Integrating Primary Care and Behavioral Health: Lessons From a Ground View to 1,000 Feet Integrating Behavioral Health Project September 11, 2008 Larry Mauksch, M.Ed Department of Family Medicine University of Washington Principles for success in practice change • Build relationships through experiential team training on clinical and operational topics • Have regular huddles and meetings • Create team ownership of change, challenges, and successes • Find out what is important to patients in life, in problem focus, in treatment, and in relationships Principles for success in practice change • Figure out what to change first, don’t change everything at once, be patient but persistent • Do not let staff turnover cause system decay • Track Progress: patient, team, system, cost • Create back-up systems to optimize clinical success: – multidisciplinary transdisciplinary Principles for success in practice change • Conserve resources and intensify care for patients with greater complexity (stepped care) • CELEBRATE SUCCESS!!! Person Obesity Depression Family Substance abuse Diabetes Primary Patient Care Provider Care Beh Health Management Consult or Tx Self Psychiatric Management Consult or Tx Group Primary Care Provider Shared Space Financial Patient Organizational Incentive Features Promoting Integrated Information To Work Integration System: Together Hallway Case Updates and Beh Health Leadership Management Electronic Medical Record Consult or Tx Shared consults / Vision Mission Provider communication Team Training Patient tracking for f/u 3-way meetings Ongoing Training Self Psychiatric Management Consult or Tx Group Marillac Clinic Background • Primary care clinic: – medical, dental, mental health, optical • Only serves people: – at or below 200% Fed poverty guidelines – uninsured (no Medicaid or Medicare) • Grand Junction, Colorado – 2004 population of Mesa Country = 127,000 • Private, non profit, not an FQHC • In 2004: 9700 visits from 3100 patients Prevalence : Marillac-500 Vs PHQ-3000 Any Diagnosis Major Depression Panic Dis Other Anxiety Disorder Bulimia Other Depression Binge Eating Dis Prob Alcohol Abuse 0% 10% 20% 30% 40% 50% 60% PHQ-3000 Marillac 500 Patient Health Concerns at Appointment n = 500 35 30 25 Percent 20 15 10 5 0 s on s rn e es iti te s s od si es ce c ch u s b e er k o n tr n en a in ia rd ec m te s co nd ea d S D o h ith er ety in e H D is /c w yp xi Sk ep c k fil l s H n d A a re lem cco B n ob ba atio Pr To ic ed M Patient Written Concerns (%) Elicited by Provider (%) M arilllac Utilization: Top 10 Provider Diagnose s 6783 visits: 6/1/98 - 5/22/99 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% DEP HTN SIN TOB ANX FHM NIDD Brnch SrTh ETOH Top 10 Diagnostic Pairs at Marillac 27% of 3036 Multiple Prob Visits 6/1/98 - Dep-Anx Dep-HTN NIDD-HTN Dep-Tob Dep-ETOH Obes-HTN Dep-FHM Sin-Tob FHM-HTN HTN-Tob 0.00% 1.00% 2.00% 3.00% 4.00% 5.00% 6.00% 7.00% Collaborative Care: Phases of Integration at Marillac • Preliminary work (1994-1996)- Therapist leaves at 6 mo • Phase 1 (1997-1998) Building a conceptual and physical commitment in the clinic and community • Phase 2 (summer, 1998 - summer, 1999) Intensive training • Phase 3 (spring 1999 – spring 2002) Building the Marillac system and design of interagency model • Phase 4 (2002-2006) Quality improvement within Marillac and across agencies • Phase 5 (2006…) Decay, retraining and transformation towards a medical home Principles of change • Lasting collaboration requires an educational and training process that builds relationships between disciplines • A new culture • Meaningful and sustainable changes in service require change in system design • Chronic care model: Information systems, provider training, promotion of self management, expert consultation and decision support, community involvement Essential Ingredient: Organizational / Structural • Strong board and executive director support • Providers co-located for better communication • Combined medical record (paper going to EHR) with full access to MH and PC providers • Inter-agency collaboration – Funding – Shared training – Inter-agency communication and referral systems Family Addictions Case Psychologist Therapist Counselor Manager & Psychiatrist Medical Medical Exam Exam Rooms Rooms Medical Provider Medical Medical Stations Exam Exam Rooms Rooms Bathroom Medical Medical Physical Exam Medical Assistant Exam Rooms Rooms Layout Stations Medical Medical Exam Exam Rooms Rooms Reception Front Office Essential Ingredients: Clinical • Staff and interdisciplinary team training Clinicians and staff Clinicians and staff from community agencies • Patient tracking and follow-up Assessment of population needs and quality of care Clinical training • Didactic topics (evidenced based) • Patient and family centered communication skills • Primary care counseling skills • Collaborative care communication skills • Experiential approaches • Shadowing • Regular interdisciplinary case conferences Collaborative Tips: Behavioral Health Provider • Adherence • Share therapeutic info – Monitor dose – Family, cultural issues – Monitor side effects – Strategies – Monitor beliefs • Monitor overall health – Assess symptoms quality of life • Consult with – Note physical MD/PA/NP symptoms – Medication – Health maintenance – Successes – Chronic illness mgmt – Obstacles – Chronic illness beliefs Collaborative Tips: Medical/Nursing Provider • Share concerns about • Ask what adherence with MHP psychotherapeutic • Share psychosocial goals you can support information about – Communication skills patient and family – Cognitive changes • Encourage – Behavioral changes participation in – Emotional awareness psychotherapy • Assess patient beliefs • Share concerns about about psychotherapy other health care issues Collaborative Tips: Care Manager • Monitor the gaps-- • Track “interstitial thinking” – Side effects • Track patients using – Adherence systems “owned” by – Outcomes the team. • Facilitate • Adapt communication – Referrals to varying styles of behavioral health and – Needed visits primary care – Defining shared goals providers – Community connections Marillac Outcomes A Proxy for Integration: Hallway consults Averages in 2003 and 2004 • 1034 consults between primary care providers and case managers or mental health therapists • 405 three way meetings between patients, behavioral health providers and primary care providers Quality of Care Improvement • Chart review comparison – All charted mental illnesses • 500 consecutive patients in 1999 • 500 consecutive patients in 2004 QI Acute Phase (120 days) 1999 2004 100 80 60 40 20 0 1 Seen • by Psych Rx 3 Seen • for Met all 3 PCP f/u criteria QI Continuation Phase 1999 2004 (9 months) 100 90 80 70 60 50 40 30 20 10 0 1 Seen • by PCP Psych Rx 3 Seen • in f/u Met all 3 criteria Stepped Care: 1999 vs 2004 Overall MH contacts and PCP contacts 12 10 8 6 4 2 0 2004 x 1d x 1999 2d 3+ H dx H M x H M 2d 1 M 3x l ta l ta P l P To PC ta P To PC PC To Primary Care Provider Contacts Acute phase (1st 120 days) 1999 2004 (149) (111) Patients with 1 mental health dx 3.2(75) 2.4(49) Patients with 2 mental health dx 3.7(54) 3.6(43) Patients with 3 mental health dx 3.7(20) 4.4(19) Continuation phase (9 months post acute phase) Patients in phase at start 36% 76% Average number of visits 3.1 2.5 3 CM 3.5 2 2.5 1 1.5 0 0.5 1 dx CM 2d x CM Co 3d un x se Co l1 un dx se l2 Co dx un se Gr l3 dx ou p 1 Gr dx ou p 2 Gr dx ou p Ps 3 yc dx hM Ps D 1d yc hM x Ps D 2d yc hM x D 3d Team member MH contacts x Stepped Care: 1999 vs 2004 1999 2004 1999 Number of Mental Health Contacts with Health Professionals in1999 and 2004 1999 2004 Patients Mean Patients Mean P-value Treated Visits Treated Visits Acute 149 3.16 111 4.81 .0001 Care Contin 139 3.76 193 4.88 .01 Care Essential Ingredients: Financial • Commitment of core organizational resources • Multi-organizational support • Development of new financial resources – Public and private grants – State health programs – New insurance relationships – State policy changes Donated FTE and Funding in Lieu of Decreased Uncompensated Care • From Local hospitals • Local mental health centers 1,000 Marillac Patient Hospital Admissions 60 Jan-April 2003 Jan-April 2004 50 40 30 20 10 0 CARDIOLOGY - PSYCH/DRUG Grand Total Medical ABUSE - Medical Psychiatry Inpatient Days January - April 2003 versus 2004 100% Marillac Medical Patients Average Length of Stay: 160 2003: 2.56 days 140 2004: 2.68 Days 120 100 80 60 40 20 0 Patient Days 2003 Patient Days 2004 Psychiatry Charges: January - April 2003 versus 2004 100% Marillac Medical Patients $350,000 $300,000 $250,000 $200,000 $150,000 $100,000 $50,000 $0 2003 2004 Research Team Larry Mauksch, M.Ed* Stephen Hurd, Ph.D# Randall Reitz, Ph.D# Susie Tucker, Ed.D# Wayne Katon, MD† Joan Russo, Ph.D† * University of Washington Department of Family Medicine # Marillac Clinic, Grand Junction, Colorado † University of Washington Department of Psychiatry and Behavioral Science Marillac Papers • Mauksch, L. B., Tucker, S. M., Katon, W. J., Russo, J., Cameron, J., Walker, E., & Spitzer, R. Mental illness, functional impairment, and patient preferences for collaborative care in an uninsured, primary care population. J Fam Pract 2001, 50(1), 41-47. • Cameron, J. and Mauksch, L. Collaborative Family Health Care in an Uninsured Primary Care Population: Stages of integration. Families, Systems and Health, 2002, 20(4) 343-363. • Mauksch, LB. Katon, W., Russo, J., Tucker, S., Walker, E Cameron, J. The content of a low income, uninsured primary care population: Including the patient perspective. Journal of the American Board of Family Practice, 2003, 16,:278-289. • Mauksch, L., Reitz, R., Tucker, S., Hurd, S., Russo, J., Katon,W. Improving Quality of Care for Mental Illness in an Uninsured, Low Income Primary Care Population, General Hospital Psychiatry, 2007, 29, 302-309 Remember • Build relationships through experiential team training on clinical and operational topics • Have regular huddles and meetings • Create team ownership of change, challenges, and successes • Find out what is important to patients in life, in problem focus, in treatment, and in relationships More to Remember • Figure out what to change first, don’t change everything at once, be patient but persistent • Do not let staff turnover cause system decay • Track Progress: patient, team, system, cost • Create back-up systems to optimize clinical success: – multidisciplinary transdisciplinary Still more to remember • Conserve resources and intensify care for patients with greater complexity (stepped care) • CELEBRATE SUCCESS!!!
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