Promoting Improved Integration

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Promoting Improved Integration: An Examination of Collaborative Health Care Models

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  • Traditional collaborative/integration models: really focused on just the main providers, may not really incorporate the pt needs, but at least is a good starting to point to think of where to place those who deliver the services
  • COORDINATED • Routine screening for behavioral health problems conducted in primary care setting• Referral relationship between primary care and behavioral health settings • Routine exchange of information between both treatment settings to bridge cultural differences • Primary care provider to deliver behavioral health interventions using brief algorithms• Connections made between the patient and resources in the community
  • CO- LOCATED• Medical services and behavioral health services located in the same facility • Referral process for medical cases to be seen by behavioral specialists• Enhanced informal communication between the primary care provider and the behavioral health provider due to proximity• Consultation between the behavioral health and medical providers to increase the skills of both groups• Increase in the level and quality of behavioral health services offered• Significant reduction of “no-shows” for behavioral health treatmentShared care:1) Washtenaw Community Health Organization (Michigan): The Washtenaw Community Health Organization is a partnership between the county public mental health system and the University of Michigan Health System. The partnership allows for pooling of funds across systems and shared risk. Mental health clinicians from the community mental health center are out-stationed to primary care practices to provide direct treatment. A psychiatrist provides consultation to local public health clinics. The project has added a reverse co-location initiative (see discussion of Practice Model 5) by having a nurse practitioner visit community mental health clinics to provide primary care as well as to coordinate with the patient’s physician if there is one.2) VHA: One model uses a nurse care manager to provide telephone monitoring to individuals with depression and referral to specialty care when needed. The other model uses a software-based assessment to determine three interventions: watchful waiting, treatment by the primary physician, and referral to specialty care.
  • CO- LOCATED• Medical services and behavioral health services located in the same facility • Referral process for medical cases to be seen by behavioral specialists• Enhanced informal communication between the primary care provider and the behavioral health provider due to proximity• Consultation between the behavioral health and medical providers to increase the skills of both groups• Increase in the level and quality of behavioral health services offered• Significant reduction of “no-shows” for behavioral health treatmentShared care in reverse:1)Health and Education Services (HES) (Massachussets): a nonprofit, fullservice mental health organization in the North Shorearea. HES is focused on improving the physical health care of its Latino population. A Spanish-speaking nurse practitioner, who has expertise in both primary care and psychiatry, regularly visits three clinics. The nurse is available on a walkin basis to see patients with a range of medical issues.2) Horizon Health Services (NY): Horizon Health Services is a provider of comprehensive substance dependence and mental health services in Buffalo. Three of Horizon’s sites have medical units, where patients are offered an appointment if they do not have a primary care physician. The medical staff includes a family physician, registered nurse, nurse practitioner, LPNs, and HIV counselors.
  • INTEGRATED• Medical services and behavioral health services located either in the same facility or in separate locations• One treatment plan with behavioral and medical elements• Typically, a team working together to deliver care, using a prearranged protocol• Teams composed of a physician and one or more of the following:physician’s assistant, nurse practitioner, nurse, case manager, family advocate, behavioral health therapist • Use of a database to track the care of patients who are screened into behavioral health servicesPrimary care psychiatrist:1) MIPS clinic (NY): Clinic located at Strong Ties in Rochester for those with SPMITypically not much focus on primary care psychiatrist – few providers, and still have multiple difficulties, including boundaries (“we don’t hug in psych”)
  • Those with low to moderate severity of mental health disorders but a higher level of medical co-morbidity would be best benefit from an integrated approach where mental health is incorporated into a primary care clinic
  • Personal physician- Each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care Physician directed medical practice- The personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients Whole person orientationThe personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals. Includes care for all stages of life; acute care; chronic care; preventive services; and end of life careCare is coordinated and/or integratedAcross all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (e.g., family, public and private community-based services) Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner Enhanced access- Care is available through systems such as open scheduling, expanded hours and new options for communication between patients, their personal physician, and practice staffQuality and safety Practices advocate for their patients to support the attainment of optimal, patient-centered outcomes that are defined by a care planning process driven by a compassionate, robust partnership between physicians, patients, and the patient’s family Evidence-based medicine and clinical decision-support tools guide decision making Physicians in the practice accept accountability for continuous quality improvement through voluntary engagement in performance measurement and improvement Patients actively participate in decision-making and feedback is sought to ensure patients’ expectations are being met Information technology is utilized appropriately to support optimal patient care, performance measurement, patient education, and enhanced communication Practices go through a voluntary recognition process by an appropriate non-governmental entity to demonstrate that they have the capabilities to provide patient centered services consistent with the medical home model Patients and families participate in quality improvement activities at the practice levelPayment: recognizes the added value provided to patients who have a PC-MH and based on the following framework Reflect the value of physician and non-physician staff patient-centered care management work that falls outside of the face-to-face visit Pay for services associated with coordination of care both within a given practice and between consultants, ancillary providers, and community resources Support adoption and use of health information technology for quality improvement Support provision of enhanced communication access such as secure e-mail and telephone consultation Recognize the value of physician work associated with remote monitoring of clinical data using technology Allow for separate fee-for-service payments for face-to-face visits. Payments for care management services that fall outside of the face-to-face visit, as described above, should not result in a reduction in the payments for face-to-face visits Recognize case mix differences in the patient population being treated within the practice Allow physicians to share in savings from reduced hospitalizations associated with physician-guided care management in the office setting Allow for additional payments for achieving measurable and continuous quality improvements **Medicaid: those with this insurance typically have more instability, more likely to utilize ED services; majority of those on this have multiple chronic conditions with wide psychosocial needs **Funding for IT will help push PCMH
  • CO- LOCATED• Medical services and behavioral health services located in the same facility • Referral process for medical cases to be seen by behavioral specialists• Enhanced informal communication between the primary care provider and the behavioral health provider due to proximity• Consultation between the behavioral health and medical providers to increase the skills of both groups• Increase in the level and quality of behavioral health services offered• Significant reduction of “no-shows” for behavioral health treatment
  • High BH-low physical health complexity/risk, served in a specialty BH system that coordinates with the PCP.
