Integrating Physical and Mental Health: SW Ohio Network Meeting Developing Policies for Integrating Care

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Integrating Physical and Mental Health SW Ohio
Network Meeting Developing Policies for
Integrating Care

• Ohio Coordinating Center for Integrating Care
• Health Foundation of Greater Cincinnati
• April 28, 2009

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Support

• Health Foundation of Greater Cincinnati
• Margret Clark Morgan Foundation
• ODMH
• Ohio Coordinating Center for ACT
• Barbara J. Mauer

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Resources

• Handouts
• Library/Pass Arounds
• INTERFACE/Website
• Each Other

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Agenda

• OCCIC
• Overview of Integrated Healthcare
• Panels
• LUNCH
• National policy and Initiative Action Areas
• Medical Home
• Networking

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We understand that you want.

• Rapid action
• Opportunities for collaboration
• Structural models
• Clinical best practices
• Billing clarity and opportunity
• Business models
• Decrease of regulatory burden
• Coordinated leadership
• Attendance to psychosocial/educational

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We understand that you want.

• Today

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History of this Initiative

• Ohio Morbidity and Mortality Research Study
• Ohio Wellness Colloquium
• Ohio Coordinating Center for Integrating Care

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OCCIC

• Infrastructure Development
• Hunt/Gather----Agrarian

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OCCIC

• Network----Learning Community
• Resources----- Toolkits
• Policy Plan------Action/Participation

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Overview

• Morbidity and Mortality
• Health Care Reform
• National Efforts
• Ohio Efforts
• Literature
• Medical Home for SMD

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• Focus Quadrants II and IV

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Morbidity and Mortality in People with Serious
Mental Illness

• Persons with serious mental illness (SMI) are
  dying 25 years earlier than the general
  population
• While suicide and injury account for about 30-40
  of excess mortality, 60 of premature deaths in
  persons with schizophrenia are due to medical
  conditions such as cardiovascular, pulmonary and
  infectious diseases (NASMHPD, 2006)

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Massachusetts Study Deaths from Heart Disease by
Age Group/DMH Enrollees with SMI Compared to
Massachusetts 1998-2000
2.2RR
4.9RR
1.5RR
3.5 RR
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Maine Study Comparison of Health Disorders
Between SMI Non-SMI Groups
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CATIE Study
CATIE source for SMI data NHANESIII source for
general population data Meyer et al., Presented
at APA annual meeting, May 21-26, 2005. McEvoy
JP et al. Schizophr Res. 2005(August 29).
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CATIE Study

• At CATIE baseline
• 88 of subjects who had dyslipidemia
• 62.4 of subjects who had hypertension
• 30.2 of subjects who had diabetes
• WERE NOT RECEIVING TREATMENT FOR THESE CONDITIONS

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Washington State General Assistance Population
DSHS GA-U Clients Challenges and Opportunities
August 2006
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Whats going on around integration of primary and
mental health?

• Health Care Reform
• Nationally?
• In Ohio?
• In the literature?

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ThemesGeneral Issues for Health Care Reform in
America

• Spending
• Quality
• Coverage
• Fragmentation

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Emerging Themes for Healthcare Reform for People
with SMI

• State and Federal
• Access
• Availability/ Coverage
• Quality
• Models/Efficacy
• Fiscal
• Payment structure
• Wellness
• Prevention/Person Centered

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Chronic Disease Management

• Chronic Care Model
• Payment/system redesign
• Medical Home
• Quality
• Outcomes
• PAC

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Overall Model for Improving Primary Care
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Implementing the Chronic Care Model

• Developing a Prepared, Proactive Practice Team
• For persons with SMI, this team will typically
  need to span multiple agencies MH, SA, medical,
  and social services
• Need strategies for linking these services
• Developing an Informed, Activated Patient
• Self-management ability to understand and
  manage ones health and medical problems
• Activation ability to act effectively in
  managing ones own healthcare
• Developing strategies for Reorganizing
  Healthcare
• Need to work across multiple stakeholders and
  agencies

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IMPACT

• Depression Treatment in Primary Care
• Adapted to other ages and conditions
• 5 most essential elements
• Collaborative Care team in PC
• Collaborative Care Manager
• Designated Psychiatrist
• Outcome Measurement/Registry
• Stepped Care

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IMPACT
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Collaborative Depression CareGilbody, et al,
Archives of Internal Medicine (2006)

• A meta-analysis of the evidence for collaborative
  depression care was published by. They examined
  37 randomized controlled trials with 12,355 total
  patients.
• Sufficient randomized evidence had emerged by
  2000 to demonstrate the effectiveness of
  collaborative care beyond conventional levels of
  statistical significance. Further and subsequent
  randomized trials have only sought to increase
  the precision of existing estimates of
  effectiveness, and it is unlikely that further
  randomized evidence will overturn this result.

