BEHAVIORAL HEALTH INTEGRATIONCollaborative Care in Delaware

Linda J Lang, MD

Chair, Department of Psychiatry

Christiana Care Health System

Disclosures• I have no relevant disclosures or financial relationships

with commercial interests.

Integrated Behavioral Health Care Definition

• The Agency for Healthcare Research and Quality (AHRQ) defines integrated behavioral health care as:

“The care a patient experiences as a result of a team of primary care and behavioral health clinicians, working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population.”

(integrationacademy.ahrq.gov)

The IMPACT Trial

• In the 1990’s, the largest study of collaborative care was piloted.

• IMPACT: Improving Mood-Promoting Access to Collaborative Treatment

• Pioneered by Jurgen Unutzer, University of Washington• IMPACT showed 50% greater improvement in outcomes for

the treatment of depression in the collaborative care group compared to the usual care group.

• IMPACT showed significant patient and primary care provider satisfaction

• IMPACT showed significant reduction in overall health care cost

(Unutzer et al: Collaborative care management of late life depression in the primary care setting. JAMA 2002)

Why Collaborate?• 60% of patients with a psychiatric diagnosis do not

receive any form of treatment.• Half of those who do get treatment will receive their

treatment in a primary care setting.• The presence of a psychiatric diagnosis can increase the

overall cost of health care two to three-fold.• The shortage of Psychiatrists nationally is over 6000!

Continued…• Patients with behavioral health conditions are more likely

to be hospitalized for medical conditions, and are readmitted more frequently.

• Limited supply of Psychiatrists calls for strategic focus• Simultaneous treatment of medical conditions such as

Diabetes, heart disease, stroke, with behavioral health conditions such as depression, anxiety, leads to improved outcomes, better adherence to treatment, improved coordination of care between specialties, fewer patients being lost to treatment.

FIVE PRINCIPLES OF COLLABORATIVE CARE

• 1. PATIENT CENTERED TEAM• 2. POPULATION-BASED CARE• 3. MEASUREMENT-BASED TREATMENT• 4. EVIDENCED-BASED CARE• 5. ACCOUNTABLE CARE

PATIENT-CENTERED TEAM

The team consists of the primary care provider, behavioral health consultant (BHC), and psychiatric consultant at minimum. Nurse practitioners, physician assistants, health coaches may also be part of the care team.

The environment is fast paced, collaborative, and uses evidenced-based strategies designed to motivate changes in behavior.

The Psychiatrist may provide formal face-to-face consultation, education, and/or back up to the primary care provider, who remains ultimately responsible for the patient’s care.

Less than 10% of patients require face-to-face consultation with a psychiatrist. The majority of patients can be managed with indirect consultation which permits the primary care provider to speak with a psychiatrist by phone or electronically about diagnosis and treatment strategies.

MEASUREMENT-BASED TEAM

• Standardized tools are used for routine screening, such as PHQ for depression.

• If patients are not showing improvement on screening measures, then treatment strategy is modified.

EVIDENCED-BASED CARE

• Evidenced-based brief interventions are used, such as motivational interviewing, CBT, along with evidenced based pharmacologic interventions.

ACCOUNTABLE CARE

• Effective collaborative care requires that providers remain accountable for cost and quality outcomes.

Reimbursement

There is currently no mechanism in place to reimburse providers for indirect non-billable patient care in the current fee-for service model.

The Affordable Care Act is testing new funding mechanisms such as bundled payments, case rates, and global capitation.

Considerations/Challenges• 1. Patient preference• 2. Relationship with consulting psychiatrist• 3. Primary Care providers managing more complex cases• 4. Electronic medical record• 5. Liability• 6. Reimbursement• 7. Shift to brief intervention

Behavioral Health Integrationinto Primary Care at Christiana Care• CCHS addressed the problem of fragmented care and the

growing trend of patients with behavioral health problems presenting to emergency departments and Primary Care offices, as well as the limited psychiatric resources in DE

• In May, 2015, CCHS fully integrated BHC’s into Primary Care offices.

• To date, CCHS has 13 BHCs embedded in 10 Primary Care offices.

• Over 500 patients and have been seen by BHCs for over 700 sessions EACH MONTH for initial evaluations, follow ups, and in room consultations and outreach.

• Patient satisfaction and Physician satisfaction surveys are currently being conducted.

QUESTIONS?