GA-U Mental Health Pilot

Integrating primary care and mental health

Jurgen Unutzer, MD, MPH, MAProfessor & Vice Chair

Psychiatry & Behavioral SciencesUniversity of Washington

The Case for Integration

Mental disorders are common, disabling, and expensive

Primary care is the ‘de facto’ health care system for common mental disorders but only 20-40 % of patients get effective treatment.

Patients with severe mental illness (SMI) receive poor medical care and have high rates of mortality

Morbidity and Mortality in People with Serious Mental Illness

Persons with serious mental illness (SMI) are dying 25 years earlier than the general population

Suicide and injury account for about 30-40% of excess mortality, but 60% of premature deaths in persons with schizophrenia are due to medical conditions such as cardiovascular, pulmonary and infectious diseases– Need for improved care of chronic medical disorders

in specialty mental health care settings

Why treat mental disorders in primary care ?

Limited access to / use of mental health specialists

Treat mental health disorders where the patients are

- Established provider-patient relationship

- Less stigma in primary care

- Better coordination with medical care

Integrated care = working effectively ‘across silos’

Primary Care

Community Mental Health

Center

PC

CM

HC

Social services?

Alcohol & substance

abuse care?

J a m e s D . R a l s t o n

20 years of collaborative care research at UW

Depression in Primary Care

Depression in Diabetes (Pathways)

Late-life Depression (IMPACT)

Depression in Adolescents

- in Primary Care

- in Schools

Telemedicine Consultation in Child Psychiatry

Anxiety Disorders in Primary Care

PTSD & Substance abuse in Trauma Care

Moving towards integrated Care

Worst case scenario = compete

Usual situation = co-exist

Helpful but not sufficient = consult (or) co-locate

Ideal = collaborate effectively

Evidence for integrated care: depression

Meta-analysis by Gilbody et al, Archives of Internal Medicine; 2006

37 trials of collaborative care for depression in primary care (US and Europe)– CC is consistently more effective than usual care– Successful programs include

• active care management (not case management)• support of medication management in primary care• psychiatric consultation

1,801 primary care patients with depression and comorbid medical disorders

Funded byJohn A. Hartford Foundation California Healthcare Foundation

Example: IMPACTJürgen Unützer, MD

EffectiveCollaboration

Prepared, Pro-activePractice Team

Informed, ActivatedPatient

IMPACT Team Care Model

Practice Support

Integrated care DOUBLES the effectiveness of usual care for

depression

0

10

20

30

40

50

60

70

1 2 3 4 5 6 7 8

Usual Care IMPACT

% p

atie

nts

Participating Organizations

50 % or greater improvement in depression at 12 months

Unutzer et al., JAMA 2002; Psychiatr Clin N America 2005

42%

19%23%

14%

54%

43%

0%

10%

20%

30%

40%

50%

60%

White Black Latino

IMPACT Care

Care as Usual

Integrated Care BenefitsEthnic Minority Populations

Areán et al. Medical Care, 2005

50 % or greater improvement in depression at 12 months

Improved Physical Functioning

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

P<0.01P<0.01 P<0.01

P=0.35

Callahan et al. JAGS. 2005; 53:367-373.

Lower long-term (4 year) healthcare costs

Other lessons from IMPACT

1) Co-location is NOT sufficient.

2) Initial treatments are rarely sufficient. Several changes in treatment are often necessary (stepped care). To accomplish this, we need - Systematic outcomes tracking (e.g., PHQ-9) to know when change in treatment is needed. - Active care management until patient is improved to facilitate changes in medication, behavioral activation.- Consultation with mental health specialist if patients not improving as expected.

DIAMOND Initiative in Minnesota

Integrated care management for depression supported by 8 large commercial payors and the state Medicaid plan in Minnesota- Organized by the Institute of Clinical Systems Improvement (ICSI)

- Common payment code for integrated care / care management

State-wide implementation- First group of 14 clinics trained in March 2008

- Goal to have evidence-based depression care management available in ~ 90 primary care clinics state-wide, reaching ~ 1.4 million Minnesotans by 2010

Evidence for integrated care: anxiety, alcohol/substance abuse

Anxiety disorders:- Roy-Byrne, et al: Integrated care for anxiety disorders

- Zatzick, et al: Trauma-center-based care for alcohol / substance abuse problems and PTSD

Alcohol / substance abuse: SBIRT (Substance use Brief Intervention Referral and Treatment)

