Integrated Care: Brian DeSantis

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Dr. Brian DeSantis, Director of Behavioral Services at Peak Vista and Project Leader of the Heart and Soul of Change Project, discusses the ins and outs of integrating behavioral care into primary care.

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Integrated Care: Brian DeSantis

  1. 1. heartandsoulofchange.com 5/29/2014 1 Brian DeSantis, Psy. D. ABPP Director, Behavioral Health Peak Vista Community Health Centers Primary Care and Mental Health: A Marriage Made in Heaven or....?  (The Challenge of Integrated Care) Despite A Changing U.S. Health Care System • Primary care will continue to be: • The foundation of the U.S. health  care system (Croghan & Brown, 2010) • The most likely first “port of call”  for patients seeking treatment for  any health problem (McDaniel et al., 2003, p.65) 2
  2. 2. heartandsoulofchange.com 5/29/2014 2 Primary Care: The “de‐Facto” MH Care Delivery System • Most common pathway for presentation of medical  illnesses, psychiatric disorders, and emotional distress  (Goldman, Rye, & Sirovatka, 2000; Petterson et al., 2008; Wang et al., 2006) • Upwards of 70% of primary care visits are related to  mental or behavioral health needs (Hunter et al., 2009) 3 • PCPs prescribe the majority of psychotropic  medications, particularly antidepressants,  anxiolytics, & stimulants (Smith, 2012; Faghi et al., 2010; Mark et al,  2009) Integrated Primary Care • Merging medical and BH care continues to evolve • Ongoing legislative reforms in health care • Patient‐centered medical home (PCMH) • Essential elements of PCMH: • Whole person orientation • Coordinated, interdisciplinary teams • Patient‐centered care • Enhanced access • Emphasis on quality & outcomes (Kaslow et al., 2007; Levant & Heldring, 2007; Bechtel & Test, 2010; Beachum et al., 2012; Baird et al., 2014) 4 “This is the greatest error of our day in the treatment of the human body, that physicians separate the soul from the body” ‐Hippocrates
  3. 3. heartandsoulofchange.com 5/29/2014 3 Barriers to Integrated Primary Care • Different missions & practice cultures • Limitations of the biomedical model for  both partners • Segregated (“carve out”) payment for BH  services 5 • An intuitive marriage for advancing health  care, but not without its challenges Different Missions & Cultures • Specialty Mental Health: • Servicing “clients” with MH/SA  conditions • “Carved out” of health care • Traditional psychotherapy provided in  50‐90 min. sessions of variable  duration  • Different confidentiality rules • Annual penetration rates 3‐7% • Bottom Line: Small case loads, slower  paced provision of MH problems • Primary Health Care: • Population‐based care providing  prevention, acute, and chronic care to  “patients” • PCPs seeing 3‐4 patients per hour  • Providers often don’t have the time,  interest, or training to stay on top of  MH treatments • Annual penetration rates 70‐80% • Bottom Line: Large patient panels,  fast paced, and full range of medical,  MH, and social problems 6
  4. 4. heartandsoulofchange.com 5/29/2014 4 The Biomedical Model • Derived from Louis Pasteur’s (1822‐1895) germ theory  of disease • Disease is a result of a biological deficit, often  initiated by a biological pathogen • Dominated for over 100 yrs. (Shore et al., 2001) • Successes included sanitation, development of  antibiotics, decline of infectious diseases, &  increased life expectancy • By 1900, eliminated leading causes of death (TB,  pneumonia, influenza, diarrheal diseases) • Life expectancy increased from 49 yrs. (1901) (Glover, 1921) to  77 yrs. (2001) (Glover, 1921; Arias, 2004). 7 Limitations of Biomedical Model • Exclusive focus on disease promotes a reductionist,  exclusionary, and mind‐body dualism. • By end of 20th century, biomedical  model inadequately addressed: • Changing nature of disease facing U.S.  health care system • Role of behavior in disease etiology,  prevention, & management • Escalating health care costs (Johnson, 2013)  8
