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Common Medical Illnesses and Depression

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									  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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