CREATING COMPREHENSIVE PRIMARY CARE: THE ROLE OF BEHAVIORAL HEALTH

Benjamin F. Miller

What do you want your mental health system to do?

Green, L. A., Fryer, G. E., Jr., Yawn, B. P., Lanier, D., & Dovey, S. M. (2001). The ecology of medical care revisited. N Engl J Med, 344(26), 2021-2025.

Mental health and primary care are inseparable; any

attempts to separate the two leads to inferior care

- IOM, 1996

deGruy, F. (1996). Mental health care in the primary care setting. In M. S. Donaldson, K. D. Yordy, K. N. Lohr & N. A. Vanselow (Eds.), Primary Care: America's Health in a New Era. Washington, D.C.: Institute of Medicine.

An Afternoon in Primary Care

Patient Presenting Concern

12 yo male abdominal pain (new)

40 yo male depression, diabetes, hypertension (f/u)

50 yo female fibromyalgia, insomnia (new)

44 yo female chronic pain, suicide attempt (f/u)

50 yo male recent heart attack, substance abuse (f/u)

59 yo female hypertension, diabetes, coronary artery disease, depression (new)

54 yo male panic attacks, morbid obesity (f/u)

46 yo female grief from death of child (new)

The problemClinical delivery

Payment /financing

Community expectation

Training/education

Fragmentation

Our Rationale

Decrease cost

Improve outcomes

Enhance patient

experience

MEETING TRIPLE AIM???

QUALITY

QUALITY

SEPARATE CLINICAL SYSTEMS

• Delayed/Limited Access

• Separate Records

• Minimal Coordination

• Training Silos

SEPARATE OPERATIONS

• Different administrative systems

• Different regulations and requirements

• Different processes and procedures

• Health Information Technology Barriers

EFFICIENCYCOST

COSTSEPARATE FINANCIAL SYSTEMS

• Carve Outs

• Fee for Service model

• Incentivizes for fragmented care

• Regulatory barriers h/t Dr. Khatri

The solution

Definition The care that results from a practice team of primary care andbehavioral health clinicians, working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population. This care may address mental health, substance abuse conditions, health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stress-related physical symptoms, ineffective patterns of health care utilization.

Value of Integration:

Physical/Behavioral Integration is good health policy and good for health.

Peek, C. J., National Integration Academy Council. (2013). Lexicon for Behavioral Health and Primary Care Integration: Concepts and Definitions Developed by Expert Consensus. In Agency for Healthcare Research and Quality (Ed.), AHRQ Publication No.13-IP001-EF.

A Tale of Two Approaches

Component of Care Traditional Integrated

Access Referral Point of Primary Care

Scope of Service Mental Health Diagnoses Overall Health Function

Scheduling Separate Shared

Collaboration of Care Individual Provider Team Based

Health Record Separate Shared

Administrative Operations Separate Shared

Payment Separate Global

Communication Minimal Frequent & Timely

Focus of Care Provider-Centric Patient-Centric

Approach to Care Case by Case Population-Based

Efficiency of Delivery Structure

Fragmented &Inconsistent Coordinated and Aligned

h/t Dr. Khatri

Head-to-Head Comparison

• Five year, federally funded study

• University of Pittsburgh

• 321 children

– 160 received treatment at PCP’s office

– 161 received treatment at mental health provider

• Outcome:

– PCP: 99.4% initiated care and 76.6% completed

– MH: 54.2% initiated care and 11.6% complete

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Overview –Path Toward Integration

First steps towards building the teamThe details

A Guidebook of Professional Practices for Behavioral Health and Primary Care Integration: Observations from Exemplar SitesSponsored by the Agency for Healthcare Research and Quality (AHRQ), the Maine Health Access Foundation (MeHAF), and CalMHSA (Tides Center)

http://integrationacademy.ahrq.gov/

Methods• Literature review

• Start with end in mind

• Identify exemplars with exemplars (leaders)

• Visit, watch, listen, and learn

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StructureOrganization-level social practices and behaviors; and

Interpersonal- and individual-level social practices and behaviors.

Organization-level social practices and behaviors

Advocating for a Mission and Vision Focused onPopulation-Based Care

“It’s all about mission. I mean, I think that that’s the driving force here. You know, people believe in our mission of outreach to populations that don’t have other opportunities for care, basically. And that is the driving force. And I tell visitors sometimes, you know, it’s really more about that than it is about integration.I mean, integration is the best way to do that. I think with a mission central organization, staff comes here and they identify with the mission. And many people come because of that. I don’t even like anybody to say they work for me…if they come here and they have a similar mission then we’re in agreement.“

Health System Emerges as a Learning Organization

“These are concrete examples of how we make decisions. For instance, clinical staff in the back complain all the time about front desk people. They screw up my schedule. My life sucks because they screw up my schedule all the time. If I had them sitting right beside me, then I could control them and make things work how I wanted. So I said, okay, let’s try it. So we took a front desk person, put them back with the clinical team, and all the phone traffic for that team goes straight to the team, and they managed the schedule. It worked pretty well.”

