Integrated Behavioral Health within the Medical Home

(1)

Integrated

Behavioral

Health within the

Medical Home

Measurement-based care,

Treatment to target

Treatment to target,

Accountable care:

t t

id P4P

a statewide P4P program

Jürgen Unützer, MD, MPH, MA

(2)

Jürgen Unützer, MD, MPH, MA

Disclosures

Employment: University of Washington

•

Professor & Vice Chair, Dept. of Psychiatry

,

p

y

–

Chief of Psychiatry, University of Washington Medical Center

–

Director, Division of Integrated Care and Public Health

–

Director, AIMS Center: Advancing Integrated Mental Health Solutions

•

Adjunct Professor, School of Public Health: Health Services

Grant funding (current & recent)

N ti l I tit t f H lth (NIMH NIDA AHRQ NLM)

• National Institute of Health (NIMH, NIDA, AHRQ, NLM)

• Department of Defense (Henry M. Jackson Foundation)

• American Federation for Aging Research (AFAR)

• John A. Hartford Foundation

• Alaska Mental Health Trust Authority

• George Foundation

• American Red Cross (RAND)

• California HealthCare Foundation

• Robert Wood Johnson Foundation

• Hogg Foundation for Mental Health Contracts (current & recent)

• Community Health Plan of Washington, Public Health of Seattle & King County

• Washington State Healthcare Authority

• California Institute of Mental Health

• Los Angeles County Department of Mental Health Santa Clara County Ventura County

• Los Angeles County Department of Mental Health, Santa Clara County, Ventura County

• Healthelink, Independent Health,

• NAVOS

• Institute for Clinical Systems Improvement (ICSI)

• Mathematica / Center for Healthcare Strategies Consultant (current & recent)

• AARP Services Incorporated (ASI)

• National Council of Community Behavioral Health Care (NCCBH)National Council of Community Behavioral Health Care (NCCBH)

• RAND Corporation

• Group Health Research Institute Advisor (current & recent)

• Carter Center Mental Health Program

(3)

University of Washington

20

f R

h

d P

ti

20 years of Research and Practice

in Integrated Mental Health Care

(4)

Example: Depression

1/10 see psychiatrist

5/10 receive

treatment in

primary care

~ 30 Million with an

30 Million with an

antidepressant Rx

but

(5)

(6)

Health Care Reform:

Moving towards coordinated / integrated care

Coordinated Care

Patient Centered

Un-managed

Moving towards coordinated / integrated care.

Integrated

Health

Fee

Accountable

Care

•

Organized care delivery

Ali

d i

i

•

Patient Care Centered

–

Personalized Health Care

–

Productive and informed interactions

between Patient and Provider

–

Cost and Quality Transparency

•

Fee For Service

Fee

for Service

Care

–

Aligned incentives

–

Linked by HIT

•

Integrated Provider

Networks

y

p

y

–

Accessible Health Care Choices

–

Aligned Incentives for wellness

•

Multiple integrated network and

community resources

Fee For Service

–

Inpatient focus

–

O/P clinic care

–

Low Reimbursement

–

Poor Access and Quality

Little oversight

•

Focus on cost avoidance

and quality performance

–

PC Medical Home

–

Care management

–

Transparent Performance

•

Aligned reimbursement/care

management outcomes

•

Rapid deployment of best practices

P ti

t

d

id

i t

ti

–

Little oversight

•

No organized networks

•

Focus on paying claims

•

Little Medical Management

Transparent Performance

Management

•

Patient and provider interaction

–

Information focus

–

Aligned self care management

–

E-health capable

•

Little Medical Management

6

(7)

IMPACT Team Care Model

(P ti

t C

t

d M di

l H

f

B h

i

l H

lth)

(Patient Centered Medical Home for Behavioral Health)

Primary Care Practice with Mental Health Care Manager

Outcome

Measures

Treatment

Protocols

Population

Registry

Psychiatric

Consultation

(8)

IMPACT Study

1998 – 2003

1,801 depressed adults in primary care

randomly assigned to usual care or IMPACT

collaborative care and followed for 24 months

18 primary care clinics

8 health care organizations in 5 states

– Diverse health care systems (FFS, HMO, VA)

– 450 primary care providers

– Urban and semi-rural settings

Funding

John A. Hartford Foundation, California HealthCare

Foundation, Robert Wood Johnson Foundation, Hogg

Foundation

(9)

IMPACT doubles effectiveness of

care for depression

50 % or greater improvement in depression at 12 months

60

70

Usual Care

IMPACT

%

40

50

20

30

0

10

1

2

3

4

5

6

7

8

Participating Organizations

Unützer et al., JAMA 2002; Psych Clin NA 2004

(10)

IMPACT improves physical function

p

p y

SF-12 Physical Function Component Summary Score (PCS-12)

P<0 01

40.5

41

P<0.01

P=0.35

39 5

40

Usual Care

39

39.5

Usual Care

IMPACT

38

38.5

38

Baseline

3 mos

6 mos

12 mos

(11)

