrists

Include nurse practitioners and other prescribing providers

Future Common core curriculum for behavioral health providers:

– EB Treatments – Team-based care – BH care

management – Technology

Train & support trainers across state

UW Psychiatry & Behavioral Sciences

UW Psychiatry & Addictions Case Conference (UW PACC) Series Telehealth resource support for providers who care for patients with behavioral health conditions

New attendees always welcome! Thursdays 12:00-1:30pm PST Email uwpacc@uw.edu to register Every PACC session includes a 20-minute educational presentation by UW psychiatrists followed by in-depth case consultations for community providers

35

Summary • Mental illness & substance use:

– Major drivers of disability & cost • Fewer than half of those in need have access to effective

care. • Current care is often not effective:

– More of the same may not get us where we need to go • Effective integration of behavioral health care and primary

care: – Better access to care – Better health outcomes – Lower costs

The Triple Aim of Healthcare Reform

Bi-directional Integration Strategies

Primary Care Settings New Team Roles:

BH Care Managers On-site BH Specialists Psychiatric Consultants

Measurement-Based Screening & Follow-up (e.g., PHQ9, GAD-7)

Screening & brief intervention for substance use disorders (SBIT)

Measurement-Based Treatment to Target

Behavioral Health Settings New Team Roles:

Primary Care Consultants Primary Care RN Care Managers

Metabolic Screening Routine Preventive Care Cardiovascular and Diabetes

Care (BP, A1C) Measurement-Based

Treatment to Target

Principles for Evidence-Based Integration in Behavioral Health and Primary Care

Population-Based A defined group of clients is tracked in a registry so that no one “falls through the cracks.”

Measurement-Based Treatment to Target Measurable treatment goals clearly defined and tracked for every patient. Treatments are actively changed until clinical goals are achieved.

Team-Based and Person-Centered Primary care and behavioral health providers collaborate effectively, using shared care plans.

unutzer@uw.edu http://aims.uw.edu

Thank you

Bi-Directional Physical and Behavioral Health Integration: Improving Care for Patients

Jeff Hummel, MD, MPH

January 10, 2017

Integrated Behavioral Health: What does it mean on a day-to

day-basis?

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Objectives

• From the primary care clinician’s perspective what does integrated behavioral health look like?

• How does it meet the needs of the primary care team and my patients?

• If integration is bi-directional what does primary care need to be prepared to do in return?

• If this isn’t a “one-size-fits-all” program, what options are there for how this might work?

© Qualis Health, 2016

42

Primary Care and Behavioral Health • Behavioral health issues are common and

primary care handles a lot of them really well • Enthusiasm & skills of clinicians vary • There is tremendous variation in severity in most

behavioral health issues • Patients with Behavioral Health issues:

– Frequently require a high degree of skill/experience – Generally take more time for emotional support – Unstable social support systems

• Net effect: a tendency to avoid if possible © Qualis Health, 2016

43

When the problem is too big, integrated care means

• Being able to say, “I can help you,” without committing to a 45-minute conversation

• Having a clear efficient pathway for quickly getting the patient connected to a skilled behavioral health professional team

• Reducing barriers to clinicians eliciting, identifying, or defining a behavioral health issue during a primary care visit

© Qualis Health, 2016

44

When a problem is not too big integrated care means

• Having evidence-based structure and tools for common behavioral health conditions

• On-going conversation with experts on best practices for common problems and the boundaries with complex problem

• Real-time access to a consultant when one reaches a limit, or the situation changes © Qualis Health, 2016

45

What Does Primary Care do in Return?

• Provide consultative services to BH clinicians on common medical issues – Accept phone calls for clinical guidance – Accept referrals from BH Agency – Develop a structured relationship for

communication with referring BH clinicians • Participate in bi-directional teaching and

case sharing

© Qualis Health, 2016

46

Options for What it Might Look Like

• Referral agreement & standardized process • Designated BH clinician to provide

consultation services to PC clinicians • Designated PC clinician to provide

consultation services to BH clinicians • PC team member present in BH agency • BH team member present in PC Clinic • Participate in monthly case conferences

© Qualis Health, 2016

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Summary • Primary care is less stressful and more enjoyable

when behavioral health is a formal or informal member of the team

• Patient experience is better care when primary care and behavioral health work together

• The opportunity for applying population health strategies for behavioral health issues, e.g. depression, is enhanced with integrated care

• Over all costs go down with behavioral health integration because self-management of chronic illness is easier when behavioral health is well managed

© Qualis Health, 2016

48

Learn More

Resources available at: http://www.safetynetmedicalhome.org/change-

concepts/organized-evidence-based-care/behavioral-health

Jeff Hummel, MD, MPH

e-mail: jeffh@qualishealth.org

© Qualis Health, 2016

• Let us know how we can help you:

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The Hub: Offering a Menu of Services to Support Practice Transformation Efforts

Questions and Discussion

For More Information Hub Help Desk: (206) 288-2540 or (800) 949-7536 ext. 2540 or by email HubHelpDesk@qualishealth.org.

Healthier Washington Practice Transformation Support Hub Web sites: http://bit.ly/2e0PpmF

www.QualisHealth.org/hub

Coming in early 2017: Transformation training links and tools on the Hub Resource Portal website

The project described was supported by Funding Opportunity Number CMS-1G1-14-001 from the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.