Health into Primary Care and the PCMH 2.0 Charles Coleman, Ph.D. - PowerPoint PPT Presentation

The Rewards of Integrating Behavioral Health & Mental Health into Primary Care and the PCMH 2.0 Charles Coleman, Ph.D. IBM Population Health Solutions Team Lead Behavioral and Mental Health May 26, 2016

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3 Does Your Population Health Strategy Integrate Behavioral Health? Part 1 of a two part Series.

Population Health Holistic Integration Compass Clinical Behavioral / Genomics Mental Social / Family / Environmental 4

OVERVIEW OF THE SCOPE OF THE PROBLEM Disorders Disease Dollars

Faces of Depression • Major depressive disorders affect 15 million American adults annually resulting in $70 billion in medical expenditures, lost productivity. • People with undiagnosed and untreated depression are 4x likely to suffer a heart attack. • 25% of all cancer patients suffer from depression • 10%-27% of post-stroke patients suffer from depression, about the same percent as those suffering from diabetes.

Some FACTS about Behavioral/Mental Health… 29% 40 million 26% mood disorders are Americans 18 and US adults (18-54) Of all patients with treated by Primary older suffer from a have an anxiety chronic illnesses Care doctors diagnosable mental disorder in given year have a mental illness disorder 28% ~80% Majority Of all mental health Of Americans receive of all patients re- drug prescriptions are their mental health care admitted to hospitals written by PCPs and through their PCP and suffer from mental family doctors. Family Medicine doctor illness Source: NAMI, APA, CMS, Project Red

Mental Health Affects Clinical Conditions and Outcomes in a BIG WAY Source: Druss, B.G., and Walker, E.R. (February 2011). Mental Disorders and Medical Comorbidity Research Synthesis Report No. 21. Princeton, NJ: The Robert Wood Johnson Foundation. Percentage of Adults with Mental Health Conditions and/or Medical Conditions, 2001-2003 Adults with Medical Conditions

Behavioral Health + Co-Morbidities Have Significant Impact on Healthcare Costs $36,730 $35,840 Annual Per Capita Costs $24,927 $24,598 $24,443 $15,691 $8,788 $9,488 $9,498 $8,000 Asthma and/or COPD Congestive Heart Failure Coronary Heart Disease Diabetes Hypertension No Mental Illness and No With Undiagnosed and/or Drug/Alcohol Abuse Untreated Mental Illness and Drug/Alcohol Abuse Source: OptumHealth

Effect of Mental Health on Various Illnesses Illness Increased Risk 2x risk of type 2 diabetes 1 Diabetes Up to 3x risk of morbidity 2 Hypertension 3x risk of MACE 3 Major Adverse Cardiac Event Stable coronary artery dis. 3x risk of 1 st ischemic event 4 Ischemia Unstable angina 3x risk of cardiac death, 6x risk of nonfatal MI 5 Myocardial Infarction Stroke 3x risk of stroke 6 2-3x risk of mortality 7 Post-myocardial infarction 8x risk of mortality 8 Congestive heart failure MACE=major adverse clinical event (cardiac death, MI, nonelective revascularization) 1 Golden SH, et al. Diabetes Care. 2004;27:429-435; 5 Lespérance F, et al. Arch Intern Med. 2000;160:1354-1360; 2 Jonas BS, et al. Arch Fam Med. 1997;6:43-49; 6 Larson SL, et al. Stroke. 2001;32:1979-1983; 3 Frasure-Smith N, et al. Arch Gen Psychiatry. 2008;65:62-71; 7 Carney RM, et al. Psychosom Med. 2009;71:253-259; 4 Bremmer MA, et al. Am J Geriatr Psychiatry . 2006;14:523-530; 8 Jünger J, et al. Eur J Heart Fail . 2005;7:261-267.

Relative Risk of Medical Admission for Diabetics Without & With MH and SU comorbidity Diabetes Relative Risk None +MH +SU +MH+SU MH = Mental Health SU = Substance abuse

Relative risk of medical admission with & without MH and SU comorbidity -- Maryland Medicaid Adults, 2011 COPD Asthma Pneumonia NOS Relative Risk Bronchitis None +MH +SU +MH+SU

N=551 depressed pts 60+ yrs > randomized Reference

2008: Chronic conditions and comorbid psychological disorders For comorbid depression , increased healthcare costs “average $505 per comorbid member per month across all chronic medical conditions we analyzed, of which nearly $400 is higher medical costs.” 79% For comorbid anxiety conditions, they “average $651 per comorbid member per month across all chronic medical conditions we analyzed, of which nearly $538 is due to higher medical costs.” 83%

