Integrated Care: Brian DeSantis

heartandsoulofchange.com 5/29/2014

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Brian DeSantis, Psy. D. ABPP

Director, Behavioral Health

Peak Vista Community Health Centers

Primary Care and Mental Health:A Marriage Made in Heaven or....?

(The Challenge of Integrated Care)

DespiteAChangingU.S.HealthCareSystem

• Primary care will continue to be:

• The foundation of the U.S. health care system (Croghan & Brown, 2010)

• The most likely first “port of call” for patients seeking treatment for any health problem (McDaniel et al., 2003, p.65)

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PrimaryCare:The“de‐Facto”MHCareDeliverySystem

• Most common pathway for presentation of medical illnesses, psychiatric disorders, and emotional distress (Goldman, Rye, & Sirovatka, 2000; Petterson et al., 2008; Wang et al., 2006)

• Upwards of 70% of primary care visits are related to mental or behavioral health needs (Hunter et al., 2009)

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• PCPs prescribe the majority of psychotropic medications, particularly antidepressants, anxiolytics, & stimulants (Smith, 2012; Faghi et al., 2010; Mark et al,

2009)

IntegratedPrimaryCare

• Merging medical and BH care continues to evolve

• Ongoing legislative reforms in health care

• Patient‐centered medical home (PCMH)

• Essential elements of PCMH:

• Whole person orientation

• Coordinated, interdisciplinary teams

• Patient‐centered care

• Enhanced access

• Emphasis on quality & outcomes

(Kaslow et al., 2007; Levant & Heldring, 2007; Bechtel & Test, 2010; Beachum et al., 2012; Baird et al., 2014)

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“Thisisthegreatesterrorofourdayinthetreatmentofthehumanbody,thatphysiciansseparatethesoulfromthebody”‐Hippocrates


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BarrierstoIntegratedPrimaryCare

• Different missions & practice cultures

• Limitations of the biomedical model for both partners

• Segregated (“carve out”) payment for BH services

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• An intuitive marriage for advancing health care, but not without its challenges

DifferentMissions&Cultures

• Specialty Mental Health:• Servicing “clients” with MH/SA conditions

• “Carved out” of health care

• Traditional psychotherapy provided in 50‐90 min. sessions of variable duration

• Different confidentiality rules

• Annual penetration rates 3‐7%

• Bottom Line: Small case loads, slower paced provision of MH problems

• Primary Health Care:• Population‐based care providing prevention, acute, and chronic care to “patients”

• PCPs seeing 3‐4 patients per hour

• Providers often don’t have the time, interest, or training to stay on top of MH treatments

• Annual penetration rates 70‐80%

• Bottom Line: Large patient panels, fast paced, and full range of medical, MH, and social problems

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TheBiomedicalModel

• Derived from Louis Pasteur’s (1822‐1895) germ theory of disease

• Disease is a result of a biological deficit, often initiated by a biological pathogen

• Dominated for over 100 yrs. (Shore et al., 2001)

• Successes included sanitation, development of antibiotics, decline of infectious diseases, & increased life expectancy

• By 1900, eliminated leading causes of death (TB, pneumonia, influenza, diarrheal diseases)

• Life expectancy increased from 49 yrs. (1901) (Glover, 1921) to 77 yrs. (2001) (Glover, 1921; Arias, 2004).

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LimitationsofBiomedicalModel

• Exclusive focus on disease promotes a reductionist, exclusionary, and mind‐body dualism.

• By end of 20th century, biomedical model inadequately addressed:

• Changing nature of disease facing U.S. health care system

• Role of behavior in disease etiology, prevention, & management

• Escalating health care costs

(Johnson, 2013) 8


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ChangingNatureofDisease

• Nearly one in two U.S. deaths has at least one chronic illness (Centers for Disease Control & Prevention, 2009)

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• Chronic diseases contribute to:

• 70% of U.S. deaths (Danaei et al., 2009)

• 75% of U.S. health care costs (www.cdc.gov/chronicdisease)

• Heart diseases• Cancer• Chronic lower respiratory diseases• Stroke

• Today most Americans die of chronic disease (Hoyert & Xu, 2012)

RoleofBehaviorinChronicIllnesses

• Estimated 40% of premature deaths attributed to modifiable health behaviors (Mokdad et al., 2004)

• Smoking is leading cause of death in U.S. with obesity a close second (Mokdad et al., 2004)

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• Centers for Disease Control & Prevention estimate:

• Health behaviors: 50% of health care outcomes

• Genetics: 20%

• Environment: 20%

• Access to health care: 10%(Amara et al., 2003)