  • This afternoon I will briefly discuss the current problems we face within the field of CAP, some creative solutions, and 2 successful models of integration. I will conclude by discussing some policy changes that have occurred to promote the development of integrative models of care.
  • In 2001, Dr. David Satcher declared a state of crisis in the mental health of children and adolescents
  • The statistics are alarming. Almost one in five children have a diagnosable mental health disorder at any given time. Up to 1/2 of all lifetime cases of mental illness begins by age 14. And yes, psychosocial and mental health concerns are often mentioned during primary care appointments, but there are still approx 80% of kids with psychopathology who are not identified or treated. The consequences of untreated mental health disorders have a domino effect. It is known that children and adolescents that are untreated have higher school absence rates, lower school performance, impaired relationships, higher rates of STDs, pregnancy, and substance abuse, limited to no employment opportunities, and poverty in adulthood.
  • Mental illness, whether untreated or treated, account for considerable costs to multiple systems of care, an estimate of over $200 billion annually.This slide, although rather busy, is another take on the domino effect. Anindividual’s health problems, in turn, may lead to adverse consequences for others. In addition, health problems typically lead to increased costs secondary to reduced productivity and earnings and the increased use of social services such as child welfare and juvenile justice. As cliché as it may sound, the children are our future and they deserve a place that not only identifies and treats pathology, but promotes physical and mental well being.
  • Such interventions can be integrated with routine health care and wellness promotion, as well as in schools, within families, and in the community. This would require the collaborative efforts of a multidisciplinary team including pediatricians, psychiatrists, educators and community based agencies to build strong children.
  • To meet the needs of the children, there has to be a sufficient number of providers. And we all are aware of the workforce shortage. A study commissioned by the AACAP in 2003 found there was, on average, only one child psychiatrist for every 15,000 youth under 18. The data shows that Pennsylvania is one of the few states with a higher number of CAPs, however the need is still abundant. The U.S. Bureau of Health Professions project that there will be 8,300 CAPs in 2020 but they are also projecting the need of 12,600 CAPs to provide services
  • These numbers highlight the need to develop prevention training standards and training programs across disciplines including health, education, and social work. There are available training programs on mental health topics for primary care resident physicians, continuing medical education courses for established primary care providers, and continuous quality improvement (CQI) initiatives for entire health care systems. However, there are some studies that show these education and training approaches have not been shown to have consistent beneficial effects on either provider behaviors or patient-level outcomes, especially long-term.
  • With the current NFL lockout , increasing numbers of children and adolescents in need of mental health services and the shortage of providers, there is a need for some creative solutions…. Thank goodness for hockey and basketball!
  • The concept of the medical home was first introduced by the American Academy of Pediatrics
  • The interpretation of the medical home has transformed over the years and in 2007 the collaborative efforts of the American Academy of Family Physicians, American Academy of Pediatrics,American College of Physicians, and American Osteopathic Association outlined 7 principals of the Patient-Centered Medical Home.
  • Personal physician: Each patient is to have an ongoing relationship with a personal physician trained to provide 1st contact, continuous and comprehensive care.Physician directed medical practice:The personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients Whole person orientation: The personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals. Care is coordinated across all elements of the complex health care system and the patient’s community.Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need in a culturally and linguistically appropriate manner Enhanced access: Care is available through systems such as open scheduling, expanded hours and new options for communication between patients, their personal physician, and practice staff Quality and safety: Practices advocate for their patients to support the attainment of optimal, patient-centered outcomes. Evidence-based medicine and clinical decision-support tools guide decision making. Information technology is utilized appropriately to support optimal patient care, performance measurement, patient education, and enhanced communication Payment should recognize the added value provided to patients who have a PC-MH and should reflect the value of physician and non-physician staff care management work that falls outside of the face-to-face visit. Payment should also support provision of enhanced communication access such as secure e-mail and telephone consultation and recognize the value of physician work associated with remote monitoring of clinical data using technology.
  • The medical home model provides children and families the opportunity to engage in mental health services within a familiar environment anddecreasing the stigma attached to seeking mental health treatment. There are several other benefits of this model, especially improving access to care.
  • While the concept of a medical home is not specifically an integrated behavioral health model, it clearly encompasses the philosophy of integration. This model has the potential to shift costs from acute care to prevention, chronic care management and recovery
  • Bridging the patient –centered medical home with integrated care is an innovative approach that facilitates partnerships between individuals and their healthcare providers
  • Collaborative care and integrated care are the two terms most often used to describe the interface of primary care and behavioral health care. They are often used interchangeably, but the terms are not used consistently in the field. Biopsychosocial model acknowledges that biological, psychological, and social factors all play a significant role in human functioning in the context of disease. This model is endorsed by most medical professionals yet seldom practiced. However, it is the theory at the root of collaborative and integrated care and is universally embraced as a “best practice.”
  • many integrated programs around the country have combined elements of two or more of the models previously discussed. These blended programs are becoming more common because programs are often designed for a particular set of local or statewide circumstances, such as target population, provider and service capacity, funding issues, and regulatory restrictions. 
  • The Child and Family Counseling Center is a program here in Pittsburgh based on the medical home model that was developed to provide an unmet need for behavioral health services within local pediatric offices.
  • There was a need to provide evaluation and treatment for common mood, anxiety, and behavioral disorders
  • A collaborative partnership was developed using consultative and co-location models of care between three systems, CCP, CHP and WPIC
  • CCP is a collective group of over 100 pediatricians and several mid level providers who deliver primary care services out of 28 offices which span 8 counties within the greater Pittsburgh area
  • CHP is a large level 1 trauma center serving Western PA. CHP was named one of 8 of America’s Best Children’s Hospitals per US News and World Report.
