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This presentation is provided free-of-charge and is supported by Grant Number 1L1CMS-331480-01-00 from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services. The contents provided in this webinar are solely the responsibility of the presenters and do not necessarily represent the official views of HHS or any of its agencies.
No Health Without Mental Health: Using Collaborative Care to Deliver
Value
Anna Ratzliff, MD,
PhD
TCPI National Faculty
APA-SAN
University of WashingtonSlide2
TCPI National Faculty Anna Ratzliff, MD, PhDDr. Anna Ratzliff is an Associate Professor in the Department of Psychiatry & Behavioral Sciences at the University of Washington. Dr. Ratzliff currently serves as the Director of the UW Integrated Care Training Program, Associate Director for Education for the AIMS Center and trains psychiatrists in Collaborative Care at the University of Washington and as part of the American Psychiatric Association Support and Alignment Network.
Her
clinical expertise includes primary care consultation and providing mental health care to underserved populations. Dr.
Ratzliff’s academic pursuits include developing strategies to provide mental health education to members of integrated care teams. Please visit the AIMS Center Website (aims.uw.edu) for Collaborative Care information. Slide3
Why Mental Health? TCPI COMMON MEASURESNQF 0018: Controlling High Blood Pressure in Patients with Hypertension NQF 0052: Use of Imaging Studies for Low Back Pain NQF 418: Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan PQRS 402: Tobacco Use and Help with Quitting Among Adolescents
NQF 2597: Substance Use Screening and Intervention Composite
NQF 2152: Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling
NQF 0028: Preventive Care & Screening: Tobacco Use: Screening and Cessation Intervention
TCPI 01: Comprehensive Health and Life Plan
TCPI 02: Referral of At-Risk Patients
TCPI 03: Medication
ManagementSlide4
Who Gets Mental Health Treatment?Wang et al., 2005Slide5
No Treatment
Primary Care Provider
Mental Health ProviderSlide6
Mental Health in Primary Care SettingsCOORDINATIONSlide7
Patient-Centered Collaborative Care TeamNew Roles
Primary Care Provider
Psychiatric Consultant
Care Manager
( MSW, RN, PhD)
Patient
© University
of WashingtonSlide8
Behavioral Health Services AvailableSlide9
Doubles Effectiveness of Care for Depression%Participating Organizations
50 % or greater improvement in depression at 12 months
Unützer
et al., JAMA 2002; Psych
Clin
North America 2004Slide10
IMPACT Care
Benefits Diverse
Populations
Arean
et al. Medical Care, 2005
50
% or
greater improvement in depression at 12 monthsSlide11
Collaborative Care Effective for Asian-American PopulationsThree groups compared:Asians at Community health center that focuses on Asians (culturally sensitive clinic)General community health centersMatched population of whites treated at the same general community clinics
Implementation study of collaborative care for 345 participants
primary
care visits with depression care managers, PCP prescribing, psychiatric consultationdepression severity (PHQ9) tracked at baseline and 16
weeks
RESULT: After
adjustment for differences in baseline demographic characteristics, all three groups had similar treatment process and depression
outcomes
Asian patients served at the culturally sensitive clinic (N=129) were less likely than Asians (N=72) and whites (N=144) treated in general community health clinics to be prescribed psychotropic
medications
CONCLUSION:
Collaborative care effective way to treat depression in Asian American populations
More Asian American served when collaborative care delivered in culturally sensitive clinics
Ratzliff et al.
Psychiatr
Serv. 2013 Slide12
Our PracticeMental Health Improvement Program (MHIP)State-wide Collaborative Care programSafety-net practices/FQHCsStarted in 2008>50,000 patients served to date
Behavioral Health Improvement Program (BHIP)
UW primary care clinics- now 19
Mixed payer population
Started in 2011
4660 indirect/ 8717 direct patient assessments to dateSlide13
Our PracticeMental Health Improvement Program (MHIP) Team1.0 - 3.0 FTE care managerVariable number of PCPs ~3-200.2 FTE psychiatric consultant
Behavioral Health Improvement Program (BHIP) Team
1.0
FTE
care manager
~ 5.0 FTE PCPs
0.2 FTE psychiatric consultantSlide14
What is performance?Process OutcomesClose follow-up (Minimum 2 contacts/month)Regular use of behavioral health measures (PHQ-9)Psychiatric consultation if patient not improvedClinical OutcomesPHQ-9 (depression measure for screening and tracking)GAD-7 (anxiety measure for screening and tracking)Slide15
Over the last 2 weeks, how many days have you been bothered by any of the following problems?