  5. 5. heartandsoulofchange.com 5/29/2014 5 Changing Nature of Disease • Nearly one in two U.S. deaths has at least one chronic  illness (Centers for Disease Control & Prevention, 2009) 9 • Chronic diseases contribute to: • 70% of U.S. deaths (Danaei et al., 2009) • 75% of U.S. health care costs  (www.cdc.gov/chronicdisease) • Heart diseases • Cancer • Chronic lower respiratory diseases • Stroke • Today most Americans die of chronic disease (Hoyert & Xu, 2012) Role of Behavior in Chronic Illnesses • Estimated 40% of premature deaths attributed to  modifiable health behaviors (Mokdad et al., 2004) • Smoking is leading cause of death in U.S. with obesity a  close second (Mokdad et al., 2004) 10 • Centers for Disease Control & Prevention  estimate: • Health behaviors: 50% of health care outcomes   • Genetics: 20% • Environment: 20% • Access to health care: 10% (Amara et al., 2003)
  6. 6. heartandsoulofchange.com 5/29/2014 6 Behavioral Comorbidity • The National Comorbidity Survey Replication (NCS‐R)  found: • More than 68% of adults with a mental disorder had at least one  medical condition • 29% of those with a  medical disorder had a comorbid MH  condition (Algeria et al., 2003) • Behavioral comorbidity, especially in patients with  chronic and complex medical conditions • Estimated $350B/yr. spent on unnecessary medical & surgical  services when BH conditions remain ineffectively treated (Melek &  Norris, 2008) 11 Rising Health Care Costs • U.S. health care costs continue to escalate with little  positive impact on health outcomes • Annual per person health expenditures rose from $147 in  1960 to $8,915 in 2012 (Centers for Medicare & Medicaid Services, 2013) 12 • U.S. leads the world in health  care spending…YET • U.S. life expectancy is equivalent  to Cuba …..and lower than most  developed countries (ucatlas.usc.edu;  O’Rourke & Iammarino, 2002)
  7. 7. heartandsoulofchange.com 5/29/2014 7 The Medical Model and the Medicalization of Mental Health 13 “By their development of special languages, institutions justify their authority  and perpetuate the status quo.” ‐Robin Lakoff The Medical Model 14 The Right Diagnosis +      The Right Treatment = Cure or Symptom Amelioration
  8. 8. heartandsoulofchange.com 5/29/2014 8 So What’s the Problem? • Seeking integration on a dominant  biomedical model is problematic for BH • BH treatment does not work in the same  way as medicine • The patient is not a diagnosis, the BH  clinician is not a technician, psychosocial  treatments are not simple prescriptions • Biology cannot adequately explain human  distress • Promotes myths (Duncan, Miller, & Sparks, 2004) 15 Mental Health Mythology • Biomedical model favors biology in  a diathesis / stress framework  creating four myths: • Myth of diagnosis • Myth of biological causality • Myth of privileged, first‐line medication  treatments • Myth of evidence‐based treatments  equating to good outcomes (Duncan & Miller, 2000)  16 “The greatest enemy of the truth is not the lie – deliberate, contrived, and dishonest, but the myth – persistent, pervasive, and unrealistic.” – John F. Kennedy
  9. 9. heartandsoulofchange.com 5/29/2014 9 Myth of Diagnosis 17  Poor reliability  Unknown validity  Fails to predict outcome  Little help in Tx selection  Mostly ignores relational,  environmental, and cultural  influences (Kirk & Kutchins,1992; Duncan et al., 2004) “In mental health disease is considered the known factor while normality is nearly impossible to  define.” —Paul Watzlawick, Ph.D. Myth of Biological Causality • Association of biological markers with  specific states of distress does not confirm biological causality (Sparks et al., 2006) • Little empirical support for the heavily touted  “serotonin shortage” hypothesis regarding the  cause of depression (Carlat, 2010; Weil, 2012; Angel, 2011; Whitaker, 2011;  Scott, 2006; Lehrer, 2006; Yapko, 2013) 18 “Daring as it is to investigate the unknown, even more so it is to question the known.” ‐ Kaspar Bottom Line:  Medical science has yet to  reliably identify any biological markers or  chemical imbalances for any psychiatric  diagnosis (Piasecki & Antonuccio, 2010; Duncan et al., 2004) 
