Sea Mar Community Health Centers Presents

9th Annual Latino Health Forum

Proven Strategies to Advance Integrated

Care

in the Latino Community

Anna Ratzliff, MD, PhDAssistant Professor

Associate Director for Education, Division of Integrated Care & Public Health

Department of Psychiatry & Behavioral Sciences

University of Washington

Disclosures

• Consulting Psychiatrist Contract, Community Health Plan of

Washington

• Supported from contracts and grants to the AIMS Center at the

University of Washington

Daniel

Mental health disorders are

common – who gets treatment?

The other 9 patients.

No Treatment Primary Care Provider

Mental Health Provider

Wang et al 2005

Disparities in Depression Care

for Minority Populations

• Worse access to mental health

treatment1

• Less likely to be identified2

• Less likely to receive antidepressant

medications 3

• Have worse outcomes 4

1- Miranda et al. Am J Psychiatry. 2008 Sep;165(9):1102-8.

2- Borowsky et al J Gen Intern Med. 2000 Jun;15(6):381-8.

3- Miranda J, Cooper L. J Gen Intern Med 2004; 19: 120-6.

4- Van Voorhees et al Med Care Res Rev. 2007 Oct;64(5 Suppl):157S-94S.

Why not just refer?

½ do not follow through

2 visit mean

Grembowski, Martin et al. 2002

Simon, Ding et al. 2012

Why not just refer?

Thomas KC et al, 2009

1 in 5: unmet need for non-prescribers

96%: unmet need for prescribers

Is there a better way?

Yes - Collaborative Care!

http://aims.uw.edu/daniels-story-introduction-collaborative-care

Principle 1:

Patient Centered Team Care

PCP

Patient BH Care

Manager

Psychiatric

Consultant

Core

Program

New Roles

Principle 2:

Population Based Treatment

Principle 3: Measurement Based Treatment To Target

Principle 4: Evidence-Based Treatment

STAR-D Summary

Level 1: Citalopram

~30% in remission

Level 2: Switch or Augmentation

~50% in remission

Level 3: Switch or Augmentation

~60% in remission

Level 4: Stop meds and start new

~70% in remission

Rush, 2007

Principle 5: Accountable Care

Pay-for-performance cuts median time to

depression treatment response in half. 0.

000.

250.

500.

751.

00

Est

imat

ed C

umu

lativ

e P

rob

ablil

ity

0 8 16 24 32 40 48 56 64 72 80 88 96 104 112 120 128 136

Weeks

Before P4P After P4P

Unützer et al. 2012.

Collaborative Care:

The Research Evidence

• Now over 80 Randomized Controlled Trials (RCTs)• Meta analysis of collaborative care (CC) for depression in

primary care (US and Europe)

Consistently more effective than usual care

• Since 2006, several additional RCTs in new populations and for other common mental disorders• Including anxiety disorders, PTSD

Archer, J. et al., 2012

Doubles Effectiveness

of Care for Depression

%

Participating Organizations

50 % or greater improvement in depression at 12 months

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

0

10

20

30

40

50

60

70

1 2 3 4 5 6 7 8

Usual Care IMPACT

43%

54%

42%

19%23%

14%

0%

10%

20%

30%

40%

50%

60%

White Black Latino

IMPACT Care

Care as Usual

IMPACT Care BenefitsDisadvantaged Populations

Arean et al. Medical Care, 2005

50 % or greater improvement in depression at 12 months

IMPACT: Summary

1) Improved Outcomes:• Less depression

• Less physical pain

• Better functioning

• Higher quality of life

2) Greater patient and

provider satisfaction

3) More cost-effective

“I got my life back”

THE TRIPLE

AIM

MHIP: > 30,000 clients served

across Washington State

•Funded by State of Washington and Public Health Seattle & King County (PHSKC)

• Administered by Community Health Plan of Washington and PHSKC in partnership

with the UW AIMS Center

2008

Pilot initiated in King &

Pierce Counties

2009

Expanded state-wide to

over 100 CHCs and 30

CMHCs

MHIP High-Risk Mothers Program

• Low income women who are pregnant or parenting

• Community health clinics in King County

• Identified by primary care provider with mental

health care need

• Enrolled in Collaborative Care

MHIP High-Risk Mothers Program

Outcomes

0

10

20

30

40

50

60

70

All Latina White Black Asian

% of Population with Depression Improvement

Huang et al. Family Practice 2012 20:394-400.

What could you do?

Daniel’s Mom

“I believe it it’s made all the difference for him.”

Menu of Inspiration Options

Patient Centered Team

Population Based Care

Measurement-Based Treatment to Target

Evidence-Based Treatment

Accountable Care

•Use patient

centered goals.

•Communication

with other

providers.

•Track patient

outcomes.

•Set a practice

improvement

goal.

•Participate in

continuing ed.

•Form a learning

collaborative.

• Use screeners

regularly.

•Track patient

goals regularly.

•Use a registry.

•Lead efforts for

implementation.

Acknowledgments:

Daniel and his family

Annie McGuire

Angel Mathis

Rebecca Sladek

Jürgen UnützerAIMS Center Staff

www.aims.uw.edu