GA-U Mental Health Pilot

Community Health Plan of Washington

GA-U Mental Health Pilot Steering Committee

UW Department of Psychiatry

Steering Committee

Graydon Andrus

Marc Avery

Amandalei Bennett

Esther Bennett

Jane Beyer

Teri Card

Abie Castillo

Mervyn Chambers

Ann Christian

Frances Collison

Mark Dalton

David DiGiuseppe

David Dula

Stephanie Earhart

Trudi Fajans

Sharon Farmer

David Flentge

Harvey Funai

Mark Johnson

Rebecca Kavoussi

Earl Long

Barbara Mauer

Linda McVeigh

Evan Oakes

Virginia Ochoa

Ed O’Connor

Amnon Schoenfeld

Anne Shields

Rose Soohoo

Karen Spoelman

Doug Stevenson

Tom Trompeter

Jurgen Unutzer

Richard Veith

Steve Vervalin

Grace Wang

GA-U Program

State-only funded program that provides:

- cash grants (up to $339/mo)

- limited medical care

- no mental health care

For adults who are: - physically or mentally disabled

- unemployable for more than 90 days

Co-occurring diagnosesDSHS | GA-U Clients: Challenges and Opportunities August 2006

Most common Dx and RxDSHS | GA-U Clients: Challenges and Opportunities August 2006

GA-U Mental Health Pilot

Based on experiences with managed medical care pilot:

- difficulty managing medical care without addressing mental health issues

GA-U Mental Health Pilot Overview

2 year demonstration pilot– Pierce & King counties– Partnership between CHP, Community Health Centers,

Community Mental Health Centers, and UW Department of Psychiatry

Goals of Mental Health Pilot– Build on success of GA-U medical pilot

Structure of Mental Health Pilot– Level I: MH Treatment in Primary Care– Level II: Community Mental Health Care for severely mentally ill– Goal: Improved access, coordination of care & outcomes

Goal: Integrated care

GA-UClient

Level II Care

Care Coordinator

Consulting Psychiatrists

CSO

CD Treatmen

tLevel I Care (~ 1,500)

PCP

DVROther clinic-based mental

health providers*

* Available in some clinics

Goals

Integrated physical health, mental health and substance abuse services to GA-U clients where they seek care

Goals:

- improve patient outcomes

- reduce costs

Level 1 mental health care

Clients with behavioral health needs are treated by primary care providers with:

- support from care coordinators and other practice-based mental health staff (if available)

- support from consulting psychiatrist

Psychiatric Consultation in Level 1

Ongoing case consultation with care managers re: Level 1 mental health treatment

- scheduled and ad hoc consultation to care managers and PCPs

- systematic, based on clinical needs and outcomes

- In-person evaluation, if needed

Participating Health Systems

• Community Health Care (Pierce)• Community Health Centers of King County• Country Doctor Clinic (King)• Puget Sound Neighborhood Health Centers

(King)• Harborview Medical Center (King)• International Community Health System (King)• SeaMar (Pierce, King)

Intensive mental health services (Level 2)

Community Mental Health services

CMHC case manager coordinates with Level-1 Care Coordinator to insure continuity of care

Participating CMHCs

Greater Lakes (Pierce)

Community Psychiatric Clinic (King)

Downtown Emergency Service Center (King)

Harborview Mental Health (King)

Highline-West Seattle (King)

SeaMar (Pierce, King)

Sound Mental Health

Therapeutic Health Services (King)

Valley Cities (King)

Integrated care

GA-UClient

Level II Care

Care Coordinator

Consulting Psychiatrists

CSO

CD Treatmen

tLevel I Care (~ 1,500)

PCP

DVROther clinic-based mental

health providers*

* Available in some clinics

Mental Health Integrated Tracking system (MHITS):

Helps CHP, CHCs, CMHCs, and care coordinators keep track of and care for client population

Facilitates communication between providers (e.g., CHC and CMHC), referrals, and mental health consultation

How does MHITS help?

Keeps track of all GA-U Mental Health clients• Up to date client contact information to facilitate

contact and follow-up• Who is being treated in level 1 and 2?• Who has been referred for services (e.g., CD,

CSO, DVR, level 2 care) and who is getting services?

Tells you quickly who needs additional attention• Who is improving or not improving?• Reminders for clinicians & managers• Customized caseload reports

How does MHITS help?(cont.)

Facilitates mental health specialty consultation

Facilitates communication between treating providers

Supports care and care coordination across settings of care (e.g., level 1 and 2)

Provides updates on program developments, clinical tools, etc.

Facilitates management decisions

J a m e s D . R a l s t o n

Integrated mental health care: a vision

WA could be the 1st state with a truly integrated MH care system

Improved access and capacity in primary care

Less stigma

Better medical care for patients with SMI

Improved communication between mental health, primary care,

Information systems to facilitate cost-effective care across systems.

Improved population health