Ipc.Meit.C

Integrated Behavioral Health: Primary Care Models of Service Delivery

Scott S. Meit, PsyD, MBA, ABPPVice Chair for Psychology & Section Head, General and Health Psychology

Department of Psychiatry & Psychology

Learning Objectives

I. To briefly review the “Medical Cost Offset” literature and understand its influence upon integrated primary care (IPC)

II. To appreciate Public Health’s impact upon emerging IPC models

III. To explore the evolution from parallel delivery systems to integrated primary care/behavioral health

IV. Traditional BH care and IPC: Viva La Difference

Psychological Distress contributes to over utilization of health care

At Group Health Cooperative of Puget Sound 10% of medical utilizers accounted for one

third of outpatient resources and one half of inpatient resources!

One half had psychiatric diagnoses!

From Katon, Von Korff, Lin, Lipscomb, Wagner & Polk, 1990

Less than 30% of people seek care for their mental and/or addictive disorder

Schurman, Kramer, Mitchell, 1985

Of the same population, 78% receive health care

services Mauksch & Leahy, 1993 - 60-90% of all visits to physicians at least partially due to psychological, emotional, and

behavioral factors (Benson, 1996)

Of those who seek treatment for mental and/or addictive disorders, 40-50% seek that care from PCPs

Miranda, Hohman, Attkisson, 1994

And yet…

Treating behavioral health disorders reduces cost of overall health care!

(Medical Cost Offset)

Kaiser-Permanente ExperienceCummings NA, and Follette WT, Health Policy Quarterly, 1968Follette W, and Cummings NA, Medical Care, 1967Cummings NA, and VandenBos, GR, Health Policy Quarterly, 1981

Findings supported in meta-analysis & in other research “camps”Jones KR and Vischi TR, Medical Care (Suppl), 1979–a review of research

literatureFriedman R, Sobel D, Meyers P, et al, Health Psychology, 1995Chiles J. et al. Clinical Psychology: Science and Practice, 1999 (57 controlled

studies show a net 27% cost savings )

Yet patients present to PCPs instead of Psychologists (and other behavioral health providers) – Why?

Perceive themselves as having poor health Often multiple somatic complaints Established rapport with PCP Avoidance of stigma Cultural and socioeconomic factors Better insurance coverage/lower co-pay HMO/Behavioral Health carve outs

Why Integrate Primary Care and Behavioral Health Care?

1. That’s where the Pts present! 50% of all MH care delivered by PCPs 92% of all elderly patients receive MH care from PCPs

2. Primary Care Process of Care Realities 90% of the most common PC complaints = no organic basis 70% of all PC visits have psychosocial drivers (Fries, Koop, & Beadle, 1993)

67% of psychotropic agents prescribed by PCPs (Beardsley et al, 1988)

K. Strosahl, PhD, Mountainview Consulting Group, Inc.

Public Health & Population-based Care: A “by the numbers” approach

Public health & epidemiology– Focuses on raising health of population– Emphasis on early identification & prevention– Designed to serve high percentage of

population– Provides triage and clinical services in

stepped care fashion– Balanced emphasis on who is and is not

accessing service

The Continuum of Integration

Model Desirability Attributes

Separate Space& Mission

- - Traditional BHSpecialty Model

1:1 ReferralRelationship +

Preferredprovider/Some informationexchange

Co-location ++ On-site BH Unit/Separate Team

CollaborativeCare

+++ On site/sharedcases w/ BHspecialist

Integrated Care +++++ PC Team Member

Another view…

So, how do you do this?

Care Matching (primary care in primary care) Triage & “EAP” like services (mid-levels) Group & psycho-educational services Psychologist as director of exam room BH

care, provider of brief on-site therapy, & liaison to tertiary BH services

Embrace the differences between traditional BH services and integrated primary care behavioral health services

Care Matching

Not every problem requires intensive intervention

Inappropriate matching = waste And can lead to iatrogenic complicationsIatros means physician in Greek, and -genic,

meaning induced by. Combined, they become iatrogenic, meaning physician-induced. Iatrogenic disease, then, is disease which is caused by a physician.

Tailoring the “mix” by setting…

Put another way…

BHC Primary Goals

Act as consultant and member of health care team. Support PCP decision making. Build on PCP interventions. Teach PCP “core” behavioral health skills. Educate patient in self management skills through

training. Improve PCP-patient working relationship. Monitor, with PCP, “at risk” patients.