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The Role of the Care Manager

• Primary Point of Contact
• Clinician
• Advocate
• Liaison
• Educator
• Coach/Cheerleader
• Translator

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Development of Medical Home Concept for people
with SMI

• General Elements (Informed by Chronic Care Model)
• Relationship with a personal physician
• Team based coordinated care
• Treat the whole person
• Enhanced access/linkage
• Payment
• Add expanded Care Management
• IMPACT Care Mgt./Stepped Care
• Registry
• Will cover in detail this afternoon

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National

• Federal Efforts
• Foundations
• National Organizations
• States

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CMHS/SAMHSA

• 10 by 10 Pledge (2007)
• We envision a future in which people with mental
  illnesses pursue optimal health, happiness,
  recovery, and a full and satisfying life in the
  community via access to a range of effective
  services, supports, and resources 
• We pledge to promote wellness for people with
  mental illnesses by taking action to prevent and
  reduce early mortality by 10 years over the next
  10 year time period
• SAMHSA Grants
• 11 Grants/ 1 National TA
• Medical Home for SMDwith IMPACT elements
• ID programs/practice considerations

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Foundations

• Health Foundation of Greater Cincinnati
• Margret Clark Morgan Foundation
• California Endowment
• Hogg Foundation
• Maine Access Foundation
• Robert Wood Johnson Foundation
• Robert Graham Foundation
• Others..

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State example

• Missouris legislature provided seed funding for
  six pairs of CHCs and CMHCs to partner in
  improving care
• Partners include state DMH,(Parks) FQHC and CMHC
  trade organizations
• Evaluation will include primary care and
  behavioral performance measures, staff attitudes,
  and access and cost indicators

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In Ohio

• Governor's Office(s)
• State Agencies
• FQHCs
• MH Advocacy Groups
• Health Care Reform
• Health Plans
• Business Roundtable

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In Ohio

• Services
• Wellness/Recovery
• Direct Service Programs
• Psychoeducational Programs
• Agency Practices
• Workforce Development
• OCCIC
• Networking
• Tools
• Policy Agenda
• EVERYONE CAN DO SOMETHING!

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Whats going on around integration of primary and
mental health?

• Themes in Literature and Experiential
• Not one size fits all
• No specific EBPs for SMD
• Consider both structure and content
• Consider both medical and psychosocial
• Design with clients (and staff)
• Multiple (simultaneous) approaches are happening
• Local needs resources determine course
• Medical Home with Care Management emerging
• EVERYONE CAN DO SOMETHING

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Examples of (current) researched approaches for
improving Primary Care for Mental Health Consumers

• Team Based Approaches
• Consumer Driven Approaches

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Team-Based Models of Care Integrated Care
Clinic1

• A medical clinic was established to manage
  routine medical problems of patients with SMI at
  a VA
• Nurse practitioner provided the bulk of medical
  services a care manager provided patient
  education and referrals to mental health and
  medical specialists
• Study randomized 120 veterans to either the
  integrated care clinic or usual care, followed
  for one year

1. Druss BG, et al. Arch Gen Psychiatry.
200158(9)861-868.
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Integrated Care Clinic Results

• Access Significantly increased the rates and
  number of visits to medical providers, reduced
  likelihood of ER use
• Quality Significantly improved quality of most
  routine preventive services (15/17)
• Outcomes Significantly improved scores on SF-36
  Health Related Quality of Life
• Costs Program cost-neutral from a VA perspective
  (primary care costs offset by reduction in
  inpatient costs)

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Team-Based Models of Care Medical Care
Management1

• PCARE (Primary Care Access, Referral, and
  Evaluation) study
• 400 persons with SMI randomized to either care
  management or usual care
• Study setting inner-city, academically
  affiliated CMHC in Atlanta, GA. Population
  largely poor, African American, with SMI