  • And WPIC, is one of the largest psychiatric facilities in Western PA serving 25 thousand patients and families a year. It is the site of two combined residency programs, TB and FP/Psych
  • To paraphrase, the initialmission of this collaboration was to provide access to quality, evidenced based behavioral health assessments, interventions and treatments in an integrated model within the pediatric primary care setting. Akey to successful implementation of such care is bidirectional communication between PCP and BH providers
  • In 2007 the CFCC pilot project was launched. Using a consultative and co-location model, BH specialists were placed in the primary care office to provide evaluation, assessment and treatment of patients referred by their pediatrician. Referral guidelines and treatment protocols were established and adhered to by all providers. Training sessions were provided and consisted of topics ranging from the general nuts and bolts of the program to management of common parental BH questions via phone triage. The use of EMR helped to streamline registration, authorizations, billing and communication.
  • I know this is a busy slide, but I wanted to give you an idea of how the CFCC system works. Who and where the care is provided is determined by the severity of symptoms and degree of impairment. Mild symptoms and impairment of various disorders are managed by the pediatrician \\during routine office visits. Moderate to severe symptoms and impairment warrants a referral to a behavioral health therapist for assessment, diagnosis and appropriate treatment. Behavioral health therapist will then refer to the child psychiatrist if medication management is required. Lastly, the pediatrician will refer pts with immediate safety issues to the psychiatric ED or appropriate community agency.
  • The pilot was a success and the Child and Family Counseling Center now has 4 child and adolescent psychiatrist providers, 2 of which are triple board trained. Therapists are located at 14 different CCP locations. The center will also see patients who are referred from non Children’s Community Pediatric offices at the central office location in Wexford
  • Since Aug of 2008, over 1500 patients have been seen with an average of approx 600 behavioral health visits/month and only a 10% no show rate. As with the national trends, 80% of the diagnoses seen are anxiety, depression or ADHD. And comorbidity does exist.
  • In speaking with the pioneers of the program, the strategies for the programs success included buy in by all parties. Everyone must see the value of integration including providers, staff, and most importantly patients and their families. BH manager attended monthly primary care meetings and CAP facilitate BH training sessions for pediatric providers and staff. There is one expert responsible for completing eligibility requirements and billing for all participating practices. For example, once a patient encounter is closed, charges are dropped into an electronic work queue that is processed by the expert.
  • The underlying theme for the success of the program is communication… not included in this slide but important role players are other systems of care such as education, the child welfare system, and juvenile justice to name a few.
  • Some of the barriers to developing collaborative models are the same as the barriers to mental health care in general… poor access, shortage of providers, stigma, and cultural differences with the traditional delivery of medicine in separate silos and last but certainly not least, funding.
  • The Patient Protection and Affordable Care Act has set aside millions of dollars to assist states in planning and implementing Medicaid medical home projects. The Medicaid accountable care organization pilot program establishes a project that will allow qualified pediatric providers to receive recognition and payments under Medicaid as accountable care organizations. In addition, $50 million in grants will be authorized for coordinated and integrated services through the co-location of primary and specialty care in community-based mental and behavioral health settings. According to the patient centered- primary care collaborative, some 44 states and the District of Columbia have passed more than 330 laws relating to the medical home
  • There is a need for continuous advocacy efforts to improve reimbursement rates, and incentives for mental health screenings and prevention during primary care well child checks are paramount.
  • Promoting Improved Integration

    1. 1. Promoting Improved Integration: An Examination of Collaborative Health Care Models<br />Council on Advocacy and Government Relations<br />Peter Martin, MD, MPH<br />John Lusins, MD<br />Marilyn Griffin, MD<br />Margaret Balfour, MD, PhD<br />
    2. 2. Disclosure Statement<br /> Drs. Martin, Griffin, and Balfour are all APA Public Psychiatry Fellows, sponsored by Bristol Myers-Squibb <br />Dr. Lusins is an APA Psychiatric Leadership Fellow<br />
    3. 3. Access to Slides<br />Viewable slideshow: http://www.slideshare.net/collaborativehealthcaremodels/<br />Downloadable PDF:<br />http://sites.google.com/site/<br />collaborativehealthcaremodels/<br />
    4. 4. Workshop Objectives<br />Identify different models of integrative health care<br />Explore the concept of the medical home and discuss how it can be incorporated into the mental health realm<br />Examine examples of different integrative models, utilizing examples from the adult and pediatric realms, as well as discussing health care coordination models as seen in different countries and cultures<br />Discuss various payment models to ensure the success of integrative health care<br />
    5. 5. Collaborative Care: Overview<br />Peter S. Martin, MD, MPH<br />Child and Adolescent Psychiatry Fellow<br />University of Rochester<br />
    6. 6. Conceptual Models<br />Provider-centered<br />
    7. 7. Conceptual Models for ProvidersTraditional<br />
    8. 8. Conceptual Models for ProvidersCoordinated Care<br />
    9. 9. Conceptual Models for ProvidersCo-Location<br />
