Behavioral Health Integration: Whole Person Care Conference · Behavioral Health Integration: Whole Person Care Conference January 27, 2017 Kathy Bradley, MD, MPH Senior Investigator

Behavioral Health Integration: Whole Person Care Conference

January 27, 2017

Kathy Bradley, MD, MPHSenior Investigator Group Health Research Institute

Affiliate Professor Medicine &Health Services,

University of Washington

Research Associate VA Puget Sound HSR&D1

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My Background

Primary care general internist

VA Women’s Health – 1995-2000

Population-based alcohol screening in VA

VA mental health integration (2002-2011)

3 models: Co-located, collaborative

care, behavioral health lab

Group Heath Behavioral Health

Integration (2014- present)

Research: collaborative care for alcohol

and opioid use disorders (2010 - present)

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Outline?

1. What is Behavioral Health Integration?

2. Evidence

3. Group Heath lessons learned

4. Road Map : how to get there:

Understanding current situation

People

Systems

What is Behavioral Health

Integration?

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Behavioral Health Integration?

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What is Behavioral Health Integration?

Three types of integration…

Primary care (PC) teams offering

behavioral health (BH) services

BH teams offering PC

PC teams and BH teams caring for

patients together: coordination

http://www/Breecollaborative.org

http://www.hca.wa.gov/about-hca/healthier-washington/medicaid-

transformation

What is Behavioral Health Integration?

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PC

What is Behavioral Health Integration?

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BH

PC

What is Behavioral Health Integration?

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BH

PC

Medical HomeAdvanced Primary Care

Elements of the Medical Home

Care Goals and Plan

Medication management

Self-management support

Preventive Care

Monitoring

Care management

Care Coordination

EvidenceBH care in PC settings

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Depression and Suicide

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Evidence - Depression

Depression Screening

Recommended by USPSTF

Adolescent & adults

Brief screen - PHQ-2

Siu JAMA 2016http://www.healthdisparities.net/hdc/hdcsearch/isysquery/8

d60cd76-98e9-47b4-b0a0-755dc6ddb7ef/9/doc/

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Evidence - Depression

Depression measurement-based care

Depression assessment: PHQ-9

10-14 – optional

15-19 medications or therapy

20+ medication and therapy

Monitor

Goal decrease by 50%

Katon NEJM 2010; Unutzer JAMA 2006

http://aims.uw.eduhttp://psychnews.psychiatryonline.org/doi/full/10.1176/appi.pn.2016.9a11

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Evidence - Depression

Collaborative Care

Care manager, coordination

Self management support

Measurement based care

Track patients supported by registry

Check-in 1-2 weeks re: side effects

Monitor response

Improves outcomes

Reimbursed by CMS: ~ 159$ per

patient per month??Katon NEJM 2010; Unutzer JAMA 2006

http://aims.uw.eduhttp://psychnews.psychiatryonline.org/doi/full/10.1176/appi.pn.2016.9a11

Evidence - DepressionCollaborative Care Management

Unutzer Am J Managed Care 2008

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Evidence - Depression

Suicide risk assessment

PHQ-9 depression screen

In the past 2 weeks how often…

Question #9: …thoughts that you

would be better off dead, or of hurting

yourself in some way

“More than half the days” (2-3 points)

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Evidence Suicidal Thoughts & Suicide Attempt or Death

Simon Psych Serv 2013

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EvidenceColumbia Suicide Risk Assessment

During the past month have you …

1. wished you were dead or wished you could go

to sleep and not wake up?

2. actually had any thoughts of killing yourself?

3. been thinking about how you might kill yourself?

4. had some intention of acting on those suicidal

thoughts?

5. worked out some or all of the details of how to

kill yourself?

6. If YES to #5, do you intend to carry out this

plan?

Posner Am J Psychiatry 2011

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EvidenceColumbia Suicide Risk Assessment

During the past month have you …

1. wished you were dead or wished you could go

to sleep and not wake up?

2. actually had any thoughts of killing yourself?

3. been thinking about how you might kill yourself?

4. had some intention of acting on those suicidal

thoughts?

5. worked out some or all of the details of how to

kill yourself?

6. If YES to #5, do you intend to carry out this

plan?

Posner Am J Psychiatry 2011

Story #1Uncontrolled diabetes in an

older woman:

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Story #1Uncontrolled diabetes in an

older woman:

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Out of control diabetes

HA1C 14.1

Non-adherent; not engaged in self care

No history of mental health conditions

Behavioral Health Integration:

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PHQ-9 score 24

PHQ-9 Question #9: 2

Suicide Risk Assessment: 5

Did not “look depressed”

Substance Use and Addiction

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Evidence – Substance UsePreventive Alcohol Screening

Substance Use - Prevention

Alcohol screening and brief preventive

counseling (USPSTF)

3rd highest prevention priority

Screens: AUDIT-C or single item

Advice re recommended limits and link

drinking to health

Jonas Ann Intern Med 2012; Moyer Ann Intern Med 2013

Solberg Am J Prev Med 2008

Fleming JAMA 1997, Alcohol Clin Exper Res 2002

Evidence – Substance UsePreventive Alcohol Screening

Outcomes

Decreased ED & hospital use

Savings 1st year: $522/patient

Savings 4 years: for each $1 spent on SBI:

$4.30 saved on inpatient & ED

$39.00 saved from societal perspective

Fleming, JAMA, 1997; Fleming 2000;

