From Head to Toe: Integrated Care to Meet the Whole Person s Needs - PowerPoint PPT Presentation

From Head to Toe: Integrated Care to Meet the Whole Person ’ s Needs �

From Head to Toe: � Trip Gardner, MD � � � � � Becky Hayes Boober, PhD � Medical Director of � � � � � � Senior Program Officer � Homeless Health Services � � � � Maine Health Access Foundation � Chief Psychiatric Officer � Penobscot Community Health Care �

Today ’ s Focus � • What is Integrated Behavioral Health and Primary Care and Why Is It Important? � • MeHAF Experience: Genomic Insertion � • What We Learned � • Policy and Leadership Issues � • PCHC: What Taking Care of Head to Toe Needs Really Looks Like �

Why is Integrated Care needed? � • 7 ¡out ¡of ¡10 ¡in ¡ primary ¡care ¡ wai3ng ¡room ¡ have ¡behavioral ¡ health-­‑related ¡ needs ¡ • 40% ¡have ¡ mental ¡health ¡ issues ¡ • 68% ¡of ¡persons ¡ with ¡MI ¡have ¡ medical ¡ condi3ons ¡

Meet people where they are � • 8 times as many would rather see PCP than MI � • 54% with psychiatric conditions treated by PCP alone � • 75% of all psychiatric prescriptions from PCPs � • 50% of mental health problems go un-identified � • Depression is risk factor for type 2 DM, post MI death � � � U.S. Dept. of Health and Human Services. (2001). Report of a Surgeon General ’ s working meeting on the integration of mental health services and primaryhealth care. Rockville, MD: Author. www.surgeongeneral.gov/library/mentalhealthservices/ mentalhealthservices.PDF4 . � National Mental Health Association.America ’ s mental health survey, May 2000. Conducted by Roper Starch Worldwide, Inc. www.roper.com/Newsroom/content/news189.htm � Druss BG, Marcus SC, Olfson M Pincus HA. The most expensive medical conditions in America. Health Aff (Millwood). 2002 Jul-Aug;21(4):105-11. Pincus, Tanielian, Marcus, Olfson, Zarin, Thompson, Zito, (1998). Prescribing trends in psychotropic medications: � Primary care, psychiatry, and other medical specialties. JAMA, 279, 526-531. � Evans DL, Charney, DS http://www.nova-health.org/index.html � Charles Nemeroff, MD, PhD “ Depression and Heart Disease: Link is Clear ” JAMA 1993;270:1819-25 � � � � � �

Maine Study: 
 Comparison of Health Disorders Between SMI & Non-SMI Groups � 80 SMI (N=9224) 70 Non-SMI (N=7352) 59.4 Percent Members 60 50 40 33.9 30 28.6 28.4 30 22.8 21.7 16.5 20 11.5 11.1 6.3 5.9 10 0 Skeletal- Connective COPD Hypertension Liver Disease Gastro-Intestinal Obesity/Dyslipid Infectious Disease Dental Disorders Diabetes Cancer Heart Disease Pneumonia/Influenza

Monthly Expenditures for Chronic Conditions 
 With and Without Comorbid Mental Illnesses � From Melek and Norris (2005 Marketscan data) 9

10 Deadly Behaviors � Tobacco use � � � � � � Poor diet � Lack of physical activity � � � Alcohol abuse � Avoidable infections/toxins � � Exposure to � Gun misuse � � � � � � � Unsafe sex � Unsafe driving � � � � � Illicit drug use � � Plus Nonadherence Behavior � More than half - smoking, being inactive and eating badly. 
 � Actual causes of death in the United States. 
 McGinnis JM - JAMA - 10-NOV-1993; 270(18): 2207-12 � http://www.nhregister.com/articles/2008/09/22/news/b1-katzcolumn.txt � 10

What is Integrated Care? � • Integrated Care brings behavioral, mental, and physical health to people in a coordinated way. It creates a relationship between a patient and a team of health professionals to achieve improved health and cost effectiveness. � • Desired Outcome : People ’ s health, daily lives, and functioning improve as a result of engaging with a health care system that treats them as whole persons. The system integrates behavioral health and primary care and is cost effective. � • Backbone of care � �

Levels ¡of ¡Collabora3on ¡ MH/Primary Care Integration Options Basic Minimal Basic Collaboration Collaboration On- Close Collaboration/ Function Collaboration from a Distance Site Partly Integrated Fully Integrated/Merged THE CONSUMER and STAFF PERSPECTIVE/EXPERIENCE Access Two front doors; Two front doors; cross Separate reception, but Same reception; some One reception area where consumers go to system conversations on accessible at same joint service provided with appointments are scheduled; separate sites and individual cases with site; easier two providers with some usually one health record, one organizations for signed releases of collaboration at time of overlap visit to address all needs; services information service integrated provider model Services Separate and distinct Separate and distinct Two physicians Q1 and Q3 one physician One treatment plan with all services and treatment services with occasional prescribing with prescribing, with consumers, one site for all plans; two physicians sharing of treatment consultation; two consultation; Q2 & 4 two services; ongoing consultation prescribing plans for Q4 consumers treatment plans but physicians prescribing and involvement in services; one routine sharing on some treatment plan physician prescribing for Q1, 2, 3, individual plans, integration, but not and some 4; two physicians for probably in all consistently with all some Q4: one set of lab work quadrants; consumers Funding Separate systems and Separate funding Separate funding, but Separate funding with Integrated funding, with funding sources, no systems; both may sharing of some on-site shared on-site expenses, resources shared across needs; sharing of resources contribute to one project expenses shared staffing costs and maximization of billing and infrastructure support staff; potential new flexibility Governance Separate systems with Two governing Boards; Two governing Boards Two governing Boards that One Board with equal little of no line staff work together with Executive Director meet together periodically representation from each partner collaboration; on individual cases collaboration on to discuss mutual issues consumer is left to services for groups of navigate the chasm consumers, probably Q4 EBP Individual EBP’s Two providers, some Some sharing of EBP’s Sharing of EBP’s across EBP’s like PHQ9; IDDT, implemented in each sharing of information but around high utilizers systems; joint monitoring of diabetes management; cardiac system; responsibility for care (Q4) ; some sharing of health conditions for more care provider across populations cited in one clinic or the knowledge across quadrants in all quadrants other disciplines Data Separate systems, Separate data sets, Separate data sets; Separate data sets, some Fully integrated, (electronic) often paper based, little some discussion with some collaboration on collaboration around some health record with information if any sharing of data each other of what data individual cases individual cases; maybe available to all practitioners on shares some aggregate data need to know basis; data sharing on population collection from one source groups

MeHAF Investment � • $10 ¡million ¡ • 10 ¡years ¡ • Convening ¡ • Grant ¡Funding ¡ • Research ¡and ¡Evalua3on ¡ • Policy ¡Support ¡for ¡Sustainability ¡ ¡ • Focus ¡on ¡Pa3ent ¡and ¡Family-­‑Centered ¡Care ¡

MeHAF Grantmaking, TA � • 3 ¡rounds ¡of ¡funding ¡ • 2007-­‑2009 ¡ • Implementa3on ¡2008-­‑2012 ¡ • Planning ¡and ¡Implementa3on ¡ • Clinical ¡Services ¡and ¡Systems ¡Transforma3on ¡ • Ac3ve ¡Learning ¡Community ¡with ¡quarterly ¡ mee3ngs, ¡Reimbursement ¡and ¡Coaching ¡TA ¡

Evaluation � • State-level � • Site Self Assessments � • Site Specific Evaluation and � Outcome Measures � • Cross-Site Evaluation--JSI �

Rapid Spread � • Maine Hospital Association efforts (with payment incentive legislated) � • SIM grant � • Patient Centered Medical Homes � • ACA Section 2703 Health Homes Stage A � • ACA Section 2703 Behavioral Health Homes (Stage B) � • MeHAF Behavioral Health Homes 5 planning grants � • BHHAC �

Medical ¡Home ¡Movement ¡ ~ ¡ 540 ¡Maine ¡Primary ¡Care ¡ Prac1ces ¡ ¡ ¡~100 ¡MaineCare ¡ 82 ¡NCQA ¡PCMH ¡ ¡ Payer : Health ¡Home ¡ Medicaid Recognized ¡ Prac1ces ¡ Prac1ces ¡ ¡ 14 ¡FQHCs ¡ ¡ Payers : CMS ¡APC ¡ 26 ¡Maine ¡ Payer : • Medicare 20 ¡Pilot ¡ Demo ¡ Medicare PCMH ¡Pilot ¡ • Medicaid Phase ¡2 ¡ • Commercials Prac1ces ¡ ¡ Prac1ces ¡ (Anthem, Aetna, HPHC)

State of Maine Initiatives (Including DHHS) Waivers Recovery ACO State ME Value-based Employees ’ Contracting contracts CDC SIMS Grants (AHRQ, Health MeHAF) Homes/ Health PCMH InfoNet Maine Health Management Coalition (Quality Indicators) Aligning Forces

What Have We Learned? (Adoption) 
 � • Model evolution � • Leadership and PC provider buy-in � • BHP willingness to adapt to PC settings and to market services � • Perception that integration provides value added � • Patient and Family involvement in planning and decision making �