heartandsoulofchange.com 5/29/2014 1 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) Despite A Changing U.S. Health Care System • 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) 2
Dr. Brian DeSantis, Director of Behavioral Services at Peak Vista and Project Leader of the Heart and Soul of Change Project, discusses the ins and outs of integrating behavioral care into primary care.
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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)
• 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)
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)
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)