    10. 10. Conceptual Models for ProvidersCo-Location in Reverse<br />
    11. 11. Conceptual Models for ProvidersIntegrated Care<br />
    12. 12. Levels of Integration<br />BASIC<br />On-site<br />CLOSE<br />Fully <br />Integrated<br />MINIMAL<br />BASIC<br />at a Distance<br />CLOSE<br />Partly<br />Integrated<br />Collaboration Continuum<br />Doherty, W. The Why’s and Levels of Collaborative Family Health Care.<br />
    13. 13. Conceptual Models<br />Patient-centered<br />
    14. 14. The Four Quadrant Clinical Integration Model<br />Quadrant II<br />↑ BH <br />↓ PH<br />Quadrant IV<br />↑ BH <br />↑ PH<br />Behavioral Health Risk/Status<br />Quadrant III<br />↓ BH <br />↑ PH<br />Quadrant I<br />↓ BH <br />↓ PH<br />Physical Health Risk/Status<br />Mauer, B. Behavioral health/primary care integration: The four-quadrant model and evidence-based practices<br />
    15. 15. Mauer, B. Behavioral health/primary care integration and the person-centered healthcare home. <br />
    16. 16. Joint Principles of the Patient-Centered Medical Home<br />Personal physician<br />Physician directed medical practice<br />Whole person orientation<br />Care is coordinated and/or integrated<br />Enhanced access<br />Quality and Safety<br />Payment<br />National Center for Medical Home Implementation<br />
    17. 17. Suggested Resources<br />Collins, C et al. Evolving models of behavioral health integration in primary care. Milbank Memorial Fund. 2010. http://www.milbank.org/reports/10430EvolvingCare/EvolvingCare.pdf<br />Mauer, B. Behavioral health/primary care integration and the person-centered healthcare home. National Council for Community Behavioral Healthcare. 2009.<br />Pautler, K., and M.-A. Gagne. 2005. Annotated Bibliography of Collaborative Mental Health Care. Mississauga, ON: Canadian Collaborative Mental Health Initiative. http://www.ccmhi.ca/en/products/documents/03_AnnotatedBibliography_EN.pdf<br />Smith, TE and Sederer, LI. A new kind of homelessness for individuals with serious mental illness? The need for a “mental health home.” Psychiatric Services. 2009;60:528–533. http://ps.psychiatryonline.org/cgi/reprint/60/4/528<br />
    18. 18. ReferencesCollaborative Care: Overview<br />Doherty, W. The Why’s and Levels of Collaborative Family Health Care. Family Systems Medicine. 1995;13(3–4):275–81.<br />Mauer, B. Behavioral health/primary care integration: The four-quadrant model and evidence-based practices. National Council for Community Behavioral Healthcare. 2006.<br />Mauer, B. Behavioral health/primary care integration and the person-centered healthcare home. National Council for Community Behavioral Healthcare. 2009.<br />
    19. 19. Towards Integrated Health Care in Northern WV<br />John Lusins, MD<br />Chief Resident<br />WVU Department of Behavioral Medicine <br />Morgantown, WV<br />
    20. 20. Conflicts<br />I owned 0.5% of Lime Medical LLC and had on-going consulting relationship.<br />Closed as of May 13th 2011<br />No further conflicts<br />
    21. 21. Theory<br />4 Quadrant Model<br />Where do we fit?<br />Two Locations<br />Valley Community Mental Health Centers<br />Chestnut Ridge Center<br />
    22. 22. Valley CMHC<br />Founded in 1969 by West Virginia University, Valley Counseling Services united with The Human Resources Association and incorporated as Valley Community Mental Health Services in 1972. Doing business as Valley HealthCare System, a nonprofit corporation.<br />Spurred by the federal government, funds became available through the passage of the Community Mental Health Center Act of 1963, introduced by President John F. Kennedy and Valley was able to establish itself as one of 13 federally-funded mental health centers in the state in the early 1970’s.<br />
    23. 23. Valley CMHC<br />Currently located in Monongalia, Marion, Preston and Taylor Counties<br />
    24. 24. Valley CMHC<br />
    25. 25. Valley CMHC<br />Services<br />Chemical Dependency<br />Developmental Disabilities<br />Mental Health<br />
    26. 26. Valley CMHC<br />Suicide Hotline<br />24/7 staffing <br />Outpatient services<br />Daily clinics by MD’s<br />Now NP’s with MD supervision<br />Therapists<br />Case Coordinators<br />Crisis Unit<br />ACT team<br />
    27. 27. Valley CMHC<br />Primary Care<br />Over the last year, push by MD’s staffing to have FP/IM MD’s to join staff<br />Non-compliance with out-sourced PCP appointments<br />Immediate non-acute health concerns<br />Coordination of care<br />
    28. 28. Valley CMHC<br />Added two Family Practitioners in last year<br />1 day/week at 4 BH locations<br />New clinic<br />Metabolic Program<br />Well-received primary care visits (172)<br />Reported increase in patient satisfaction<br />No change in show-rate for BH<br />2 MD positions to NP’s<br />
    29. 29. Chestnut Ridge Hospital<br />Home of WVU Department of Psychiatry<br />Free-standing hospital with 65 inpatient beds<br />Over 50,000 outpatients seen last year<br />
    30. 30. Chestnut Ridge Hospital<br />Specialty Clinics<br />Memor y Disorders<br />Thought Disorders<br />Sleep Disorders<br />Geriatric Psychiatry<br />All patients previously referred to main hospital outpatient for Primary Care needs<br />
    31. 31. Chestnut Ridge Hospital<br />2010<br />WVU Family Medicine/Psychiatry Graduate hired to create Integrated Care clinic<br />Thought Disorders Clinic<br />Chronic severe mental illness with low-moderate primary care needs<br />Patients given option of continuing care at Main Outpatient clinic vs. seen as part of scheduled clinic<br />Care coordinated by BH Physicians and Social Workers<br />
    32. 32. Chestnut Ridge Center<br />Results (prelim)<br />Patient adherence to primacy care recommendations increased:<br />BP medications<br />Glucose control<br />Weight loss<br />Patient satisfaction increased<br />Physician satisfaction increased<br />Decreased No-Show rate <br />
    33. 33. Quadrant II<br />PCP:<br /> Provides primary care services and collaborates with the specialty BH providers<br />BH: <br /> Provide BH assessment and arrange for/deliver specialty BH services<br /> Assure case management (housing, community supports)<br /> Assure access to health care<br /> Create a primary care communication approach that assures coordinated service planning<br />