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BehavioralComorbidity

• The National Comorbidity Survey Replication (NCS‐R) found:• More than 68% of adults with a mental disorder had at least one medical condition

• 29% of those with a medical disorder had a comorbid MH condition (Algeria et al., 2003)

• Behavioral comorbidity, especially in patients with chronic and complex medical conditions• Estimated $350B/yr. spent on unnecessary medical & surgical services when BH conditions remain ineffectively treated (Melek &

Norris, 2008)

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RisingHealthCareCosts

• U.S. health care costs continue to escalate with little positive impact on health outcomes

• Annual per person health expenditures rose from $147 in 1960 to $8,915 in 2012 (Centers for Medicare & Medicaid Services, 2013)

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• U.S. leads the world in health care spending…YET

• U.S. life expectancy is equivalent to Cuba …..and lower than most developed countries (ucatlas.usc.edu; O’Rourke & Iammarino, 2002)


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TheMedicalModel

andthe

MedicalizationofMentalHealth

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“By their development of special languages, institutions justify their authority and perpetuate the status quo.”

‐Robin Lakoff

TheMedicalModel

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The Right Diagnosis

+

The Right Treatment

=

Cure or Symptom

Amelioration


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SoWhat’stheProblem?

• Seeking integration on a dominant biomedical model is problematic for BH• BH treatment does not work in the same way as medicine

• The patient is not a diagnosis, the BH clinician is not a technician, psychosocial treatments are not simple prescriptions

• Biology cannot adequately explain human distress

• Promotes myths

(Duncan, Miller, & Sparks, 2004)

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MentalHealthMythology

• Biomedical model favors biology in a diathesis / stress framework creating four myths:• Myth of diagnosis

• Myth of biological causality

• Myth of privileged, first‐line medication treatments

• Myth of evidence‐based treatments equating to good outcomes

(Duncan & Miller, 2000)

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“The greatest enemy of the truth is not the lie – deliberate, contrived, and dishonest, but the myth –persistent, pervasive, and unrealistic.” – John F. Kennedy


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MythofDiagnosis

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Poor reliability

Unknown validity

Fails to predict outcome

Little help in Tx selection

Mostly ignores relational, environmental, and cultural influences

(Kirk & Kutchins,1992; Duncan et al., 2004)

“In mental health disease is considered the known factor while normality is nearly impossible to define.” —Paul Watzlawick, Ph.D.

MythofBiologicalCausality

• Association of biological markers with specific states of distress does notconfirm biological causality (Sparks et al., 2006)

• Little empirical support for the heavily touted “serotonin shortage” hypothesis regarding the cause of depression (Carlat, 2010; Weil, 2012; Angel, 2011; Whitaker, 2011;

Scott, 2006; Lehrer, 2006; Yapko, 2013)

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“Daring as it is to investigate the unknown, even more so it is to question the known.” ‐ Kaspar

Bottom Line: Medical science has yet to reliably identify any biological markers or chemical imbalances for any psychiatric diagnosis (Piasecki & Antonuccio, 2010; Duncan et al., 2004)


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TheMythofPrivilegedMeds

• Medication vs. Psychotherapy?

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“He’s the best physician who knows the worthlessness of most medicines.” ‐ Benjamin Franklin

Critical analysis of the clinical trial research strongly

challenges meds skyrocketing prescription rates &

their privileged status as an often first time TX

(Sparks et al., 2010)

The efficacy of psychotherapy has been irrefutably

supported across all domains of symptoms distress‐

with a few, if any, instances of comparative superior

outcomes for meds, especially in the long run (Brown et al., 2008; Sparks et al., 2010; Kirsch, 2010)

MythofEBTs(BATTLEOFTHEBRANDS)

• Cognitive Therapy

• Behavioral Therapy

• Cognitive Behavioral Therapy

• Motivational Therapy

• Twelve Steps

• Dialectical Behavioral Therapy

• Multidimensional Family Therapy

• Structural Family Therapy

• Functional Family Therapy

• Skills Training

• Acceptance and Commitment Therapy

• Client‐Centered Therapy• Systemic Therapy• Biopsychosocial Therapy• Solution‐focused Therapy• Multimodal Therapy• Psychodynamic Therapy• Narrative Therapy• Integrative Problem‐solving Therapy

• Eclectic Therapy• Interpersonal Therapy• Transtheoretical Therapy• Multisystemic Therapy

• Existential Therapy

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TheDodoBirdVerdict

• Summarizes robust findings that

no particular treatment is

demonstrably superior to

another.