  10. 10. heartandsoulofchange.com 5/29/2014 10 The Myth of Privileged Meds • Medication vs. Psychotherapy? 19 “He’s the best physician who knows the worthlessness of most medicines.” ‐ Benjamin Franklin  Critical analysis of the clinical trial research strongly  challenges meds skyrocketing prescription rates  &  their privileged status as an often first time TX  (Sparks et al., 2010)  The efficacy of psychotherapy has been irrefutably  supported across all domains of symptoms distress‐ with a few, if any, instances of comparative superior  outcomes for meds, especially in the long run (Brown et al.,  2008; Sparks et al., 2010; Kirsch, 2010) Myth of EBTs (BATTLE OF THE BRANDS) • Cognitive Therapy  • Behavioral Therapy • Cognitive Behavioral Therapy • Motivational Therapy • Twelve Steps • Dialectical Behavioral Therapy • Multidimensional Family Therapy • Structural Family Therapy • Functional Family Therapy • Skills Training • Acceptance and Commitment  Therapy  • Client‐Centered Therapy • Systemic Therapy • Biopsychosocial Therapy • Solution‐focused Therapy • Multimodal Therapy • Psychodynamic Therapy • Narrative Therapy • Integrative Problem‐solving  Therapy • Eclectic Therapy • Interpersonal Therapy • Transtheoretical Therapy • Multisystemic Therapy • Existential Therapy                       20
  11. 11. heartandsoulofchange.com 5/29/2014 11 The Dodo Bird Verdict • Summarizes robust findings that  no particular treatment is  demonstrably superior to  another. 21 At last the Dodo said, “Everybody has won, and all must have prizes.” ‐ Lewis Carroll’s Alice in Wonderland • Most replicated finding in the  psychological literature. (Rosenzweig,1936; Wampold et al.,1997, Assay & Lambert, 1999) SHORTCOMINGS OF EBT (LIMITATION OF RCTs) • “All RCTs do is show that what you’re  dealing with is not snake oil. They  don’t tell you the critical information  you might need, which is which  patients are going to benefit from the  treatment” (Williams, APA Monitor, 2010, p. 54) 22
  12. 12. heartandsoulofchange.com 5/29/2014 12 What Works in Behavioral Health Treatment (The Science of Change) 23 “The foolish reject what they see, not what they think; the wise reject what they  think, not what they see.” ‐ Huang Po (9th century) Problems with Medical Model 24 MH Practitioners can competently: • Assign diagnoses • Complete comprehensive treatment plans • Use the latest evidence‐based treatments • Dispense latest variety of psychoactive drugs Bottom Line:  These factors are just not that critical to  improving outcomes in mental health! … Overall, effectiveness of therapy will not improve in the least! (Duncan et al., 2010)
  13. 13. heartandsoulofchange.com 5/29/2014 13 Best Predictors Of Retention & Progress • Client’s rating of the alliance is the  best predictor of engagement and  outcome. 25 • Client’s subjective experience of  change early in the process is the  best predictor of success for any  particular pairing. Evidence‐Based Medicine (http://www.cebm.utoronto.ca/glossary/mmtsprint.htm#table) AREA TREATMENT NNT* Cardiology Aspirin 176 Cardiology Beta Blockers 40 Post Menopausal Osteoporosis Alendronate Sodium 21 Influenza Vaccine 12 Smoking Cessation Nicotine Inhalers 10 Acute Asthma Budesonide 9 Cataracts Surgery 3‐7 Mental Health (depression, PTSD) Therapy 3‐7 26 * NNT is the number needed to treat in order to achieve one successful outcome that would not have  been accomplished in the absence of treatment
  14. 14. heartandsoulofchange.com 5/29/2014 14 Behavioral Health’s Shortcomings • Drop outs are a substantial problem • Many clients do not benefit; some even get worse • Therapists vary significantly in their effectiveness  & are overly optimistic • Therapists are poor judges of client deterioration • Evidence‐based treatment does not tell you which  particular clients will benefit from the “best  practice” 27(Hansen et al., 2002; Duncan et al., 2004; Beutler et al., 2004; Hubble et  al., 2010) Making the Marriage Work • How do we pay for integrated primary care & lower per  capita cost? • What’s the appropriate healing paradigm? • How does one merge different missions & practice  cultures? • How can the partners coordinate quality care & adhere  to the principles of PCMH? 28 “It’s not the strongest of the species that survives, nor the most intelligent, but the one most responsive to change.” ‐Charles Darwin