1Funded by NIMH R01MH070437
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PCARE Intervention

• 2 nurse care managers (one psychiatric, one
  public health) help patients get access to and
  follow-up with regular medical care but do not
  provide any direct medical services
• Examples of services include patient education
  scheduling appointments, advocacy (e.g.,
  accompanying patients to appointments,
  communicating with PCPs)

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Consumer Based Approaches 1 HARP (Health and
Recovery Peer) Project1

• Adapting Stanfords Chronic Disease
  Self-Management Program (CDSMP), for MH Consumers
• Peer-led, manualized program designed to improve
  individuals self-management of chronic illnesses
• In general populations with chronic illnesses,
  the CDSMP has been shown to improve self-efficacy
  and reduce unnecessary health service use2

1. Funded by NIMH R34MH078583\ 2. Lorig K et al.
Med Care. 2001 Nov39(11)1217-23.
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Improving Self-Efficacy through Action Plans

• Set short and long-term goals
• Identify the specific steps and actions to be
  taken in order to pursue those goals
• Rank confidence, on a scale of 1-10, in achieving
  these objectives if the confidence is less than
  7 reexamine the barriers

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The HARP Program

• Much of the CDSMP was retained
• Six session format focuses on promoting
  self-efficacy through goal setting and action
  plans
• Sessions focus on health and nutrition, exercise,
  and being a more effective patient
• Changes
• Addition of content on MH and general health
  interaction symptoms and systems was added
• MH certified peer leaders trained to become
  master CDSMP trainers
• Diet and exercise recommendations tailored for
  socioeconomic status (SES) of public sector
  population

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Shared Care Plan

• Perhaps the best established community-based
  Electronic Personal Health Record developed at
  Peace Health in Seattle, WA
• Microsoft worked closely with the Shared Care
  developers in establishing Health Vault, its new
  platform for PHRs

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Adapting the Shared Care Plan

• Working with Shared Care developers (Pierson), MH
  consumer leaders (Fricks, Jenkins), integration
  experts (Mauer)
• Focus groups with consumers, MH and medical
  providers
• Enormous excitement from consumers
• Providers some concerns about TMI,
  trustworthiness of information

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Enhancements for My Health Record

• Advanced MH directives
• Personal recovery plan
• Notifications about upcoming visits and
  preventive services

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The Role of the Care Manager

• My Health Record
• Differs from PCARE in distinct and important
  ways
• Incorporating a personal health record
• Promoting an informed and activated patient as
  the focus of person-centered health care
• Connecting patients with community-based peer
  centers for training, web access and supportive
  networking
• Enlisting the help of a patient-identified health
  buddy who is already a supportive person in the
  patients life

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Local Considerations in Choosing a Integrated
Primary Care Model

• Community Resources What are the medical
  referral options in the community?
• Onsite Medical Capacity Are there qualified
  staff onsite who can deliver primary care
  services?
• Reimbursement Factors Who will pay for the
  services?
• Consumer Preferences Are people more likely to
  accept care in primary care or specialty
  settings?

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Implications for Community Practice

• Medical Home models for persons with SMI should
  target both practice teams and consumers
• Approaches can draw on existing resources
  including care managers and peer specialists
• Partnerships, particularly between state and
  local agencies are critical for system wide
  reorganization efforts

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Conclusions

• There are a growing number of approaches to
  improving health and health care in mental health
  consumers
• There is no one size fits all approach to
  improving health and health care for persons with
  SMI appropriate models will depend on patient
  needs, onsite capacity, the funding environment,
  and community resources
• The medical home movement nationally offers an
  opportunity to develop models specifically for
  the population with serious mental illnesseswe
  should assure that these consumers benefit from
  the intended improvements in access and quality
  of care that are targeted by medical homes
• EVERYONE CAN DO SOMETHING!