Fleming, ACER, 2002; Mundt 2006

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Evidence – Substance Use

Substance Use Disorder Medications

Alcohol use disorders (AUDs):

Naltrexone,

Acamprosate,

Disulfiram

Opioid Use Disorders (OUDs):

Buprenorphine

Injectable naltrexone

Jonas JAMA 2014; Bradley & Kivlahan JAMA 2014

Mattick Cochrane Reviews 2008 and 2009

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Evidence – Substance Use

Substance Use care management

Medications for AUD vs referral to

treatment

5 fold increased engagement

Decreased heavy drinking

Jonas JAMA 2014; Bradley & Kivlahan JAMA 2014

Oslin JGIM 2014

Alcohol Care Management vsReferral to Treatment

0

10

20

30

40

50

60

Perc

en

t d

ays o

f h

eavy d

rin

kin

g

Alcohol CareManagement

Specialty Addictioncare

Oslin JGIM 2014; Combine Manual

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Evidence – Substance Use

Substance Use care management

Medications for AUD

Medications for OUDs

Access: 100-125 patients/RN

67% retention at 12 months

PCPs: most satisfying patients

Jonas JAMA 2014; Bradley & Kivlahan JAMA 2014

Alford Arch Intern Med 2011; Korthuis Ann Intern Med 2016

Why Medication Treatment of OUDs is Critical

Long-term OUD treatment with medications,

compared to non-medication treatment

improves outcomes including

Marked improvements in quality of life

Decreases relapse

Increased survival

Decreases acute care (ED & hospital)

Often decreases total health care costs

Lo-Ciganic Addiction 2015, Murphy Pharmaco economics, 2016

Clark Health Affairs 201132

Story #2Uncontrolled diabetes in

older man

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Story #2Uncontrolled diabetes in

older man

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Previous lower extremity amputation

Diabetes out of control

Foot ulcer

RN seeing weekly

Story #2Uncontrolled diabetes and

foot ulcer in older man

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AUDIT-C score 10

Symptoms alcohol use disorder: 6

Pint of vodka a day +

Wanted help

How to Get from Here to There?

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How to Get from Here to There?

Example: Group Heath’s Behavioral Health

Integration

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Goals

Screening & assessment – routine

All patients, every year

Prevention

Treatment

Depression

Substance use disorders

Monitoring – measurement-based care

Severity at baseline & over time

Example Group Heath

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Screen

Assess

Shared decision

making & treatment

Monitor and

Adapt

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Strategies

Leadership support – BH Service

Evidence-based care

Design with front line staff

Simple systems

EHR support

Local implementation team & champions

Supported by coach (weekly)

Social workers trained in outreach and

engagement for addiction first

Barriers

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Barriers… Time

Barriers… Lack of Buy-in

“No Thursday is out.

How about never—is never good for you?”

Barriers… Attitudes

You

Want

Me

To

Do

What

????

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Lack of

“Shared

Meaning”

Barriers… Inadequate Communication

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Friday afternoon “disasters”

Suicidal patients

“Detox”

Barriers…

What Helps?

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What Helps? Teamwork

Youtube: https://youtu.be/tbKbq2IytC4

Addressing Attitudes

What Helps? Taking Time and Talking

Tell and Use Stories

What Helps?Pick a Goal; Take the Leap

What Helps? Trial and Error

Solve for worst case scenarios first56

What Helps? Resilience

Roadmap

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Step 1Environmental Scan

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Road Map – Step 1

1. Environmental scan:

Assess current state of care system

Who: all stakeholders

What: ideally visit each others worlds,

ask about care organization, observe

and listen

Identify gaps in quality of care

Summarize findings

Bring results to stakeholder meetings

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Road Map – Step 2

2. People - identify team

All stakeholders

Why you are there

All voices heard

Take turns leading meeting

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Road Map – Step 3

3. Pick a goal to start on …

Screening & assessment – routine?

Treatment – add substance use disorders?

Monitoring – measurement-based care?

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Road Map – Step 3

3. Pick a goal to start on …

Screening & assessment – routine?

Treatment – add substance use disorders?

Monitoring – measurement-based care?

Crisis management

Suicidal patients

Patients wanting “detox”

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Road Map – Step 4

4. Quality Improvement systems

Regular meetings

Change goal

Pilot test, adapt, repeat

Measure progress

Make meetings effective

Healthier Washington medicaid transformation project toolkit draft

for public comment January 2017

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SummaryBehavioral Health Integration

Change in way we think about PC & BH

Strong evidence

Apply medical home concepts

One step at a time

Its possible!

Thank You!

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Questions & Discussion

Acknowledgements

CHOICE Trial -– NIAAA- R01 AA018702

SPARC Trial – AHRQ – R18HS023173

3:30 Project – GH Partnership for Innovation

Options Study – NIAAA – R21 AA023037

Mentoring Award – NIAAA – K24AA022128

Clinical Trials Network – NIDA – 5UG1DA040314

Health Systems Node

Screening for marijuana and drugs

PROUD Trial Phase 1

Group Health Behavioral Health Service

GH Development Fund – Mike Evans video

Resources

http://www/Breecollaborative.org

Youtube: https://youtu.be/tbKbq2IytC4

Healthier Washington medicaid transformation

project toolkit draft for public comment January

2017

Thursdays at noon: Webinar - UW psychiatry

case reviews for primary care