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At last the Dodo said, “Everybody has won, and all must have prizes.”‐ Lewis Carroll’s Alice in Wonderland

• Most replicated finding in the

psychological literature.

(Rosenzweig,1936; Wampold et al.,1997, Assay & Lambert, 1999)

SHORTCOMINGSOFEBT(LIMITATIONOFRCTs)

• “All RCTs do is show that what you’re dealing with is not snake oil. They don’t tell you the critical information you might need, which is which patients are going to benefit from the treatment” (Williams, APA Monitor, 2010, p. 54)

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WhatWorksin

BehavioralHealthTreatment

(TheScienceofChange)

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“The foolish reject what they see, not what they think; the wise reject what they think, not what they see.”

‐ Huang Po (9th century)

ProblemswithMedicalModel

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MH Practitioners can competently:

• Assign diagnoses

• Complete comprehensive treatment plans

• Use the latest evidence‐based treatments

• Dispense latest variety of psychoactive drugs

Bottom Line: These factors are just not that critical to improving outcomes in mental health!

… Overall, effectiveness of therapy will not improvein the least! (Duncan et al., 2010)


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BestPredictorsOfRetention&Progress

• Client’s rating of the alliance is the

best predictor of engagement and

outcome.

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• Client’s subjective experience of

change early in the process is the

best predictor of success for any

particular pairing.

Evidence‐BasedMedicine(http://www.cebm.utoronto.ca/glossary/mmtsprint.htm#table)

AREA TREATMENT NNT*

Cardiology Aspirin 176

Cardiology Beta Blockers 40

Post Menopausal Osteoporosis Alendronate Sodium 21

Influenza Vaccine 12

Smoking Cessation Nicotine Inhalers 10

Acute Asthma Budesonide 9

Cataracts Surgery 3‐7

Mental Health (depression, PTSD) Therapy 3‐7

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* NNT is the number needed to treat in order to achieve one successful outcome that would not have been accomplished in the absence of treatment


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BehavioralHealth’sShortcomings

• Drop outs are a substantial problem

• Many clients do not benefit; some even get worse

• Therapists vary significantly in their effectiveness & are overly optimistic

• Therapists are poor judges of client deterioration

• Evidence‐based treatment does not tell you which particular clients will benefit from the “best practice”

27(Hansen et al., 2002; Duncan et al., 2004; Beutler et al., 2004; Hubble et al., 2010)

MakingtheMarriageWork

• How do we pay for integrated primary care & lower per capita cost?

• What’s the appropriate healing paradigm?

• How does one merge different missions & practice cultures?

• How can the partners coordinate quality care & adhere to the principles of PCMH?

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“It’snotthestrongestofthespeciesthatsurvives,northemostintelligent,buttheonemostresponsivetochange.”‐CharlesDarwin


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OurVisionofaSuccessfulMarriage

• Whole‐person care

• Adhering to PCMH principles• Patient‐centered care

• Coordinated, interdisciplinary teams

• Enhanced access to BH services

• Focus on quality & outcomes

• Emphasis on wellness & life functioning

• Payment reform

(Epstein & Street, 2011; Baird et al., 2014, Beacham et al., 2012; Kathol et al., 2014)

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“Thedogmasofthequietpastareinadequatetothestorypresent”‐AbrahamLincoln

AnnualMessagetoCongress,1862

NecessaryPaymentReform

• Payment for BH clinicians would be part of the PCMH’s total health budget

• Shifting from segregated, fee‐for‐service reimbursements to integrated, prospective outcomes‐based payment (Kathol et al., 2014; Colorado Framework, 2013)

• Per‐member per‐month primary care capitation that includes funding for integrated BH (Baird et al., 2014)

• BH providers sharing in cost savings

• Reward patients for health behavior change

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MARRIAGEOFTWOHEALINGPARADIGMS

MindBH Care

(Relational Model)Marriage

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BodyMedical Care(Biomedical Model)

Biopsychosocial Model (Engel,1977)

↓(Collaborative Provider Team)

TheBiopsychosocialModel(Engle,1977)

• Whole‐person care

• Expanding biomedical framework to include environmental, psychological, social, and behavioral factors to understand illness and health

• Treatments may be behavioral, environmental, and/or biological

• Beyond disease and diagnosis, life functioning & well‐being are important outcomes

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ModelsofCollaborativeBHCare(Blountetal.,2008;Blount,2003;Keesler,2003;Hungeretal.,2010;Colorado’sFrameworkModel,2013)

Coordinated Care• PCPs & BH providers work in separate systems and facilities, delivering separate care

• Usually a referral‐based system to specialty mental health care

• May only communicate sporadically; exchange info on an as‐needed basis (releases required)

