What drives high utilization? Psychological distress (doesn’t have to be a disorder) Work pace hinders management of mild MH or CD problems; better with severe conditions BPC push is to have access for medical care; how can we do this if we address the BH disorders
Not based in a clinical case model - we were trained in this - MH & specialty med: don’t see people if they are not sick PCP: a gatekeeper and a shepherd for a flock - 50% of work could be preventive; sxs in pc tend to be less severe & easier to tx MH - 3% - a few people get a lot PCP - most get a little; can effect a large part of the population Why aren’t rates of dep going down? No emphasis on prevention, only TX Case specific: see people for an episode of care or a consultation Training model: is fee for service - Managed care hasn’t financialized hc, it’s always been a business
Colocation does not equal integration
2.5 million consumers; 19 medical centers - Implemented in Kaiser NC In rural MH, hc team is PCP and Bh PCP has good ideas about tx - just help PCP refine them to get better pt adherence to behavioral tx Core beh health skills in PCP are effective self-management skills (Ed Wagner: father of depression collaborative: can’t teach MD, just show them what you do; do something that’s effective and have the client tell the MD about it) If BHC is wrong a lot, they don’t get used. Can’t be sayig I have to see this client 12 times - need to have 60 minute interventions
Never take over a case; PCP is always the primary provider You are not a specialist Best outcome is resolution of mh problem in pc If you have to refer to specialty mh, indicate number of sessions and request a prevention plan for patient at time of specialty Primary care takes the people specialty rejects - borderlines 20% of pc patients get 1 bh visit per year
Cummings: targeted brief psychotherapy off-site: prob solving cost offset: saving med $ cost effectiveness: cost more
Integrated Behavioral Health:Primary Care Models of Service DeliveryScott S. Meit, PsyD, MBA, ABPPVice Chair for Psychology & Section Head,General and Health PsychologyDepartment of Psychiatry & Psychology
Learning ObjectivesI. To briefly review the “Medical Cost Offset” literature and understand its influence upon integrated primary care (IPC)II. To appreciate Public Health’s impact upon emerging IPC modelsIII. To explore the evolution from parallel delivery systems to integrated primary care/behavioral healthIV. Traditional BH care and IPC: Viva La Difference
Psychological Distress contributes to overutilization of health care At Group Health Cooperative of Puget Sound 10% of medical utilizers accounted for one third of outpatient resources and one half of inpatient resources! One half had psychiatric diagnoses! From Katon, Von Korff, Lin, Lipscomb, Wagner & Polk, 1990
And yet… Less than 30% of people seek care for their mental and/or addictive disorder Schurman, Kramer, Mitchell, 1985 Of the same population, 78% receive health care services Mauksch & Leahy, 1993- 60-90% of all visits to physicians at least partially due to psychological, emotional, and behavioral factors (Benson, 1996) Of those who seek treatment for mental and/or addictive disorders, 40-50% seek that care from PCPs Miranda, Hohman, Attkisson, 1994
Treating behavioral health disorders reduces cost of overall health care! (Medical Cost Offset) Kaiser-Permanente Experience Cummings NA, and Follette WT, Health Policy Quarterly, 1968 Follette W, and Cummings NA, Medical Care, 1967 Cummings NA, and VandenBos, GR, Health Policy Quarterly, 1981 Findings supported in meta-analysis & in other research “camps” Jones KR and Vischi TR, Medical Care (Suppl), 1979–a review of research literature Friedman R, Sobel D, Meyers P, et al, Health Psychology, 1995 Chiles J. et al. Clinical Psychology: Science and Practice, 1999 (57 controlled studies show a net 27% cost savings )
Yet patients present to PCPs instead ofPsychologists (and other behavioral health providers) – Why? Perceive themselves as having poor health Often multiple somatic complaints Established rapport with PCP Avoidance of stigma Cultural and socioeconomic factors Better insurance coverage/lower co-pay HMO/Behavioral Health carve outs
Why Integrate Primary Care and Behavioral Health Care?1. That’s where the Pts present! 50% of all MH care delivered by PCPs 92% of all elderly patients receive MH care from PCPs2. Primary Care Process of Care Realities 90% of the most common PC complaints = no organic basis 70% of all PC visits have psychosocial drivers (Fries, Koop, & Beadle, 1993) 67% of psychotropic agents prescribed by PCPs (Beardsley et al, 1988)K. Strosahl, PhD, Mountainview Consulting Group, Inc.
Public Health & Population-based Care:A “by the numbers” approach Public health & epidemiology – Focuses on raising health of population – Emphasis on early identification & prevention – Designed to serve high percentage of population – Provides triage and clinical services in stepped care fashion – Balanced emphasis on who is and is not accessing service
The Continuum of Integration Model Desirability Attributes Separate Space -- Traditional BH & Mission Specialty Model 1:1 Referral Preferred Relationship + provider/ Some information exchange Co-location ++ On-site BH Unit/ Separate Team Collaborative +++ On site/shared Care cases w/ BH specialist Integrated Care +++++ PC Team Member
So, how do you do this? Care Matching (primary care in primary care) Triage & “EAP” like services (mid-levels) Group & psycho-educational services Psychologist as director of exam room BH care, provider of brief on-site therapy, & liaison to tertiary BH services Embrace the differences between traditional BH services and integrated primary care behavioral health services
Care Matching Not every problem requires intensive intervention Inappropriate matching = waste And can lead to iatrogenic complicationsIatros means physician in Greek, and -genic, meaning induced by. Combined, they become iatrogenic, meaning physician-induced. Iatrogenic disease, then, is disease which is caused by a physician.