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Panels

• Panel 1 Lessons Learned
• Panel 2 Operations/Utilization
• Panel 3 Ohio Health Plans

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Panel 1 Lessons Learned

• Anne Combs
• Clermont Counseling
• Shana Trent
• Centerpoint

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Panel 2 Operations/Utilization

• Jeff ONeil
• GCBHS
• Brenda Coleman
• Health Care Connection

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Panel 3 Ohio Health Plans

• Jeff Davis
• Buckeye
• Lisa Warner
• Molina
• Bruce Pickens
• AMERIGROUP
• Kelly Kopecky
• CareSource

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LUNCH
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An EmergingNational Policy Agenda for
CMHCs/Integrated Health

• CMHC as Medical Home
• Payment methods/funding
• FQBHCs
• Research

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Payment Changes

• Some Ideas.
• Case Rate
• FQBHC prospective payment
• Gain sharing
• Federal Funding

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(Potential) FQBHC requirements

• Eligible
• Service Area
• Target Population
• Clinical Operations
• Service Provider mix
• IT
• QI
• Productivity

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(Potential) Research areascore CMHC competencies
(rooted in medical home)

• Clear model/strategy
• Full array of BH
• Assessment/LOC
• Prevention/Wellness
• Team models
• Clinical guidelines/EBPs
• Measurement systems/tools
• HER/Registry
• QI/Data
• Financial systems

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Additional issues

• Coverage
• Workforce
• IT/EMR

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OCCIC

• Network----Learning Community
• Tools-----Toolkits
• Policy Plan------Action/Participation

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Initiative Update

• 4 Action Areas
• Developed by 12/18 participants

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Fiscal

• Engaging partners
• Clarifying BH Medicaid
• Identifying current mechanisms
• Recognizing need for tools and policy

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Voice of Consumer

• Focus on Wellness
• COS as Critical
• Identifying Practices/Tools/Curricula
• Focus Groups

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State-Level Leadership

• Identifying Opportunities
• Developing Plan
• Engaging Groups
• Developing this initiative

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Medical Home
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Service Structure/Delivery ModelMedical Home

• Language
• Elements
• BH

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The Patient-Centered Medical Home

• Principles of the Patient-Centered Medical Home
• Personal physician
• Physician directed medical practice (team care
  that collectively takes responsibility for the
  ongoing care of patients)
• Whole person orientation
• Care that is coordinated and/or integrated
• Quality and safety (including evidence based
  care, use of information technology and
  performance measurement/quality improvement)
• Enhanced access to care
• Payment structure that reflects these
  characteristics beyond the current
  encounter-based reimbursement mechanisms
• The American Academy of Family Physicians,
  American Academy of Pediatrics,
• American College of Physicians, and American
  Osteopathic Association
• http//www.pcpcc.net/

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NCQA Certification Standards Patient Centered
Medical Home
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Person-Centered Healthcare Home

• Elements 6

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Person-Centered Healthcare Home

• Medical Home
• Regular Screening/Tracking Registry
• APN/PCP in CMHC
• PC Supervising Physician
• Embed Nurse Care Manager/Stepped Care
• EBPs for PH
• Linked Wellness Programs

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Measurement of Health Status for People with SMI
(NASMHPD 2008)

• Standard set of health indicators that will be
  gathered and used for the clinical care of each
  person served, as well as aggregated to provide
  population health data
• To be piloted in 2009

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Person-Centered Healthcare Home

• 4 quadrant

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• Focus Quadrants II and IV
• (when CMHC is Medical Home)

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Where Should Care Be Delivered?The National
Council Four Quadrant Integration Model

• Organize our understanding of the many differing
  approachesthere is no single method of
  integration
• Think about the needs of the population and
  appropriate targeting of services
• Clarify the respective roles of PCP and BH
  providers, depending on the needs of the person
  being served
• Identify the system tools and clinician skill and
  knowledge sets needed and how they vary by
  subpopulation
• Population based for system planning, services
  should be person-centered

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Where Should Care Be Delivered? Stepped Care

• There is always a boundary between primary care
  and specialty care
• There will always be tradeoffs between the
  benefits of specialty expertise and of
  integration
• Stepped care is a clinical approach to assure
  that the need for a changing level of care is
  addressed appropriately for each personIMPACT
  research demonstrates the effectiveness of a
  stepped care model and is the basis for the
  National Council Collaborative Care Project
• We need to implement this model
  bi-directionallyto identify people in primary
  care with MH conditions and serve them there
  unless they need specialty care, and to identify
  people in MH care that need basic primary care
  and step them to a full scope medical home for
  more complex carethe Four Quadrant model has
  been revised to reflect this thinking