  15. 15. heartandsoulofchange.com 5/29/2014 15 Our Vision of a Successful Marriage • Whole‐person care • Adhering to PCMH principles • Patient‐centered care • Coordinated, interdisciplinary teams • Enhanced access to BH services • Focus on quality & outcomes • Emphasis on wellness & life functioning • Payment reform (Epstein & Street, 2011; Baird et al., 2014, Beacham et al., 2012; Kathol et al., 2014) 29 “The dogmas of the quiet past are inadequate to the story present” ‐Abraham Lincoln Annual Message to Congress, 1862 Necessary Payment Reform • Payment for BH clinicians would be part of the PCMH’s  total health budget • Shifting from segregated, fee‐for‐service reimbursements to  integrated, prospective outcomes‐based payment (Kathol et al., 2014;  Colorado Framework, 2013) • Per‐member per‐month primary care capitation that  includes funding for integrated BH (Baird et al., 2014) • BH providers sharing in cost savings • Reward patients for health behavior change 30
  16. 16. heartandsoulofchange.com 5/29/2014 16 MARRIAGE OF TWO HEALING PARADIGMS Mind BH Care (Relational Model) Marriage 31 Body Medical Care (Biomedical Model) Biopsychosocial Model (Engel,1977) ↓ (Collaborative Provider Team) The Biopsychosocial Model (Engle, 1977) • Whole‐person care • Expanding biomedical framework to  include environmental, psychological,  social, and behavioral factors to  understand illness and health • Treatments may be behavioral,  environmental, and/or biological • Beyond disease and diagnosis, life  functioning & well‐being are  important outcomes 32
  17. 17. heartandsoulofchange.com 5/29/2014 17 33 Models of Collaborative BH Care (Blount et al., 2008; Blount, 2003; Keesler, 2003; Hunger et al., 2010; Colorado’s Framework Model, 2013) Coordinated Care • PCPs & BH providers  work in separate  systems and facilities,  delivering separate care • Usually a referral‐based  system to specialty  mental health care • May only communicate  sporadically; exchange  info on an as‐needed  basis (releases required) Co‐Located Care • PCPs & BH deliver  separate care in same  setting  • BH still delivers  specialty MH services • Communication and  coordination, but with  separate systems and  workflows • Separate Tx records • May include care  coordination/managem ent Integrated Care • PCPs & BHCs work  together in a shared  system, delivering  population based care • Access to BHCs  maximized with “warm  handoffs” and short‐term  follow‐ups • Shared care plans, clinical  documentation, billing  procedures • Clinical workflow, role  clarity, and regular  communication for max  accessibility/ coordination Components to a Successful Marriage • Use EHRs, registries, & claims data to proactively  identify patients with greater health complexity,  utilization & cost for targeted BH assessment &  treatment • Employ BH providers with various levels of expertise  and match them to the clinical needs or goals of  patients in a stepped approach to care (Kathol, deGruy, & Rollman, 2014) 34
  18. 18. heartandsoulofchange.com 5/29/2014 18 Other Components • Use care coordinators trained in cross‐disciplinary  medical & behavioral support to coordinate care across  the inpatient to outpatient community medical‐ behavioral continuum • Prospectively define desired medical & BH outcomes (e.g. clinical, functional, QOL, and satisfaction) and  evaluate progress in real time, as treatment is given (Kathol, deGruy, & Rollman, 2014) 35 Critical Issues • Merging different practice cultures, different  healing models, & creating new patient care/flow  processes requires establishing trust in an   egalitarian environment • Real and perceived barriers to communication  must be clarified and addressed to make the  regular sharing of information, shared decision  making, & shared responsibility for a patient’s care  plan routine (Baird et al., 2014) 36
