I am like a stinging fly. I am just trying to get you to consider what is right.

Socrates to the Athenians 399 BC

WE

Collaborative Care

COLLABORATIVE CARESOLUTION OR PROBLEM:WHERE ARE WE GOING?

CFHA October 2011

Rodger Kessler Ph.D. ABPPDirector, Primary Care Behavioral Health Fletcher Allen Health Care Assistant Professor University of Vermont College of MedicineDirector, Collaborative Care Research Network, NRN/AAFPFellow, Jeffords Center for Health Care Policy University of Vermont

Every truth passes through three stagesbefore it is recognized.In the first, it is ridiculed.In the second, it is opposed.In the third, it is regarded as self-evident.

Schopenhauer

Collaborative care is:

Brilliant

• Lots of it• Creative people and programs• Getting great public relations• Has much greater penetration

than other health care disciplines like pharmacy or dentistry

• The national organization is rapidly growing

Irrelevant

• It is its own silo - outside of mainstream primary care, substance abuse and health behavior

• Not evidence cost or outcome driven

• Not engaged with commercial insurers, thus creating a 2-tiered health care system. Again.

“The significant problems we face cannot be

solved by the same level of thinking that

created them.”

A. Einstein

Do not ask for more - You need to:

• Improve quality at no additional cost or demonstrate reduced cost

• Provide results demonstrating outcomes to policy makers and decisions makers based on rigorous data and research

• Identify the processes that are crucial for success

Melinda Abrams Vice President of the Commonwealth FundSpeaking October 21st at PCPCC meeting

How to do it? At a minimum…• Missouri Health Home Medicaid Integrated Primary Care

Behavioral Health Project• 23.9% net program savings

Sub sample of 50 patients• $180 dollars PMPM annual overall total health care costs

Peikes and Mertz PCMH What do we know?AHRQ Annual Meeting

The Field Needs: Common, Agreed Upon Metrics

• Measurements that produce summarized data for various stakeholders that describe the function or performance of a group of patients, a practice or group of practices or elements of practice or patient activity around which to make decisions on policy, funding, resource allocation and their continued use.

Clinical, Operational and FinancialDimensions: Integrated PCBH care is…

All three at the same timeC.J. Peek

What Is Primary Care Behavioral Health?• A method of organizing care delivery to specific clinical

populations with specific interventions• The organization and delivery of care using the same processes

as the primary care practice (i.e. Time of sessions, Scheduling, EHR, metrics)

• Evidence based clinical care • Provided by clinicians with specific training in primary care

behavioral health• Operates within the existing work flow of the care delivery site

Which Populations Should Be Served?

Severe Mental Health/ Substance Abuse Management

Identification and Treatment of Mental Health and Substance Abuse

Comorbid Medical and Psychological Presentations

Medical Presentations Which Need Behavioral Treatment

Primary Care Functions Manage pharmacology; coordinate w/ community providers; crisis management

Identification; motivational interviewing; brief intervention; pharmacology, refer to mental health/substance abuse

Identification; patient education, co-treatment w/ mental heath, monitor activation and adherence (e.g. chronic medical disorders, non-adherence)

Identification; education; referral for consultation and co-treatment (e.g. primary insomnia, Gastrointestinal, headache)

Primary Care Mental Health Clinician

Crisis intervention; communication w/ outside specialty care providers

Treatment of depression/anxiety; co-treatment w/ PCP; evidence based treatment; medication monitoring

Psychoeducation; motivational interviewing; behavioral activation

Health behavior change; psychoeducation; evidence based treatment

Panel Based Range of Need for Collaboration in the Patient Centered Medical Home (Kessler & Miller, 2009)

Mental Health Substance Abuse Health Behavior

Silos• Exist in the specialty care system• Exist in collaborative care• Exist in training and clinician recruitment• Exist in primary care perception• Are expensive• Ignore greatest impact and cost areas of care• Exist at NIH where SAMHSA and HRSA are generally not even at

the table• The Silo of Health Behavior and its inattention within

collaborative care is a significant reason for the disconnect between NIH focus and cc

• In general, CC is certainly not taken seriously in PCMH’s

Results - PCMH Support Systems for MH, SA & Health Behavior • Clinician part of practice

Psychiatry 16%Psychology 22%Social Work 25%

SA 09%Care Manager 62%

• Scheduling same as other providers 36%

• Same day appointments 28%

• EB protocols for MH,SA 20%

• EB protocols for HB rated as working wellHeadaches 11%Insomnia 13% Obesity 23%Smoking 37%

• MH,SA, HB results in EHR rated as working well 35%

Kessler et al., in preparation

Cost

• Cost of delivering the intervention• Cost because of delivering the intervention• Costs savings in the future if intervention is effective

The Ultimate Question

•What are the cost and clinical consequences of responding to patient behavioral and health behavior needs done by whom to which patients generating what outcomes at what cost?