Not
at All
Several Days
More than Half the Days
Nearly Every
Day
1. Little interest or pleasure in doing things
0
1
2
3
2. Feeling down, depressed or
hopeless
0
1
2
3
3. Trouble falling asleep, staying
asleep or sleeping too much
0
1
2
3
4. Feeling tired or having little energy
0
1
2
3
5. Poor appetite or overeating
0
1
2
3
6.
Feeling bad about yourself – or that you are
a failure or have let yourself or your family
down.
0
1
2
3
7.
Trouble concentrating on things, such as
reading the newspaper or watching television
0
1
2
3
8.
Moving or speaking so slowly that other people
could have noticed. Or the opposite – being so
fidgety or restless that you have been moving
around a lot more than usual.
0
1
2
3
9.
Thoughts that you would be better off dead or of
hurting yourself in some way.
0
1
2
3
If you checked off any problem on this questionnaire so far, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
Not difficult at all
Somewhat difficult
Very Difficult
Extremely difficult
PHQ-9
: Scale 0 to 27 (
increasing severity)Slide16
High Performance Areas: MHIPInitial results from pilot showing taking a long time for patients to show improvement in depression
Pay
for performance on process measures
Complete initial assessment
Meet with psychiatric
consultant weekly and obtain indirect assessments on all patients not improving
Half of caseload had to receive 2 contacts per month
Population management target = 50% of patients show improvement on PHQ-9Slide17
MHIP: Pay-for-performance cut in half the median time to achieve improvement in 50% of patients.
Unützer et al., 2012
© University
of
Washington
AFTER P4P:
~ 26 week s to 50% of patients to improve
BEFORE P4P:
~68 week s to 50% of patients to improveSlide18
BHIP: High Performance AreasPopulation management target >50% of patients show improvement on PHQ-9Estimated costs savings: defined
as medical care cost savings per patient enrolledSlide19
BHIP: High Performance over 4 years20122013
2014
2015
Number of Clinics
10
12
15
15
Number of
Patients Enrolled
262
771
763
705
Average PHQ-9 at First Assessment
14.5
13.5
12.9
12
IndirectPsychiatric Consultations231
1505
1087
1417
Face-to-Face
Psychiatric Consultations
320
2346
2394
3044
Percent
of Patients Improved
81%
68%
64%
63%
Estimated Cost Savings
$340,000
$1,002,000
$991,900
$916,500Slide20
BHIP: High Performance SpreadEarly success helped with implementationStarted with 5 clinics now at 19 clinics
PCP
satisfaction helped with
spread“I practiced for 16 years without it and I will never go back” primary care physician, UW Neighborhood ClinicSlide21
Using Data to Manage PerformanceRegistry tool allows practice to track patient data and response to treatmentVisits Indirect assessmentsGraphs of measuresClinic level dataCaseload numberProcesses ( ex. Completed clinical assessment)Outcomes (ex current number of patient with clincial
improvement)Slide22
Behavioral Health Measurement-Based Treatment to Target
Regular use of behavioral health measures to track response to treatment
Use of psychiatrists to help intensify treatment
Stepped care makes efficient use of behavioral health resourcesSlide23
Continuous Quality Improvement
Care
Manager 1
Care
Manager 2
© University
of
WashingtonSlide24
Individual Patient Records
Care Manger Caseload Registries
Clinic Level Summaries
Data WorkflowSlide25
Lessons LearnedCritical to communicate a clear vision the ‘Why’ to everyone involvedIT infrastructure importanttools to support the registry, tracking of patients and metricsEffective recruitment and training of care managers was essentialOperationally, it helped to have strong pilot sitesSlide26
Need and DemandSlide27
How to Get StartedGather stakeholders and develop a visionWhat are behavioral health needs?What resources are available?Establish clear goals to determine valueDefine value broadly: patient and provider experience, PCP efficiency, etc…How will you measure?Map on to other organizational change
NCQA, PCMH, TCPISlide28
Questions?Slide29
Presenter Info Anna Ratzliff, MD, PhDEmail: annar22@uw.eduTelephone: 206-543-4292Websites: APA-SAN - https://www.psychiatry.org/psychiatrists/practice/professional-interests/integrated-care
UW
AIMS - http://aims.uw.edu/ UW ICTP - http://ictp.uw.edu
/