“Health Homes” and Behavioral Health/General Medical Care Integration
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“Health Homes” and Behavioral Health/General Medical Care Integration

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“Health Homes” and Behavioral Health/General Medical Care Integration “Health Homes” and Behavioral Health/General Medical Care Integration Presentation Transcript

  • Health Homes andBehavioral Health/General Medical Care Integration On the Banks or in the Mainstream? Harold Alan Pincus, MD Professor and Vice Chair, Department of Psychiatry Co-Director, Irving Institute for Clinical and Translational Research Columbia University Director of Quality and Outcomes Research New York-Presbyterian Hospital Senior Scientist, RAND Corporation HHS Health Homes Webinar February 25, 2011 1
  • The Bottom Line•  Co-morbidity of behavioral disorders and general medical conditions is highly prevalent (especially in Medicaid populations•  This pattern of co-morbidity is especially concentrated among those who have high costs and frequent hospital admissions•  These individuals die at younger ages•  Impacts and solutions go both ways across the GM/BH divide –  Primary Care patients needing Mental Health care, and Mental Health patients needing Primary /Specialty Medical Care•  Evidence-based models for integrating care have been well documented•  These models have not been widely implemented due to structural barriers and financial disincentives•  Health Home option provides flexibility and incentives and opportunity HHS Health Homes Webinar February 25, 2011 2
  • BH/GMC Clinical Examples•  35 year old male with schizophrenia, diabetes, and tobacco dependence –  Can expect up to 25 year shortened life span, increased medical costs•  25 year old HIV+ female IV drug user with PTSD –  Frequent ED visits, non adherence to meds, increased medical costs•  60 year old female with diabetes, CHF and depression –  Frequent (re-) hospitalizations, poor self management and adherence, early candidate for LTC HHS Health Homes Webinar February 25, 2011 3
  • Currently, Poor Quality and Care Coordination for All Populations•  Patients primarily in contact with the general medical sector with co-morbid BH conditions (e.g., depression) –  Not treated or treated as acute problems with little follow-up•  Patients with severe and persistent BH conditions (e.g., schizophrenia) and treated in BH specialty settings –  Poor self-care, medications worsen general medical conditions –  Limited provider capacity and incentives for •  Accessing treatment of co-morbid medical conditions •  Preventive and wellness care•  Medical and BH providers operate in silos HHS Health Homes Webinar February 25, 2011
  • HHS Health Homes Webinar LPHI/CIBHA Conference February3-4, 2011 February 25, 5
  • HHS Health Homes Webinar LPHI/CIBHA Conference February3-4, 2011 February 25, 6
  • HHS Health Homes WebinarLPHI/CIBHA Conference February3-4, 2011 February 25, 2011 7
  • HHS Health Homes Webinar February 25, 2011 8
  • Crossing the Quality Chasm 9
  • Crossing the Quality Chasm Quality problems occur typically not because of failure of goodwill, knowledge, effort or resources devoted to health care, but because of fundamental shortcomings in the ways care is organized The American health care delivery system is in need of fundamental change. The current care systems cannot do the job. Trying harder will not work: Changing systems of care will! LPHI/CIBHA Conference February3-4, 2011 10
  • HHS Health Homes Webinar February 25, 2011 11
  • Overarching Recommendation 1The aims, rules, and strategies for redesignset forth in Crossing the Quality Chasmshould be applied throughout M/SU healthcare on a day-to-day operational basis buttailored to reflect the characteristics thatdistinguish care for these problems andillnesses from general health care. HHS Health Homes Webinar February 25, 2011 12
  • Overarching Recommendation 2Health care for general, mental, andsubstance-use problems and illnesses mustbe delivered with an understanding of theinherent interactions between the mind /brain and the rest of the body. HHS Health Homes Webinar February 25, 2011 13
  • René Descartes HHS Health Homes Webinar February 25, 2011 14
  • Don t Split Mind and Body HHS Health Homes Webinar February 25, 2011 15
  • GM/BH Integration Questions•  Why not?•  Who?•  When?•  Where?•  How?•  For whom?•  Why? HHS Health Homes Webinar February 25, 2011 16
  • Who? Responsibility for Care Primary Care Provider (PCP) Behavioral Health Specialist (BHS) HHS Health Homes Webinar February 25, 2011 17
  • When? Risk Factor Diagnosis/ Short-term ContinuingIdentification/ Assessment Management Care Prevention HHS Health Homes Webinar February 25, 2011 18
  • How? Integrated Team Collaborative Care Consultative Care Referral Independent Autonomous (PCP) Autonomous (MHS)HHS Health Homes Webinar February 25, 2011 19
  • Evidence-Based Chronic (Planned) Care Approaches for Treating Depression Are Effective Community Health System Resources and Policies Health Care Organization Self- Delivery Clinical Decision Information Management System Support Systems Support Design Productive Interactions Patient-Centered CoordinatedInformed, Empowered Prepared, Proactive Patient and Family Timely and Evidence- Practice Team Efficient Based and Safe Improved Outcomes HHS Health Homes Webinar February 25, 2011 20
  • Where? Models of Linkage / IntegrationEmbedded PCP in BHS Co-location of BHS in PCP B P P B Unified Coordination / Collaboration B B P HHS Health Homes Webinar February 25, 2011 21
  • For Whom?•  Two Populations –  General/Primary Care with mild to moderate BH conditions (e.g., anxiety, depression) –  Severe/Persistent Behavioral Health Conditions (e.g., schizophrenia, drug dependence)•  Two Strategies –  Mainstream –  Separate BH Specialty Adaptations HHS Health Homes Webinar February 25, 2011 22
  • Two Overall Strategies Strategy 1: Primary Care Health HomeFor patients primarily in contact with general medical sector (and mild to moderate BH conditions):•  Organize around primary care/general medical setting•  Apply evidence-based clinical and organizational strategies•  Design specific policy tools to hold medical providers accountable for meeting the BH care needs of patients. HHS Health Homes Webinar February 25, 2011
  • Two Overall Strategies Strategy 2: BH Health HomeFor patients with severe and persistent BH conditions and primarily treated in a BH specialty setting:•  Organize health home around BH setting•  Apply evidence-based clinical and organizational strategies•  Develop specific policy tools to assure access to high- quality primary care and non-BH specialty care HHS Health Homes Webinar February 25, 2011
  • Evidence-Based Integration Mechanisms•  Clinical integration of services, or•  Co-location of services•  Formal agreements with external providers•  Shared patient records•  Screening and longitudinal monitoring•  Clinical registry•  Care management•  Evidence-based guideline support/training•  Measurement-based / Stepped care•  Close collaboration with other specialty, substance abuse care and human services providers HHS Health Homes Webinar February 25, 2011 25
  • Policy Strategies•  Medical/ Health Home Models•  Accreditation –  New NCQA criteria expand BH expectations•  Quality Incentives•  Mutual Accountability Across BH and GM Providers –  For Quality and Costs•  Payment Related to Complexity –  Tiers/Risk Adjustment•  Support Improved Communication –  EMRs, Health Information Exchanges (with protections)•  Training and Technical Assistance•  Flexibility HHS Health Homes Webinar February 25, 2011 26
  • BH/GMC Programmatic Examples•  SAMHSA Primary and Behavioral Health Care Integration Program•  Minnesota DIAMOND Project•  Community Care of North Carolina•  IMPACT Model•  PCARE Model•  SAMHSA/HRSA-funded Technical Assistance Center (NCCBH) HHS Health Homes Webinar February 25, 2011