Depression Increases 30-Day Readmission Risk by Nearly 40% Mitchell et al, J Hosp Med 2010 Slide courtesy of Wayne Katon MD

Poor Care Coordination: $12 Billion Avoidable Costs Poor coordination of care cost an estimated $25 billion to $45 billion dollars per year (Donald M. Berwick, 2012). At least $12 billion of that total is considered avoidable (Health Affairs, 2012)

MAY, 2016 Mental Disorders Top The List Of The Most Costly Conditions In The United States: $201 Billion Charles Roehrig1,* Abstract Estimates of annual health spending for a comprehensive set of medical conditions are presented for the entire US population and with totals benchmarked to the National Health Expenditure Accounts. In 2013 mental disorders topped the list of most costly conditions, with spending at $201 billion.

MENTAL DISORDERS BY THE NUMBERS

LATEST CHANGES IN CARE MODELS AND DELIVERY SYSTEMS

Practice Transformation: Moving Away from Provider- Centric Episode of Care & Fee for Service Chronic disease Preventive Medication Acute Test monitoring medicine refills care results Doctor Case Clinical Medical Nursing Manager Specialists Assistants Source: Southcentral to . . . . Foundation, Anchorage AK

To an Evolving PCP-based Patient-Centered Medical Home and Value-Based Payments for Patient/Member Care Chronic disease compliance Chronic disease Acute mental monitoring health complaint Behavioral health Test RN/Case results Healthcare Manager Support Team Point of care testing Medical Assistants Medical Medication Specialists refills Clinician Acute Source: Southcentral Preventive care Foundation, Anchorage AK medicine

Example Value Stream Defined by the 2014 Standards: Behavioral Health Integration Sequence in PCMH Standard 2: Team-based care includes behavioral health Team- How Do Daily providers and services Based Huddles and Care Pre-Visit Prep Fit In this Standard 3: Assesses each patient and the PHM-- Sequence? population for behavioral health issues Assess Standard 3: Implements point of care reminders related PHM-- Engage to behavioral health conditions Standard 4: Provides coaching and self- Care Mgt management support for behavioral and Think Support health conditions Horizontally: Standard 5: Coordinates Create and tracks referrals to Care Coordination Customer- behavioral health services Centric Processes Standard 6: Measure, Measure evaluate, take action, Performance NCQA PCMH 2014 improve, re-measure

Requirements to Optimize PHM Automation Technology PHM and Engagement EMR Analytics Training LEAN & Process Design People Processes Knowledge, Efficient Ways Skills, Teams, of Working, Leadership, Scale Culture 23 IBM Phytel

Current PCMH for Collaborative Care for Diabetes Diabetes Consulting Care Endocrinologist Manager Engagement Programs Administrator Other Community-Based Resources Source: Unutzer, UW 24

PCMH: 2.0 Integrated Behavioral and Primary Care Model Adapted from Unutzer 25

PCMH: 2.0 Integrated Behavioral and Primary Care Model Managing a Chronic Disease and Mental Health Disorders Primary Care Physician T2 Diabetic with Consulting Healthcare Depression and Endocrinologist Coaches Bipolar Disorders & Psychiatrist Other Specialists and Health Aids Substance Treatment Centers/ Clinics Rehabilitation Centers / Home Health Care Agencies / State Agencies Adapted from Unutzer 26

BEHAVIORAL HEALTH AND MENTAL HEALTH RISK STRATIFICATION, DIFFERENTIAL ASSESSMENT AND DIAGNOSTIC TOOLS

At-Risk Populations with Co-Morbidities and Identified Mental Health Disorders 800 N = 1917 Patients N = 346 Patients 18% of this Patient 680 700 with Chronic Diagnosed with Population has co- Conditions Mental Health 600 morbidities that Disorder 500 452 include one or 370 400 more diagnosed 300 225 190 mental illnesses. 164 200 85 How many remain 100 52 45 38 36 21 12 undiagnosed? How 0 1 2 3 4 5 6 7 8 9 will we know? Selected Conditions 1.Diabetes Mellitus Type 2 & Unspec Type Maintenance 6.Depression 2.Hypertension 7.Anxiety 3.Cancer 8.Bi Polar Disorder 4.Congestive Heart Failure 9.PTSD 5.COPD IBM Analysis of Sample Population Data — 2014