Co‐Located Care• PCPs & BH deliver separate care in same setting

• BH still delivers specialty MH services

• Communication and coordination, but with separate systems and workflows

• Separate Tx records

• May include care coordination/management

Integrated Care• PCPs & BHCs work together in a shared system, delivering population based care• Access to BHCs

maximized with “warm handoffs” and short‐term follow‐ups

• Shared care plans, clinical documentation, billing procedures

• Clinical workflow, role clarity, and regular communication for max accessibility/ coordination

ComponentstoaSuccessfulMarriage

• Use EHRs, registries, & claims data to proactively identify patients with greater health complexity, utilization & cost for targeted BH assessment & treatment

• Employ BH providers with various levels of expertise and match them to the clinical needs or goals of patients in a stepped approach to care

(Kathol, deGruy, & Rollman, 2014)

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OtherComponents

• Use care coordinators trained in cross‐disciplinary medical & behavioral support to coordinate care across the inpatient to outpatient community medical‐behavioral continuum

• Prospectively define desired medical & BH outcomes(e.g. clinical, functional, QOL, and satisfaction) and evaluate progress in real time, as treatment is given

(Kathol, deGruy, & Rollman, 2014)

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CriticalIssues

• Merging different practice cultures, different healing models, & creating new patient care/flow processes requires establishing trust in an egalitarian environment

• Real and perceived barriers to communication must be clarified and addressed to make the regular sharing of information, shared decision making, & shared responsibility for a patient’s care plan routine

(Baird et al., 2014)

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AdditionalCriticalIssues

• Understanding the central role of the patient (family) in articulating needs & developing care plans

• Respecting patients’ preferences should be justified on moral grounds alone, independent of their relationship to health outcomes

• Defining the different roles & skill sets required for all health team members

• Hiring multidisciplinary staff with the “right fit” and implement integrated team training

(Epstein & Street, 2011; Baird et al., 2014)

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TheIssueofScience

• How can evidence‐based medicine (EBM), which tends to focus on populations, mesh with patient‐centered care, with its focus on individual needs?

• Proponents of EBM concur a good outcome is defined in terms of what is meaningful and valuable to the individual patient (Epstein & Street, 2011)

• EBM is not “cookbook” medicine as it requires a bottom up approach that integrates the best research with clinical expertise and patients’ choice (Sackett et al., 1996)

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TheIssueofScienceforBH

• Do BH clinicians simply apply evidence‐based treatment algorithms & protocols as “standard BH interventions?”

• We adhere to APA’s definition of evidence‐based practice as:

“The integration of the best available research with clinical expertise in the context of patient characteristics, cultures, & preferences” (APA Task Force, 2006, p. 273)

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PartnersforChangeOutcomeManagementSystem

(PCOMS)

ORSIndividually:

(Personal well-being)

______________________________

Interpersonally:(Family, close relationship)

______________________________

Socially:

(Work, school, friendships)______________________________

Overall:(General sense of well-being)

______________________________

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Reliable

Valid

Feasible

Relationship:

Goals and Topics:

Approach or Method:

Overall:

SRS

There was something missing in the session today

I felt heard, understood and respected

We worked on and talked about what I wanted to work on and talk about

The therapist's approach is a good fit for me

Overall, today's session was right for me

I did not feel heard, understood and respected

We did not work on or talk about what I wanted to work on and talk about

The therapist's approach is not a good fit for me

Outcome Rating Scale (ORS) Session Rating Scale (SRS)

www.heartandsoulofchange.com


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:ASAMHSAEBPButDifferent

• PCOMS is a‐theoretical; additive to any therapeutic orientation, including other EBPs

• PCOMS applies to clients of all diagnostic categories

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Meta-analysis of PCOMS

• Feedback group had 3.5 higher odds of experiencing reliable change

• Feedback group had less than half the odds of experiencing deterioration

• Feedback attained .48 ES

Lambert, M. J., & Shimokawa, K. (2011). Collecting client feedback. Psychotherapy, 48, 72‐79.