  19. 19. heartandsoulofchange.com 5/29/2014 19 Additional Critical Issues • Understanding the central role of the patient (family)  in articulating needs & developing care plans • Respecting patients’ preferences should be justified on  moral grounds alone, independent of their relationship to  health outcomes • Defining the different roles & skill sets required for all  health team members • Hiring multidisciplinary staff with the “right fit” and  implement integrated team training (Epstein & Street, 2011; Baird et al., 2014) 37 The Issue of Science • How can evidence‐based medicine (EBM),  which tends to focus on populations, mesh  with patient‐centered care, with its focus on  individual needs? • Proponents of EBM concur a good outcome is  defined in terms of what is meaningful and  valuable to the individual patient (Epstein & Street, 2011) • EBM is not “cookbook” medicine as it requires a  bottom up approach that integrates the best  research with clinical expertise and patients’  choice (Sackett et al., 1996) 38
  20. 20. heartandsoulofchange.com 5/29/2014 20 The Issue of Science for BH • Do BH clinicians simply apply evidence‐based  treatment algorithms & protocols as “standard  BH interventions?” • We adhere to APA’s definition of evidence‐ based practice as:  “The integration of the best available research with  clinical expertise in the context of patient  characteristics, cultures, & preferences”  (APA Task Force, 2006, p. 273) 39 Partners for Change Outcome Management System (PCOMS) ORS Individually: (Personal well-being) ______________________________ Interpersonally: (Family, close relationship) ______________________________ Socially: (Work, school, friendships) ______________________________ Overall: (General sense of well-being) ______________________________ 40 Reliable Valid Feasible Relationship: Goals and Topics: Approach or Method: Overall: SRS Therewassomethingmissingin thesessiontoday I feltheard,understoodand respected Weworkedonandtalked aboutwhatI wantedtowork onandtalkabout Thetherapist'sapproachis agoodfitforme Overall,today'ssessionwas rightforme Ididnotfeelheard, understoodandrespected Wedidnot workonortalk aboutwhatIwantedtoworkon andtalkabout Thetherapist'sapproachisnot agoodfitforme Outcome Rating Scale (ORS) Session Rating Scale (SRS) www.heartandsoulofchange.com
  21. 21. heartandsoulofchange.com 5/29/2014 21 : A SAMHSA EBP But Different • PCOMS is a‐theoretical; additive  to any therapeutic orientation,  including other EBPs • PCOMS applies to clients of all  diagnostic categories 41 Meta-analysis of PCOMS • Feedback group had 3.5 higher odds of  experiencing reliable change • Feedback group had less than half the  odds of experiencing deterioration • Feedback attained .48 ES Lambert, M. J., & Shimokawa, K. (2011). Collecting client feedback. Psychotherapy, 48, 72‐79.
  22. 22. heartandsoulofchange.com 5/29/2014 22 PCOMS & Integrated BH Care “However beautiful the strategy, you should occasionally look at the results” ~ Sir Winston Churchill • An ultra‐brief & non‐symptom specific  clinical & outcome measure that can also  be used for BH screening • Addresses medical model shortcomings &  adheres to the evidence of “what works” • Brings accountability to the marriage • Aligns with PCMH principles • Fits with outcome‐based payment reform (Duncan, 2012; Lambert, 2010; Lambert & Skimokawa, 2011) 43 Brian’s ORS/CORS Data (Feb 2012 ‐April 2014) 44 • 170 children/adolescents given  ORS/CORS  (co‐visits included) • Range: 4.2 – 40.0 • Mean: 23.5  • Mode: 25.2 • 62 children/adolescents with 2+ follow‐ up sessions • 77% of patients improved/recovered • Range: 2‐8 • Mean: 2.4  ORS Individually: (Personal well-being) ______________________________ Interpersonally: (Family, close relationship) ______________________________ Socially: (Work, school, friendships) ______________________________ Overall: (General sense of well-being) ______________________________ www.heartandsoulofchange.com