Identification • How do you identify

and recognize individuals with behavioral health needs that might not currently be addressed?

Identification cont.

• In your practice is there someone responsible for screening/identifying BH?– Examples include:

• Front desk administers a screener

• Patient self identifies with symptoms and a screener is administered

• Providers use screener to help assess possible underlying BH condition

– Once a screener has been administered and it is positive, what next?

• Who is responsible for following up with the patient?

• Who stores the data from the assessment tool (and where)?

• How is the screening tool uses to monitor treatment?

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Patients who need Integrated behavioral health

Mental Health and Substance Abuse conditions commonly presenting in primary caree.g. depression, anxiety, PTSD, or other depending on population

Medical conditions with strong MH or SA contribution, even if ptdoesn’t see self as having MH or SA probleme.g., diabetes, CV, asthma or other depending on population

Straightforward situations: Typical protocols apply—usual care and decision-making with usual team arrangements

Complex situations: Interferences with usual care and decision-making that require unusual attention, non-standard care processes or team arrangements

“Zones”

“Buckets”

Defining functions for both “buckets” and both “zones”:1. Teams defined at the level of the patient “bucket” and “zone”2. Shared care plans and targets that integrate behavioral health3. Clinical systems to support Integrated treatment to target

What are the range of behavioral health services offered?

IV.

Multimorbid

Mental and

Physical

Health

Problems

V. Severe

Mental Health

I. Psychosocial

barriers to care

II. Medical

health problems

requiring

behavioral or

psychological

intervention

III. Mental

Health and

Substance

Use

Problems

There is no one one-size-fits all approach – need to identify what will work best in your practiceWorkflow trumps technology

Designing workflowsWhere• Where are important events happening?• Examples: clinic, patient’s home, partner site, internet/webWhat or How• What is being done to help integrate care? • How much time is being spent on this activity?• Examples: ask questions, look at data, talk with someone, provide instructions, make a decision,

connect to a resourceWhen• When is the action performed or in what sequence?• Examples: before, during or after a visit, three months from now, once a year. Who• Who is participating, receiving, or doing something?• Examples: PCP, BH provider, staff, collaborator, patient, computer/Electronic Health Records

ChoicesDefining populations and paying for pieces

The “two pots” of money: Financing

http://sustainingintegratedcare.net/

Key Concepts

1. Know the population

2. Create a budget

3. Set targets

4. Invest in value

5. Monitor performance and report feedback

6. Own the results

Global Budget – Conventional Network

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Emergency3.7%

Inpatient22.6%

Outpatien18.3%

Pharmacy17.5%

Primary Care4.6%

Specialists20.8%

Ancillary12.5%

Global Budget – Integrated Practices

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Emergency3.4%

Inpatient20.9%

Outpatien16.9%

Pharmacy18.4%Behavioral

0.5%

Primary Care9.1%

Specialists19.3%

Ancillary11.5%

Isn’t the Second Pie Bigger? No.

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Total Cost PMPM

Advanced Practices $479.30

Behavioral Health $3.55

Total $482.85

Network Average $505.83

Risk Normalized Difference -4.54%

Financing summary (just do it)

• Comprehensive primary care is a “high leverage” investment

• Integrated BH is just another (important) aspect of comprehensive primary care

• Small part of the total health care budget

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MEETING TRIPLE AIM: INTEGRATION

INTEGRATED PRIMARY CARE TEAM

• Access, Communication, Collaboration at Point of Care

• Shared Space, Workflow, Documentation, Support Staff

• Collaborative treatment planning

• Anchored in Patient Engagement

INTEGRATED POPULATION BASED CARE

• Integrated Operations• Global Payment for Integrated

Services

• Integrated Health Record• Clinical Informatics to address

population health needs

• Flexible Healthcare delivery to appropriately distribute resources

• Integrated Health Record for quality improvement and assurance

• Clinical informatics at population level

Resources

• One stop: http://integrationacademy.ahrq.gov/• More: http://www.integration.samhsa.gov/• Case study: http://www.advancingcaretogether.org/• Webinars:

http://www.youtube.com/CUDFMPolicyChannel• State example: http://coloradosim.org/• National organization: http://www.cfha.net/• More: http://www.pcpcc.org/behavioral-health• Email: Benjamin.miller@ucdenver.edu

Benjamin.miller@ucdenver.eduwww.farleyhealthpolicycenter.org