    34. 34. Future<br />Expand Primary Care integration to all specialty clinics<br />Measure results at Valley and WVU<br />Hospitalizations?<br />Integrate FP into ACT team<br />
    35. 35. References and Resources<br />“Valley MCHC Annual Report”- 2010-2011<br />Collins, C et al. Evolving models of behavioral health integration in primary care. Milbank Memorial Fund. 2010. http://www.milbank.org/reports/10430EvolvingCare/EvolvingCare.pdf<br />
    36. 36. Regards<br />APL Fellowship<br />CAGR Committee <br />Co-presentors<br />
    37. 37. “Hello Primary Care, I’m home!” An Overview of Behavioral Health and Pediatric Primary Care Integration<br />Marilyn Griffin, MD PGY 5<br />Triple Board Resident<br />APA Public Psychiatry Fellow<br />APA Council on Advocacy and Government Relations<br />May 18, 2011<br />
    38. 38. Outline<br />“Houston, we have a problem”<br />Creative solutions<br />Successful models<br />Change<br />Discussion<br />
    39. 39. “Houston, we have a problem…”<br />
    40. 40. The Facts<br />2001: Surgeon General’s Report on Children's Mental Health indicated the mental health of children and adolescents was a public crisis <br />
    41. 41. The Facts, Cont.<br />≈ 1 in 5 children in US with diagnosable mental health disorder<br />≈ 80% of mentally ill children are not identified or treated<br />Suicide is the 3rd leading cause death in 10-24 yo<br />Mental Illness is the 2nd leading cause of disability and premature mortality in the U.S. <br />Burden of untreated mental illness on various systems of care<br />
    42. 42. The Facts, Cont.<br />Source: Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities (2009 pg 246). Adapted from Eisenberg and Neighbors (2007).<br />
    43. 43. “It is easier to build strong children than to repair broken men.” <br />Frederick Douglass<br />
    44. 44. Workforce Shortage<br />
    45. 45. Workflow Shortage, Cont.<br />Prevention training standards & programs <br />Training resources<br />Medical and graduate medical education curriculum changes<br />
    46. 46. Creative Solutions<br />
    47. 47. http://www.medicalhomesummit.com/past2010/past.html<br />
    48. 48. The Patient - Centered Medical Home <br />1967 AAP introduced the medical home concept<br />2002-2006 expanded definitions of medical home and creation of other models<br />2007 AAFP, AAP, ACP, AOA, developed: Joint Principles of the Patient-Centered Medical Home <br />
    49. 49. The Patient - Centered Medical Home: Joint Principals<br />Personal physician<br />Physician directed medical practice<br />Whole person orientation<br />Care coordination/integration<br />Enhanced access to care<br />Quality and safety<br />Appropriate payment<br />National Center for Medical Home Implementation<br />
    50. 50. The Patient - Centered Medical Home: Benefits<br />Unique opportunity to engage in services without stigma<br />Improved access to specialty care<br />Appropriate level of care by providers in familiar environment<br />
    51. 51. Bridging Medical Home and Integrated Care<br />Patients designated for medical home care represent those potentially targeted for integrated care<br />The medical home has the potential to shift costs from acute care to preventive, chronic care management, and recovery<br />
    52. 52. Bridging Medical Home and Integrated Care, Cont.<br />Medical home will provide <br />more comprehensive approach to primary care <br />more holistic and integrated care<br />a more collaborative physician-patient relationship<br />
    53. 53. Collaboration +/- Integration = Confusion<br />Terms not used consistently in the field<br />Engel (1977)<br />biopsychosocial model <br /> theory at the root of collaborative and integrated care<br />Strosahl (1998)<br />collaborative care involves behavioral health working with primary care<br />integrated care involves behavioral health working within and as a part of primary care<br />(you say tomato, I say tomhato)<br />
    54. 54. Successful Models<br />
    55. 55. Child and Family Counseling Center(CFCC)<br />Pittsburgh, PA<br />
    56. 56. Child and Family Counseling Center (CFCC)<br />Based on patient centered medical home model<br />Unmet behavioral health service need<br />Provide evaluation and treatment:<br />Mood disorders<br />Anxiety disorders<br />Attention-deficit and disruptive behavior disorders <br />Adjustment disorders<br />http://www.chp.edu/CHP/counseling<br />
    57. 57. CFCC Partnership<br />Children’s Community Pediatrics<br />Children’s Hospital of Pittsburgh<br />Western Psychiatric Institute and Clinic<br />
    58. 58. CFCC: Children’s Community Pediatrics<br />110 Pediatricians<br />Several mid-level providers<br />19 practices<br />28 offices<br />8 counties<br />http://www.cc-peds.net/main/index.shtm<br />
    59. 59. CFCC: Children’s Hospital of Pittsburgh<br />Only children’s hospital serving Western PA<br />Level 1 Pediatric Trauma Center<br />One of 8 pediatric hospitals in US named to: <br />U.S. News & World Report's Honor Roll of America’s <br />“Best Children’s Hospitals” <br />for 2010–2011 <br />http://www.chp.edu/CHP/Home<br />
    60. 60. CFCC: Western Psychiatric Institute and Clinic<br />Largest psychiatric facility in Western PA<br />Serves over 25,000 patients and families/yr<br />Full continuum of services including 24 hour psychiatric emergency room<br />Residency training site for Triple Board Program and Family Practice/Psychiatry Program<br />http://www.upmc.com/HospitalsFacilities/Hospitals/wpic/Pages/default.aspx<br />
    61. 61. CFCC Partnership Mission Statement<br />“ …a collaborative effort between pediatricians, licensed clinical social workers, psychologists and psychiatrists to provide timely access to high-quality, empirically-supported behavioral health assessments, behavioral interventions, and psychiatric interventions to children and families in an integrated model of care provided within the pediatric primary care office.”<br />
