“health homes” and behavioral health/general medical care integration

HHS Health Homes Webinar February 25, 2011

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“Health Homes” and Behavioral Health/General

Medical Care Integration

On the Banks or in the Mainstream?

Harold Alan Pincus, MD Professor and Vice Chair, Department of Psychiatry

Co-Director, Irving Institute for Clinical and Translational Research Columbia University

Director of Quality and Outcomes Research New York-Presbyterian Hospital

Senior Scientist, RAND Corporation


The Bottom Line •  Co-morbidity of behavioral disorders and general medical conditions is highly

prevalent (especially in Medicaid populations

•  This pattern of co-morbidity is especially concentrated among those who have high costs and frequent hospital admissions

•  These individuals die at younger ages

•  Impacts and solutions go both ways across the GM/BH divide –  Primary Care patients needing Mental Health care, and

Mental Health patients needing Primary /Specialty Medical Care

•  Evidence-based models for integrating care have been well documented

•  These models have not been widely implemented due to structural barriers and financial disincentives

•  Health Home option provides flexibility and incentives and opportunity

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BH/GMC Clinical Examples

•  35 year old male with schizophrenia, diabetes, and tobacco dependence –  Can expect up to 25 year shortened life span,

increased medical costs •  25 year old HIV+ female IV drug user with PTSD

–  Frequent ED visits, non adherence to meds, increased medical costs

•  60 year old female with diabetes, CHF and depression –  Frequent (re-) hospitalizations, poor self management

and adherence, early candidate for LTC

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Currently, Poor Quality and Care Coordination for All Populations

•  Patients primarily in contact with the general medical sector with co-morbid BH conditions (e.g., depression) –  Not treated or treated as acute problems with little follow-up

•  Patients with severe and persistent BH conditions (e.g., schizophrenia) and treated in BH specialty settings –  Poor self-care, medications worsen general medical conditions –  Limited provider capacity and incentives for

•  Accessing treatment of co-morbid medical conditions •  Preventive and wellness care

•  Medical and BH providers operate in silos


LPHI/CIBHA Conference February3-4, 2011

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“Crossing the Quality Chasm”


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Crossing the Quality Chasm “Quality problems occur typically not because of failure of goodwill, knowledge, effort or resources devoted to health care, but because of fundamental shortcomings in the ways care is organized” The American health care delivery system is in need of fundamental change. The current care systems cannot do the job. Trying harder will not work: Changing systems of care will!


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Overarching Recommendation 1

The aims, rules, and strategies for redesign set forth in Crossing the Quality Chasm should be applied throughout M/SU health care on a day-to-day operational basis but tailored to reflect the characteristics that distinguish care for these problems and illnesses from general health care.


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Overarching Recommendation 2

Health care for general, mental, and substance-use problems and illnesses must be delivered with an understanding of the inherent interactions between the mind / brain and the rest of the body.


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René Descartes


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Don’t Split Mind and Body


GM/BH Integration Questions

•  Why not? •  Who? •  When? •  Where? •  How? •  For whom? •  Why?

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Who? Responsibility for Care

Primary Care

Provider (PCP) Behavioral

Health Specialist

(BHS)


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When?

Risk Factor

Identification/ Prevention

Diagnosis/

Assessment

Short-term

Management

Continuing

Care


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Referral

Consultative Care

Collaborative Care

Integrated Team

Independent

Autonomous (PCP)

Autonomous (MHS)

How?


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Evidence-Based Chronic (Planned) Care Approaches for Treating Depression

Are Effective

Prepared, Proactive Practice Team

Informed, Empowered Patient and Family

Productive Interactions Patient-Centered Coordinated

Timely and Evidence-

Efficient Based and Safe

Improved Outcomes

Delivery System Design

Decision Support

Clinical Information

Systems

Self- Management

Support

Health System Community Health Care Organization Resources and Policies


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Where? Models of Linkage / Integration

Embedded PCP in BHS Co-location of BHS in PCP

B P

Unified Coordination / Collaboration

B

P B

B P P


For Whom?

•  Two Populations – General/Primary Care with mild to moderate

BH conditions (e.g., anxiety, depression) – Severe/Persistent Behavioral Health

Conditions (e.g., schizophrenia, drug dependence)

•  Two Strategies – Mainstream – Separate BH Specialty Adaptations

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Two Overall Strategies Strategy 1: Primary Care Health Home

For patients primarily in contact with

general medical sector (and mild to moderate BH conditions):

•  Organize around primary care/general medical setting

•  Apply evidence-based clinical and organizational strategies

•  Design specific policy tools to hold medical providers accountable for meeting the BH care needs of patients.


Two Overall Strategies Strategy 2: BH Health Home

For patients with severe and persistent BH

conditions and primarily treated in a BH specialty setting:

•  Organize health home around BH setting

•  Apply evidence-based clinical and organizational strategies

•  Develop specific policy tools to assure access to high-

quality primary care and non-BH specialty care


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Evidence-Based Integration Mechanisms

•  Clinical integration of services, or •  Co-location of services •  Formal agreements with external providers •  Shared patient records •  Screening and longitudinal monitoring •  Clinical registry •  Care management •  Evidence-based guideline support/training •  “Measurement-based”/ “Stepped” care •  Close collaboration with other specialty, substance abuse

care and human services providers


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Policy Strategies •  Medical/ Health Home Models

•  Accreditation –  New NCQA criteria expand BH expectations

•  Quality Incentives

•  Mutual Accountability Across BH and GM Providers –  For Quality and Costs

•  Payment Related to Complexity –  Tiers/Risk Adjustment

•  Support Improved Communication –  EMRs, Health Information Exchanges (with protections)

•  Training and Technical Assistance

•  Flexibility


BH/GMC Programmatic Examples

•  SAMHSA Primary and Behavioral Health Care Integration Program

•  Minnesota DIAMOND Project •  Community Care of North Carolina •  IMPACT Model •  PCARE Model •  SAMHSA/HRSA-funded Technical Assistance

Center (NCCBH)

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