The Paradigm Case of Collaborative Care Metrics

The Elements of the Paradigm CasePeek Kessler Miller 2011

• A defined team• Shared population and mission• A defined clinical system•Office practice and financial system support

•Evidence of continuous quality improvement and effectiveness measurement

Elements to be measured and metricsMiller BF, Kessler R, Peek CJ. A National Agenda for Research in

Collaborative Care: PapersFrom the Collaborative Care Research Network Research

Development Conference. AHRQPublication No. 11-0067. Rockville, MD: Agency for Healthcare

Research and Quality. June 2011

Defining Clauses Elements measured Metric Data source

Team Clinical functions identified for team members

Treatment by physician/ provider and BHC

EHR

Level of shared space BHC onsite Employment record or document

Level of collaborative training

Documentation evidence

CE documentation

Level of shared culture Percent of total markers for shared professional culture

Doherty McDaniel and Baird

If you are going to measure with metrics you need to first know what you are measuring…

The NIH core measures

• Rationale: One thing is missing from all the investment and advances in EHRs—patient reports

• Scope: 13 areas most commonly encountered in adult primary care related to:

• Health Behaviors: tobacco, healthy eating, medication adherence, physical activity, substance use

• Psychosocial Factors: Outcomes: quality of life, depression, anxiety, sleep, stress/distress Influences: health literacy/numeracy, patient goals and preferences,

demographics

Glasgow 2010

Identifying Practical Patient-Report Measures for the Electronic Health Record

RECOMMENDED Common Data Elements

Domain Final Measure

Assessment Frequency Items

Eating PatternsModified from

Starting the Conversation

Annual

Over the past 7 days:a. How many times a week did you eat fast food or snacks or pizza? (Revised item # 1)b. How many servings of fruits/vegetables did you eat each day? (Combine items # 2 and 3)c. How many soda and sugar sweetened drinks (regular, not diet) did you drink each day? (Revised item # 4)

Physical Activity The Exercise Vital Sign items Annual

a. How many days of moderate to strenuous exercise, like a brisk walk, did you do in the last 7 days? b. On those days that you engage in moderate to strenuous exercise, how many minutes, on average, do you exercise at this level?

Risky Drinking Single-Question Screener Annual How many times in the past year have you had X or more drinks in a day? (where X is 5

for men and 4 for women)

Tobacco Use Single-Question Screener Annual

Have you used tobacco in the last 30 days?Smoked Cigarettes: Yes/NoSmokeless Tobacco Product: Yes/No

Substance Use Single-Question Screener Annual How many times in the past year have you used an illegal drug or used a prescription

medication for non-medical reasons?

Anxiety and Depression PHQ-4 Annual

Over the past 2 weeks have you been bothered by these problems? a. Feeling nervous anxious, or on edgeb. Not being able to stop or control worryingc. Feeling down, depressed, or hopelessd. Little interest or pleasure in doing things

Stress Distress Thermometer Annual Please circle the number (0-10) that best describes how much distress you have been

experiencing in the past week including today.

Quality of life PROMIS Single Item Each Visit In general would you say your health is: Excellent, Very Good, Good, Fair, or Poor?

You Gotta Walk the Walk – Work in progress

For Futurists and Early Adapters:What We Did in New York City

There are ongoing conversations with originally 9, now 14, national commercial insurance executives about:• What would we all agree behavioral health in primary care

should look like? • What would it take in a multi-company project to design, pilot

and test a common model of primary care behavioral health?• My colleague Bill Hancur from Rhode Island BC and I are

heading this up and will:• Identify primary care practices or systems of practices who want

to collaborate and –• Turn the idea into Foundation proposal to generate support for

the project

The Collaborative Care Checklist v 1.0Kessler and Colleagues

The Collaborative Care Checklist v 1.0Kessler and Colleagues

Primary Care Behavioral Health Implementation Research Project

• NIH R-01 application between the University of Vermont, the Robert Wood Johnson Medical School, The National research Network of the AAFP, and the CCRN

• Mixed method Pragmatic Clinical Trial• Two conditions, PCBH and IMPACT• Full RE-AIM evaluation• 3 dimension economic analysis cost, cost effect/offset,

projected future cost savings

Rodger, this seems a little daunting…

What are the next steps??

The Kessler 555 Plan

The 5 5 5 PlanA Five Year Moratorium on Five Areas of Collaborative Care

• New Collaborative Care Practices• New hiring of Collaborative Care Clinicians• Consultants advising practices on Collaboration• Collaborative Care Training programs• National Collaborative Care Meetings

Unless any of the above can meet the following Five Criteria

Minimum Five Activities for Collaborative Care Practice, Consultation and Training

• Evidence of continuous process and quality improvement training and projects

• PCBH seamless inputting and cross sharing of EHR data• PCBH clinicians trained in process improvement• PCBH clinicians trained in substance abuse and co-occurring

disorders and evidence based Health Behavior interventions• PCBH clinicians trained in and participating in clinical research

and business and financial management

The Benefits of the 5 5 5 Plan

• It will create new jobs and eliminate those that are not producing

• It will impact the health care economy and lower some costs of care

• Finally - it will get us on the right track and restore the greatness that is the promise of collaborative care

So in closing I say to you in this great city of Philadelphia

Pass This Plan!Pass this plan in your thinking

Pass this plan in your practices

Pass this plan in your hiring

Pass this plan in your training programs

Pass this plan in your professional organizations

Questions and Comments

?Rodger Kessler, Ph.D. ABPP

Rodger.Kessler@uvm.edu

http://www.aafp.org/online/en/home/clinical/research/natnet/get-involved/ccrn-info.html