    62. 62. CFCC: 2007 Pilot Project<br />BH specialist in 1 CCP office 2 days/week (therapist, child & adolescent psychiatrist)<br />Referral indications and exclusions identified<br />Clinical treatment protocol outlined<br />Training sessions for all staff<br />Centralized registration and billing <br />Electronic Medical Records<br />
    63. 63. Pediatrician identifies<br />behavioral health needs<br />Collaborative Care Team<br />Routine Care in theOffice<br />Psychiatric Facility/ED<br />Moderate to severe Symptoms/Impairment<br /><ul><li>ADHD/Need for family treatment
    64. 64. ADHD/Comorbid anxiety mood sx
    65. 65. Anxiety/phobia/OCD
    66. 66. Chronic illness
    67. 67. Depression/mood sx
    68. 68. Defiance/opposition
    69. 69. Disordered eating
    70. 70. Encopresis/enuresis
    71. 71. Grief/Loss
    72. 72. Parent management training</li></ul>Immediate/Safety Issues<br /><ul><li>Suicidality
    73. 73. Homocidality
    74. 74. Severe substance abuse
    75. 75. Violence
    76. 76. CYF report
    77. 77. Safety concerns</li></ul>Mild symptoms/mild impairment<br /><ul><li>ADHD managed by meds within practice
    78. 78. Mild adjustment issues
    79. 79. Mild anxiety or depression
    80. 80. Parenting/child development education
    81. 81. Family support</li></ul>Referral to Behavioral Health<br />Therapist for assessment and <br />possible treatment<br />Pediatrician refers to Emergency Dept.<br />or appropriate community agency<br />Managed by the Pediatrician<br />Non-behavioral concerns are not<br />referred to behavioral provider:<br /> Custody Issues<br /> CYF/child welfare issues<br /> Learning/school evals<br /> Financial/housing, etc.<br />If no symptoms resolution or specialized<br />care required (bipolar disorder, psychosis, etc.)<br />Referral to child psychiatrist<br />Pediatrician refers to appropriate<br />community agency<br />Therapists/psychologist collaborate<br />with psychiatrist and pediatrician<br />G.Crum/A.Schlesinger 5-13-08<br />
    82. 82. CFCC: Beyond the Pilot<br />2 Child and Adolescent Psychiatrists <br />2 Triple Board trained Physicians<br />Therapists at 14 different locations<br />Non CCP patients seen at central location (Pine Center, Wexford Office)<br />
    83. 83. CFCC: Beyond the Pilot, Cont.<br />> 1500 patients seen since Aug 2008<br />Ave approx 600 visits/month<br />Approx 10% no show rate<br />80% diagnoses = anxiety, depression, or ADHD<br />Comorbidity<br />Depressive & Anxiety d/o<br />Anxiety d/o & ADHD<br />
    84. 84. CFCC: Strategies for Success<br />Buy in by all invested parties<br />Monthly meetings <br />Provide staff with appropriate tools/support<br />Centralized billing<br />
    85. 85. Communication is the key<br />Office Managers<br />Nurses<br />Operations<br />Scheduling Staff<br />Front desk<br /> Triage Staff<br />Families<br />
    86. 86. “Nothing changes, if nothing changes”<br />- Earnie Larsen<br />
    87. 87. Policy Implications<br />2010: Patient Protection and Affordable Care Act<br />Demonstration Projects<br />Medicaid Medical Home Pilot: Sec 2703<br />Medicaid Accountable Care Organization Pilot Program: Sec 2706<br />Co-location of Primary and Specialty Care in Community-Based Behavioral Health: Sec 5604<br />
    88. 88. Policy Implications, Cont.<br />Improve reimbursement rates<br />Improve incentives for screening and prevention<br />Recommend collaboration among Department of Health and Human Services agencies (HRSA, SAMHSA, etc)<br />
    89. 89. Thank You!<br />Kenneth Thompson, MD<br />Abigail Schlesinger, MD<br />Norman Cohen, MD<br />Roberto Ortiz-Aguayo, MD<br />Art Kovel, MD<br />Carl Bell, MD<br />Kristin Dalope, MD<br />Lynn Malec, MD<br />Sheree Shafer<br />Gretchen Crum<br />WPIC Triple Board Program<br />APA Public Psychiatry Fellowship<br />
    90. 90. References<br />AACAP Committee on Health Care Access and Economics, AAP Task Force on Mental Health. Improving Mental Health Services in Primary Care. Pediatrics Volume 123, Number 4: 1248-1251, April 2009 <br />American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Osteopathic Association. Joint Principles of the Patient-Centered Medical Home. Elk Grove Village, IL: American Academy of Pediatrics; 2007. Available at: http://www.medicalhomeinfo.org/Joint%20Statement.pdf.<br />Capko J., Practice Points: Home Sweet Medical Home. Repertoire, January 2011;19:<br />Collins C, Hewson DL, et al. “Evolving Models of behavioral Health Integration in Primary Care. Milbank Memorial Fund. May 2010<br />Doherty, W. The Why’s and Levels of Collaborative Family Health Care. Family Systems Medicine. 1995;13(3–4):275–81.<br />Goinik A, et al. Medical Homes for Children with Autism: A Physician Survey. Pediatrics Volume 123, Number 3: 966-971, March 2009<br />Horowitz L.M, Ballard ED, Pao M. Suicide screening in schools, primary care and emergency departments. Current Opinion in Pediatrics. 2009; 21 (5): 620-627<br />Holt, W. “The Massachusetts Child Psychiatry Access Project: Supporting Mental Health Treatment in Primary Care, A Case Study by the Commonwealth Fund,” March 2010. <br />Lake, Raymond. How academic psychiatry can better prepare students for their future patients. Part I: the failure to recognize depression and risk for suicide in primary care; problem identification, responsibility, and solutions. Behav Med. 2008 Fall;34(3):95-100.<br />Martin P., Griffin M., Krasnik C., “All in the Family: The Benefits and Challenges of Collaborative Health Care Models.” APA 62nd Institute on Psychiatric Services. October 15, 2010<br />Merikangas KR, He J, Burstein M, Swanson SA, Avenevoli S, Cui L, Benjet C, Georgiades K, Swendsen J. Lifetime Prevalence of Mental Disorders in U.S. Adolescents: Results from the National Comorbidity Survey Replication-adolescent Supplement (NCS-A). JAACAP . 2010; 49 (10): 980-989 <br />