IMPACT reduces health care costs

ROI $ 6 5

d / $ 1 i

t d

ROI: $ 6.5 saved / $ 1 invested

4-year Intervention Usual

care

Cost Category

y

costs

in $

group cost

in $

group cost in

$

Difference in

$

IMPACT program cost

522

0

522

S

i

Outpatient mental health costs

661

558

767

-210

Pharmacy costs

7,284

6,942

7,636

-694

14 306

14 160

14 456

296

Savings

Other outpatient costs

14,306

14,160

14,456

-296

Inpatient medical costs

8,452

7,179

9,757

-2578

Inpatient mental health /

114

61

169

-108

Inpatient mental health /

substance abuse costs

114

61

169

-108

Total health care cost

31,082

29,422 32,785

-$3363

(12)

IMPACT: Summary

y

-

Less depression

-

Less depression

IMPACT more than doubles

effectiveness of usual care

-

Less physical pain

-

Better functioning

-

Higher quality of life

-

Greater patient and

provider satisfaction

-

Lower health care costs

The Triple Aim

(13)

Patient Centered Medical Home

P ik

t l A

J M

C

2012 18(2) 105 116)

Peikes et al, Am J Manag Care 2012; 18(2): 105-116)

•

498 studies => 12 evaluations that meet criteria: practice

p

innovation with >= 3/5 key PCMH components and

quantitative study of triple aim outcomes.

O l 6

l

ti

d

d i

id

1

•

Only 6 evaluations produced rigorous evidence on 1 or

more outcomes

•

Some favorable effects on all 3 triple aim outcomes: quality,

cost, patient / provider experience

•

Conclusion: PCMH is a promising innovation but rigorous

tit ti

l

ti

d

h

i

quantitative evaluations and comprehensive

implementation analyses are needed to assess

effectiveness.

(14)

(15)

UW AIMS Center:

5 000 providers trained in > 600 primary care clinics

5,000 providers trained in > 600 primary care clinics

4000

4500

5000

3000

3500

4000

ained

2000

2500

C

linicians

Tr

a

~ 600 clinics

500

1000

1500

C

~ 600 clinics

CMMI

Innovation

0

Grrant

(16)

Washington State

g

•Funded by State of Washington and Public Health Seattle & King County

(PHSKC)

• Administered by Community Health Plan of Washington and PHSKC in

partnership with the UW AIMS Center

Initiated in 2008 in King & Pierce Counties & expanded to over 100 CHCs

• Initiated in 2008 in King & Pierce Counties & expanded to over 100 CHCs

and 30 CMHCs state-wide in 2009.

(17)

Mental Health Integration Program

g

> 25,000 clients served

(18)

Web-based Registry (CMTS

g

y (

©

)

• Access from anywhere

• Access from anywhere.

• Population-based.

• Keeps track of ‘caseloads’.

• Allows research on highly

representative populations

• Structures clinical encounters.

• Prompts follow-up.

F

ilit t

lt ti

• Facilitates consultation.

(19)

(20)

MHIP Community Health Centers

(6 clinics; over 2 000 clients served)

(6 clinics; over 2,000 clients served)

Population

Mean

baseline

Follow-up (%)

Mean

number of

% with

psych iatric

% with

significant

baseline

PHQ-9

depression

score

up (%)

number of

care

coordinator

contacts

psych iatric

case-review

consultation

significant

clinical

improvement

Disability

Lifeline

16 / 27

92 %

8

69%

43 %

Uninsured

15 / 27

83 %

8

59%

50 %

Older Adults

15 / 27

92 %

8

55%

43 %

Vets &

Family

15 / 27

92%

7

54%

53%

High risk

15 / 27

81%

7

50 %

60%

High risk

mothers

15 / 27

81%

7

50 %

60%

(21)

Quality Improvement through P4P

Quality Improvement:

pay-for-performance initiative introduced in

2009

–

25 % of clinic payments for services are

contingent on meeting quality indicators

•

2 contacts / month

•

Clinical improvement or psychiatric case

consultation

(22)

P4P-based quality improvement

cuts median time to depression treatment response in half.

1.

00

0.

75

P

ro

ba

bl

ili

ty

0.

50

C

u

m

ul

at

iv

e

P

0.

25

Es

ti

m

a

te

d

C

0.

00

0

8

16 24 32 40 48 56 64 72 80 88 96 104 112 120 128 136

Weeks

Before P4P

After P4P

(23)

Kaplan-Meier Survival Curve by Enrolled After 2009

1.

00

b

lil

it

y

Time to 50% PHQ improvement

0

0.

75

tiv

e

l P

rob

a

2

5

0.

5

0

e

d Cu

m

u

la

t

0

.0

0

0.

2

Es

ti

mat

e

Log-rank test for equality of survivor functions, p<0.001

0

8

16

24

32

40

48

56

64

72

80

88

96 104 112 120

Weeks

Before 2009, n=61

After 2009, n=592

(24)

Principles of Effective Integrated

Behavioral Health Care

Patient Centered Team Care / Collaborative Care

•

Colocation is not Collaboration. Team members have to learn new skills.

Population-Based Care

Population Based Care

• Patients tracked in a registry: no one ‘falls through the cracks’.

Measurement-Based Treatment to Target

g

• Treatments are actively changed until the clinical goals are achieved.

Evidence-Based Care

• Treatments used are ‘evidence-based’.

Accountable Care

• Providers are accountable and reimbursed for quality of care and clinical

outcomes, not just the volume of care provided.

(25)

Thank you

Thank you.

Jurgen Unutzer, MD, MPH, MA

unutzer@uw.edu

http://uwaims org

James D. Ralston

http://uwaims.org