BHC Primary Goals Act as consultant and member of health care team. Support PCP decision making. Build on PCP interventions. Teach PCP “core” behavioral health skills. Educate patient in self management skills through training. Improve PCP-patient working relationship. Monitor, with PCP, “at risk” patients.
BHC Goals (cont.) Manage chronic patients with PCP in primary provider role Assist in team building Simultaneous focus on health and behavioral health issues Effective triage of patients in need of specialty behavioral health Make IPC/BH services available to a large percentage of eligible population
Behavioral Health Consultant Session Structure Limited to 1-3 visits in typical case 15-30 minute visits Critical pathway programs may involve 4-8 appointments (e.g. Diabetes & Depression, Chronic Pain) May use classes and group care clinics Multi-problem patients seen regularly but infrequently over time
Behavioral Health Consultant Intervention Structure Informal, revolves around PCP assessment and goals Low intensity, between session interval longer Relationship generally not primary focus Visits timed around PCP visits Long term follow up rare; reserved for high risk patients
Behavioral Health Consultant Intervention Methods Limited face to face contact Uses patient education model Consultant is a technical resource to patient Emphasis on home-based practice to promote change May involve PCP in visits with patient
BHC Termination and Follow-up Responsibility returned to PCP (the BHC is a subject matter expert & resource; the Pt is and remains the Pt of the PCP) PCP provides relapse prevention or maintenance treatment BHC may provide planned booster sessions for at risk patients
Behavioral Health Consultant Information “Products” Consultation report to PCP Part of medical record “Curbside consultation” Written relapse prevention plans (e.g. “Mood First-Aid Kit”)
Qualities of A Successful Integrate Primary Care Service Provides timely access for PCP Service is integrated within primary care setting Service is viewed as a form of primary care Service is provided in collaboration with the PCP Service is provided as part of the health care process Improved clinical outcomes, satisfied patients (and health care providers), and managing productivity & financial risk as key goals
Economic Benefits of Integration Increased Productivity Capacity – Estimate of revenue ceiling of a health care system is closely tied to productive capacity of medical providers – PC capacity is commonly impacted by behavioral health management demands of (50% of medical practice time directed toward BH conditions) – Integrated behavioral health re-directs BH patients and “leverages” PCP practice time – PCP’s are freed to see medical patients with higher RVU conditions
Cost Effectiveness Measuring the impact of adding additional dollars to a medicalprocedure for value received (e.g. better diagnostic accuracy, clinical effectiveness) – Collaborative Care increased initial depression treatment costs but improved the cost-effectiveness of treatment for patients with major depression – Cost offset for specialty mental health costs – A positive cost effectiveness index of $491 per case of depression treated Von Korff et. al., 1998. Treatment costs, cost offset, and cost-effectiveness of collaborative management of depression Psychosomatic Medicine, Vol 60, Issue 2 143-149.
In SummaryIPC Benefits the Patient (and a broader Pt.Population) Mind-Body dualism avoided More diagnostic accuracy Greater range of treatment options
IPC/BH Benefits PCPs Assistance with diagnostic differential Less time/fewer visits required with PCP Concomitant medical conditions often improve BHC typically obtains more information regarding psychosocial factors BHC may assist in monitoring pharmacotherapy treatment adherence
IPC benefits BH Providers PCP can endorse the BH Provider and psychotherapy PCP will evaluate for medical illness and/or medication effects PCP can prescribe pharmacotherapy (often diminishing a need for psychiatrist consult) PCP often has helpful background information, with established Pts
How do you train for this? (if you want to) Alexander Blount, Ed.D. - UMass Dept of Family Medicine, Certificate Program in Primary Care Behavioral Health Connect with the integrated primary care/BH initiatives of the Family Medicine Education Consortium (Laurence Bauer, MSW, M.Ed., Chief Executive Officer – and in Dayton!)www.fmec.net and Read, Read, Read
Who pays for this?The Family Medicine Education Consortium recently conducted a series of meetings and a summit in Pittsburgh to begin to organize a tri-state (OH-PA- WV) IPC initiative. They have previously facilitated efforts in the Pacific NW & New England regions. Promoting a broad and inclusive membership of providers, consumer groups, & payors is their model In NE, this resulted in the President of the regional BC/BS group authorizing 10% higher reimbursements for all PCP services where IPC/BH model of services are in place.
Good Web Siteswww.integratedprimarycare.com/www.integratedprimarycare.com/Blount.htm (Blount Link)www.behavioral-health integration.com/news.php(Strosahl’s site, Mountainview Consulting)www.healthpsych.com/practice/ipc/primarycare1.html(a little dated, but a good basis for understanding evolution of IPC)