    91. 91. References, Cont.<br />O'Connell ME, Boat T, Warner KE. Preventing Mental, Emotional, and Behavioral Disorders Among Young People:<br /> Progress and Possibilities. The National Academies Press 2009.<br />Policy Statement- The Future of Pediatrics: Mental Health Competencies for Pediatric Primary Care.  Committee on Psychosocial Aspects of Child and Family Health and Task Force on Mental Health. Pediatrics Volume 124, Number 1:410-417,July 2009<br />Sarvet B., Gold J., Bostic, J.Q., et al., “Improving Access to Mental Health Care for Children: The Massachusetts Child Psychiatry Access Project,” Pediatrics, December2010; 126;1191-1200<br />U.S. Department of Health and Human Services. Mental Health: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health, 199<br />The President’s New Freedom Commission on Mental Health. Achieving the Promise: Transforming Mental Health Care in America. July 2003<br />http://www.ahrq.gov/<br />http://www.mcpap.com/index.asp<br />http://www.nacronline.com/recovery-issues/dealing-with-your-dark-side-part-4<br />http://www.nih.gov<br />http://samhsa.gov<br />www.aap.org<br />www.aacap.org<br />www.psych.org<br />www.thenationalcouncil.org<br />
    92. 92. Promoting Improved Integration: An Examination of Collaborative Health Care ModelsPresented by the APA Council on Advocacy and Government Relationsat the 2011 Annual Meeting of the American Psychiatric AssociationMay 17, 2011 | Honolulu, HawaiiPaying for Integration<br />Margaret Balfour, MD, PhD<br />APA/BMS Public Psychiatry Fellow<br />Public Psychiatry/T32 Postdoctoral Research Fellow<br />University of Texas Southwestern Medical Center at Dallas<br />
    93. 93. Integration can be…<br />How services are organized, infrastructure, etc. <br />Payment mechanisms <br />and policies<br />What the consumer experiences<br />
    94. 94. Foundations of clinical integration<br />Clinical integration is the ultimate goal.<br />Financial and structural integration don’t automatically result in clinical integration.<br />But it’s difficult to have clinical integration without financing and infrastructure that support collaboration.<br />
    95. 95. Many barriers to financial integration<br />http://www.thenationalcouncil.org/galleries/resources-services%20files/BHCoverage_onSameDay_byState_9_14.BMP<br />
    96. 96. Lack of Medicaid reimbursement for:<br />Same-day visits<br />Undermines the concept of “warm-handoffs” and co-location<br />Care management and provider communication<br />Which is the centerpiece of collaborative models<br />PCPs coding primary mental health diagnoses<br />Screening and prevention<br />SAMHSA. Reimbursement of Mental Health Services in Primary Care Settings. 2008.<br />http://download.ncadi.samhsa.gov/ken/pdf/SMA08-4324/SMA08-4324.pdf<br />
    97. 97. Health plan barriers<br />Carve-outs: <br />lack of reimbursement for PCPs outside the health plan<br />no financial incentive for coordination of care with physicians in other panels<br />Medical cost savings not on the radar<br />No reimbursement for consultation, team meetings or phone calls<br />Even if one health plan has a perfect reimbursement model, most practices have patients on many different plans <br />AHRQ. Integration of Mental Health/Substance Abuse and Primary Care, 2008. <br />http://www.ahrq.gov/downloads/pub/evidence/pdf/mhsapc/mhsapc.pdf<br />
    98. 98. Looking to the literature<br />Many programs are grant funded, and extra FTEs and services may not be sustainable outside the pilot/clinical trials environment<br />Studies usually don’t go into detail about funding mechanisms<br />Many studies compare different clinical and structural models, but none directly compare financial models<br />Mostly have to rely on case studies at this point<br />But groups are starting to study “real-world” implementation/financing issues.<br />AHRQ. Integration of Mental Health/Substance Abuse and Primary Care, 2008. <br />http://www.ahrq.gov/downloads/pub/evidence/pdf/mhsapc/mhsapc.pdf<br />
    99. 99. RWJF Depression in Primary Care Program<br />Goal is to identify and implement economic and organizational strategies that will sustain care improvements.<br />Identified seven reimbursement models for care management<br />Differ in where the care managers are based and how they’re funded.<br />J. Bachman et al. Funding mechanisms for depression care management: opportunities and challenges. General Hospital Psychiatry 28 (2006) 278–288<br />
    100. 100. Care management funding models<br />Practice-based care management on a fee-for service basis<br />Care managers are employees of the practice and located on-site<br />Revenue flows from insurer to practice based on billing<br />Depends on insurer/state policies and coverage<br />Requires knowledge of covered CPT and HBAI codes<br />J. Bachman et al. Funding mechanisms for depression care management: opportunities and challenges. General Hospital Psychiatry 28 (2006) 278–288<br />
    101. 101. Care management funding models<br />Practice-based care managers under contract to health plans<br />Health plans contract with practices to provide CM to targeted plan members <br />CMs can be employees of either the practice, the health plan, or a 3rd party entity<br />Revenue for their services based on historical estimates of service costs and numbers served and paid in yearly or monthly retrospective payments<br />J. Bachman et al. Funding mechanisms for depression care management: opportunities and challenges. General Hospital Psychiatry 28 (2006) 278–288<br />
    102. 102. Care management funding models<br />Global capitation<br />Fully capitated HMOs have the flexibility to allocate resources<br />They may choose to fund CMs internally<br />Example: Kaiser Permanente Care Management Institute: www.kpcmi.org<br />J. Bachman et al. Funding mechanisms for depression care management: opportunities and challenges. General Hospital Psychiatry 28 (2006) 278–288<br />
    103. 103. Care management funding models<br />Pay for Performance (P4P)<br />Health plans offer financial incentives for meeting pre-defined performance improvement targets<br />Revenue is re-invested to support care managers and other quality improvement initiatives<br />J. Bachman et al. Funding mechanisms for depression care management: opportunities and challenges. General Hospital Psychiatry 28 (2006) 278–288<br />