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Person-Centered Healthcare Home

• 3- 4 levels

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Person-Centered Healthcare Home

• Level 1- Full Integration

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The Person-Centered Healthcare Home for People
with SMI

• Note the proposed renaming of the concept from
  patient-centered medical home
• See Behavioral Health/Primary Care Integration
  and The Person-Centered Healthcare Home, recently
  prepared by the National Council
• For BH providers envisioning a future role as
  person-centered healthcare homes, there are two
  pathways to follow
• Providers who want to become full scope
  person-centered healthcare homes for people with
  SMI should look to the Cherokee model and seek to
  become full scope providers of primary care
  services, for a broad community population as
  well as for those receiving BH services
• Providers who want to partner with full scope
  primary care organizations to create
  person-centered healthcare homes for individuals
  with SMI should organize a parallel to the IMPACT
  primary care model, with collaborative care, care
  management, a designated PCP consultant, outcome
  measurement, and stepped care for primary care
  needs in BH settings

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Person-Centered Healthcare Home

• Level 2- Partnership

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The Person-Centered Healthcare Home for People
with SMI Partnership

• Assure regular screening and registry
  tracking/outcome measurement at the time of
  psychiatric visits for all BH consumers receiving
  psychotropic medications
• Locate medical nurse practitioners/PCPs in BH
  clinicsprovide routine primary care services in
  the BH setting via staff out-stationed under the
  auspices of a full scope person-centered
  healthcare home
• BH organization hiring a nurse practitioner
  directly, without the backup of a skilled PCP and
  a full scope healthcare home cannot be described
  as providing a healthcare home, and is not a
  recommended pathway
• Identify a primary care supervising physician
  within the full scope healthcare home to provide
  consultation on complex health issues
• Assign nurse care managers to support individuals
  with elevated levels of glucose, lipids, blood
  pressure, and/or weight/BMI
• Use evidence based practices developed to improve
  the health status of all individuals with chronic
  health conditions, adapting these practices for
  use in the BH system.
• Create wellness programs

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Person-Centered Healthcare Home

• Level 3- specialty care and linkage

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The Person-Centered Healthcare Home for People
with SMI Link

• Assure regular screening and registry
  tracking/outcome measurement at the time of
  psychiatric visits for all BH consumers receiving
  psychotropic medications
• Identified PCP
• Clear communication/coordination mechanisms and
  expectations
• Education and Linking

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Person-Centered Healthcare Home

• Treating the Whole Person
• National Councils
• Minimum Expectations

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BH Providers Clinical Responsibility and
Accountability (National Council, 2008)

• If BH services include prescribing psychotropic
  medications, there are a set of accountabilities
  related to the whole health of the person
• Assure regular screening and tracking at the time
  of psychiatric visits for all consumers receiving
  psychotropic medications
• Check glucose and lipid levels, blood pressure
  and weight/BMI
• Record and track changes, response to treatment
  and use the information to adjust treatment
  accordingly
• The individual and family history, baseline and
  longitudinal monitoring as recommended by the
  ADA/APA should be the standard of practice
• Identify the current PCP for each individual, and
  when none exists, assist the individual in
  finding a PCP and accessing care
• Establish specific methods for communication and
  treatment coordination with PCPs and assure that
  timely information is shared in both directions

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OCCIC

• Emerging.Policy Areas---Action/Participation
• Broad Vision
• Access
• Quality
• Fiscal
• Wellness
• Broad Areas
• Partners
• Fit
• Best Practice
• Data

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OCCIC

• Broad Vision
• Access
• Availability
• Comprehensive
• Quality
• Models
• Outcomes

• Fiscal
• Medicaid
• New Mechanisms
• Wellness
• Person Focus
• Prevention

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OCCIC

• Broad AreasState and FederalEngaging
• Partners
• Funders
• Community Health Providers/Groups
• Fit
• Medicaid
• State Agencies
• Best Practices
• Wellness Prevention
• Clinical/Medical Home
• Data
• EMR/IT/Registry
• Evaluation/Research

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You
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NETWORK!
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Please complete your evaluations
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Thanks

• Jonas Thom
• Ohio Coordinating Center for Integrating Care
• 513-458-6733
• jthom_at_healthfoundaiton.org