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PCOMS&IntegratedBHCare“Howeverbeautifulthestrategy,youshouldoccasionallylookattheresults”

~SirWinstonChurchill

• An ultra‐brief & non‐symptom specific clinical & outcome measure that can also be used for BH screening

• Addresses medical model shortcomings & adheres to the evidence of “what works”

• Brings accountability to the marriage

• Aligns with PCMH principles

• Fits with outcome‐based payment reform(Duncan, 2012; Lambert, 2010; Lambert & Skimokawa, 2011)

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Brian’sORS/CORSData(Feb2012‐April2014)

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• 170 children/adolescents given ORS/CORS (co‐visits included)

• Range: 4.2 – 40.0• Mean: 23.5 • Mode: 25.2

• 62 children/adolescents with 2+ follow‐up sessions

• 77% of patients improved/recovered• Range: 2‐8• Mean: 2.4

ORSIndividually:

(Personal well-being)

______________________________

Interpersonally:(Family, close relationship)

______________________________

Socially:

(Work, school, friendships)______________________________

Overall:(General sense of well-being)

______________________________

www.heartandsoulofchange.com


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Chronic Illnesses Mental Health Life Stressors Health Behaviors

• Diabetes• Cardiovascular Disease• Chronic Lung Disease• Chronic Pain• Cancer

• Depression• Anxiety• Substance Abuse/ Dependence• Cognitive Disorders• ADHD, ODD

• Relationship Problems• Sleep Problems• Phase of Life Issues• Bereavement• Stress Related Physical

Symptoms

• Tobacco Use• Overeating• Physical Inactivity• ETOH/Drug Misuse • Medication Adherence

BH Consult (“co‐visit”)(5‐10 mins)

(Initial assessment & possible intervention)

Are Further Integrated BH Services Needed?(Stage of change, payer source, patient preference, accessibility issues)

Probably Yes Probably No

Short‐Term Follow‐ups(30 mins., 6‐8 sessions ‐ further assessment and/ or intervention)

Return to PCP Refer to Specialty MH

• Traditional MH psychotherapy (not time‐limited)

• Psychiatric medication management• Other community specialty referable

(i.e neuropsych evals, LD testing)

• Co‐visit sufficient

• Relaxation Training• Self‐Monitoring• Stimulus Control• Behavior Modification• Motivational Interviewing• Problem Solving

• Cognitive Disputation• Mindfulness• Brief Solution‐Focused Tx• Hypnosis• Biofeedback

OurBHConsultantModel


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EvaluatingandTreatingDepression

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PCP/ Patient Visit• Initial medical eval• DX impression

Labs?

BH Consulted• Baseline level of distress (ORS)• Augment medical eval• Confirm diagnosis (es)

BH / Patient Collaboration• Patient’s goals / preferences• Discuss Tx options

Referral to specialty MH?

Meds Only‐Monitor Outcomes

Combo Med + BH Interventions

‐Monitor outcomes

BH Interventions‐Monitor outcomes

Patient self‐changeor

No current Flu

PCP / Pharmacist / Patient Discussion of meds, side effects, etc.

EvaluatingandTreatingADHD

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Initial PCP visit BH co‐visit assessment

Is ADHD still suspected?

Follow‐up BH Assessment & Diagnosis

Collaborative Discussion of Treatment options

Yes

BHC Assists Evaluating Outcomes

No

Possible BH/PCP Follow‐up

PCP Meds Consult

BH Interventions


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ManagingChronicPain

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New PatientsExisting Patients>120mg MED

BH AssessmentBHC co‐visit Assessment

BH Follow‐upAssessment

Medical (PCP) Evaluation

Monitor Outcomes

PCP‐BHC‐PatientCollaboration on Tx options

Monitor Outcomes

PCP‐BHC‐PatientCollaboration on Tx options

ImplicationsfortheMarriage

• BH must maintain its non‐medical relationship identity in a collaborative & equal partnership

• BHCs should extend rather than just confirm medical diagnostic assessments

• Familial, environmental, sociocultural

• Assessing BH comorbidities & readiness for change

• Functional assessments

• BHCs are not seen as technicians administering one‐size‐fits‐all interventions prescribed by PCPs

(Duncan & Antonnucio, 2011)

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FurtherImplications

• BHCs are not viewed as an adjunctive service to medication, or a lowered tier way to deliver care

• Psychotropics are not an automatic & privileged first‐line intervention

• Patient’s preferences, based on their own values & cultural context, will be honored

• BH must bring accountability to the marriage

• Focus on “what works” and APA’s definition of EBP

• Use feasible, patient‐directed outcome measures that align with PCMH

(Duncain & Antonmucio, 2011)

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AdvantagesofIntegration

• Multidisciplinary collaborative care teams with improved communication/coordination of whole‐person care

• Improved patient satisfaction, improved health care outcomes, and reduced costs

• Enhanced access to BH care, especially for uninsured

• Improved PCP efficiency & satisfaction

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“Oft times it is better to know what kind of patient has a disease than what

kind of disease the patient has.”

‐Sir William Osler (1849‐1919)

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Education

Integrated Care: Brian DeSantis