  23. 23. heartandsoulofchange.com 5/29/2014 23 46 Chronic Illnesses Mental Health Life Stressors Health Behaviors • Diabetes • Cardiovascular Disease • Chronic Lung Disease • Chronic Pain • Cancer • Depression • Anxiety • Substance Abuse/ Dependence • Cognitive Disorders • ADHD, ODD • Relationship Problems • Sleep Problems • Phase of Life Issues • Bereavement • Stress Related Physical  Symptoms • Tobacco Use • Overeating • Physical Inactivity • ETOH/Drug Misuse  • Medication Adherence BH Consult (“co‐visit”) (5‐10 mins) (Initial assessment & possible intervention) Are Further Integrated BH Services Needed? (Stage of change, payer source, patient preference, accessibility issues) Probably Yes Probably No Short‐Term Follow‐ups (30 mins., 6‐8 sessions ‐ further  assessment and/ or intervention) Return to PCP Refer to Specialty MH • Traditional MH psychotherapy (not  time‐limited) • Psychiatric medication management • Other community specialty referable  (i.e neuropsych evals, LD testing) • Co‐visit sufficient • Relaxation Training • Self‐ Monitoring • Stimulus Control • Behavior Modification • Motivational Interviewing • Problem Solving • Cognitive Disputation • Mindfulness • Brief Solution‐Focused Tx • Hypnosis • Biofeedback Our BH Consultant Model
  24. 24. heartandsoulofchange.com 5/29/2014 24 Evaluating and Treating Depression 47 PCP/ Patient Visit • Initial medical eval • DX impression Labs? BH Consulted • Baseline level of distress (ORS) • Augment medical eval • Confirm diagnosis (es) BH / Patient Collaboration • Patient’s goals / preferences • Discuss Tx options Referral to  specialty MH? Meds Only ‐ Monitor Outcomes Combo Med + BH  Interventions ‐ Monitor outcomes BH Interventions ‐ Monitor outcomes Patient self‐change or No current Flu PCP / Pharmacist / Patient  Discussion of meds, side effects, etc. Evaluating and Treating ADHD 48 Initial PCP visit BH co‐visit assessment Is ADHD still suspected? Follow‐up BH  Assessment & Diagnosis  Collaborative Discussion of  Treatment options Yes BHC Assists  Evaluating Outcomes No Possible BH/PCP  Follow‐up PCP Meds  Consult BH Interventions
  25. 25. heartandsoulofchange.com 5/29/2014 25 Managing Chronic Pain 49 New Patients Existing Patients >120mg MED BH Assessment BHC co‐visit  Assessment BH Follow‐up Assessment Medical (PCP)  Evaluation Monitor Outcomes PCP‐BHC‐Patient Collaboration on Tx options Monitor Outcomes PCP‐BHC‐Patient Collaboration on Tx options Implications for the Marriage • BH must maintain its non‐medical relationship identity  in a collaborative & equal partnership • BHCs should extend rather than just confirm medical  diagnostic assessments • Familial, environmental, sociocultural • Assessing BH comorbidities & readiness for change • Functional assessments • BHCs are not seen as technicians administering one‐ size‐fits‐all interventions prescribed by PCPs (Duncan & Antonnucio, 2011) 50
  26. 26. heartandsoulofchange.com 5/29/2014 26 Further Implications • BHCs are not viewed as an adjunctive service to  medication, or a lowered tier way to deliver care • Psychotropics are not an automatic & privileged first‐ line intervention • Patient’s preferences, based on their own values &  cultural context, will be honored • BH must bring accountability to the marriage • Focus on “what works” and APA’s definition of EBP • Use feasible, patient‐directed outcome measures that  align with PCMH (Duncain & Antonmucio, 2011) 51 Advantages of Integration • Multidisciplinary collaborative care teams with  improved communication/coordination of whole‐ person care • Improved patient satisfaction, improved health care  outcomes, and reduced costs • Enhanced access to BH care, especially for uninsured • Improved PCP efficiency & satisfaction 52
  27. 27. heartandsoulofchange.com 5/29/2014 27 “Oft times it is better to know what kind of patient has a disease than what  kind of disease the patient has.”  ‐Sir William Osler (1849‐1919) 53

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