    104. 104. Care management funding models<br />Health-plan based care management<br />Care managers are employees of the health plan<br />Provide services in the form of utilization review and care coordination with patients, behavioral health providers, PCP.<br />Usually have little face-to-face contact with the patients <br />Funded through administrative overhead paid to the health plan<br />Works best when health plan is in close geographical proximity to providers so relationships can be developed.<br />J. Bachman et al. Funding mechanisms for depression care management: opportunities and challenges. General Hospital Psychiatry 28 (2006) 278–288<br />
    105. 105. Care management funding models<br />Third-party based care management under contract to health plans<br />Health plans subcontract for CM services with disease management organizations, managed behavioral healthcare organizations, or CMHCs<br />Payments typically capitated with a PMPM payment based on historical estimates of costs and numbers served<br />J. Bachman et al. Funding mechanisms for depression care management: opportunities and challenges. General Hospital Psychiatry 28 (2006) 278–288<br />
    106. 106. Care management funding models<br />Hybrid models<br />Combinations of all the above<br />For example: CMHC care managers placed in primary care, partly funded via fee-for-service billing, and partly through health plan contracts<br />J. Bachman et al. Funding mechanisms for depression care management: opportunities and challenges. General Hospital Psychiatry 28 (2006) 278–288<br />
    107. 107. Coding tips: Diagnosis and CPT E&M <br />Study of depression claims in primary care settings to evaluate reasons for denials<br />Found that most were coding errors not necessarily specific to MH policy issues<br />http://www.machc.org/<br />
    108. 108. Coding tips: HBAI codes<br />Health and Behavior Assessment/Intervention Codes for non-physicians in primary health settings<br />American Psychological Association online tool<br />http://flash1r.apa.org/apapractice/hbcodes/player.html<br />
    109. 109. State-by-state variability<br />http://www.thenationalcouncil.org/galleries/business-practice%20files/Map_of_Available_HBAI_CPT_Codes1.pdf<br />
    110. 110. Other tools<br />To assess funding environment<br />Kaiser Commission Report on Medicaid and the Uninsured<br />State by state description of covered services and reimbursement methods, available Level II HCPCS codes, etc.<br />http://www.kff.org/medicaid/benefits/service.jsp?nt=on&so=0&tg=0&yr=2&cat=7&sv=40<br />NCCBH Environmental Assessment Tool State Level Policy and Financing<br />Questionnaire to assess whether state polices will promote or act as a barrier towards integration<br />http://www.thenationalcouncil.org/galleries/business-practice%20files/PC-BH%20Environment-State%20Policy.pdf<br />Lots of other resources: <br />SAMHSA-HRSA Center for Integrated Solutions<br />http://www.thenationalcouncil.org/cs/center_for_integrated_health_solutions<br />
    111. 111. The future?<br />PPACA creates new Center for Medicare and Medicaid Innovation (CMI)<br />Funds payment reform pilots that promote payment for value rather than payment for volume.<br />Case-rate: bundled payments for an individual for an episode of care<br />Global payments: bundled payments for an individual for a period of time<br />Removes barriers, creates more flexibility, incentives for prevention and integration models<br />Dale Jarvis, The Business Case for Bidirectional Integrated Care. 2010.<br />http://www.thenationalcouncil.org/galleries/policy-file/CiMH%20Business%20Case%20for%20Integration%206-30-2010%20Final.pdf<br />
    112. 112. Further in the future?<br />Move away from our “sick care” system<br />Towards Patient-Centered Medical Homes supported by Accountable Care Organizations<br />(The following slides were gratuitously stolen (with permission) from a presentation at the recent NCCBH conference by Dale Jarvis and Andy Keller.)<br />
    113. 113. Typical Current “Wiring Diagram”<br />
    114. 114. Care System<br />Supportive <br />Payment <br />and<br />regulatory<br />environment<br />High <br />performing <br />patient-<br />centered<br />teams<br /> Outcomes<br /><ul><li>Safe
    115. 115. Effective
    116. 116. Efficient
    117. 117. Personalized
    118. 118. Timely
    119. 119. Equitable</li></ul>ACO delivery <br />organizations <br />that facilitate <br />the work of<br />patient-<br />centered <br />teams <br />The Fix:<br />There is an emerging consensus about how to fix the health care system. The Institute of Medicine describes the fix with the following diagram. <br />In order to achieve desired outcomes, the delivery system must organize itself into high performing patient-centered teams supported by health care organizations that facilitate this work. This requires: <br />Person-Centered Healthcare Homes Supported by Accountable Care Organizations. <br />These organizations, in turn, must be supported by the payment and regulatory system.<br />
    120. 120. Which requires the Customization of the Accountable Care Organization<br />
    121. 121. And Organizing the Safety Net Payors<br />Washington State’s<br />fledgling two-part effort:<br />A Regional Health Authority to organize the payors to create a supportive payment and regulatory system<br />That will, in turn, support organizing the delivery system into accountable systems of care<br />
    122. 122. KEY IDEA: Get the payors working together in the same way we’re expecting the providers to work together<br />
    123. 123. Questions?<br />Viewable slideshow: http://www.slideshare.net/collaborativehealthcaremodels/<br />Downloadable PDF:<br />http://sites.google.com/site/collaborativehealthcaremodels/<br />Contact Information<br />Peter Martin: psmartin@gmail.com<br />John Lusins: drjlusins@gmail.com<br />Marilyn Griffin: griffinm3@upmc.edu<br />Margaret Balfour: margaret.balfour@gmail.com<br />

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