BHC Goals (cont.)

Manage chronic patients with PCP in primary provider role

Assist in team building Simultaneous focus on health and behavioral

health issues Effective triage of patients in need of specialty

behavioral health Make IPC/BH services available to a large

percentage of eligible population

Behavioral Health ConsultantSession Structure

Limited to 1-3 visits in typical case 15-30 minute visits Critical pathway programs may involve 4-8

appointments (e.g. Diabetes & Depression, Chronic Pain)

May use classes and group care clinics Multi-problem patients seen regularly but

infrequently over time

Behavioral Health ConsultantIntervention Structure

Informal, revolves around PCP assessment and goals

Low intensity, between session interval longer Relationship generally not primary focus Visits timed around PCP visits Long term follow up rare; reserved for high risk

patients

Behavioral Health ConsultantIntervention Methods

Limited face to face contact Uses patient education model Consultant is a technical resource to patient Emphasis on home-based practice to promote

change May involve PCP in visits with patient

BHCTermination and Follow-up

Responsibility returned to PCP (the BHC is a subject matter expert & resource; the Pt is and remains the Pt of the PCP)

PCP provides relapse prevention or maintenance treatment

BHC may provide planned booster sessions for at risk patients

Behavioral Health Consultant Information “Products”

Consultation report to PCP Part of medical record “Curbside consultation” Written relapse prevention plans (e.g. “Mood

First-Aid Kit”)

Qualities of A Successful Integrated Primary Care Service

Provides timely access for PCP Service is integrated within primary care setting Service is viewed as a form of primary care Service is provided in collaboration with the PCP Service is provided as part of the health care

process Improved clinical outcomes, satisfied patients (and

health care providers), and managing productivity & financial risk as key goals

Economic Benefits of Integration

Increased Productivity Capacity– Estimate of revenue ceiling of a health care system is closely

tied to productive capacity of medical providers– PC capacity is commonly impacted by behavioral health

management demands of (50% of medical practice time directed toward BH conditions)

– Integrated behavioral health re-directs BH patients and “leverages” PCP practice time

– PCP’s are freed to see medical patients with higher RVU conditions

Cost Effectiveness Measuring the impact of adding additional dollars to a medical

procedure for value received (e.g. better diagnostic accuracy, clinical effectiveness)

– Collaborative Care increased initial depression treatment costs but improved the cost-effectiveness of treatment for patients with major depression

– Cost offset for specialty mental health costs – A positive cost effectiveness index of $491 per case

of depression treated

Von Korff et. al., 1998. Treatment costs, cost offset, and cost-effectiveness of collaborative management of depression Psychosomatic Medicine, Vol 60, Issue 2 143-149.

In SummaryIPC Benefits the Patient (and a broader Pt. Population)

Mind-Body dualism avoided More diagnostic accuracy Greater range of treatment options

IPC/BH Benefits PCPs

Assistance with diagnostic differential Less time/fewer visits required with PCP Concomitant medical conditions often improve BHC typically obtains more information

regarding psychosocial factors BHC may assist in monitoring

pharmacotherapy treatment adherence

IPC benefits BH Providers

PCP can endorse the BH Provider and psychotherapy

PCP will evaluate for medical illness and/or medication effects

PCP can prescribe pharmacotherapy (often diminishing a need for psychiatrist consult)

PCP often has helpful background information, with established Pts

How do you train for this? (if you want to)

Alexander Blount, Ed.D. - UMass Dept of Family Medicine, Certificate Program in Primary Care Behavioral Health

Connect with the integrated primary care/BH initiatives of the Family Medicine Education Consortium (Laurence Bauer, MSW, M.Ed., Chief Executive Officer – and in Dayton!)

www.fmec.net and Read, Read, Read

Who pays for this?

The Family Medicine Education Consortium recently conducted a series of meetings and a summit in Pittsburgh to begin to organize a tri-state (OH-PA-WV) IPC initiative.

They have previously facilitated efforts in the Pacific NW & New England regions.

Promoting a broad and inclusive membership of providers, consumer groups, & payors is their model

In NE, this resulted in the President of the regional BC/BS group authorizing 10% higher reimbursements for all PCP services where IPC/BH model of services are in place.

Recommended Books

Seaburn, DB. (Editor), et al Models of Collaboration: A Guide for Mental Health Professionals Working with Health Care Practitioners New York: Basic Books ©1996

Cummings, NA, O’Donohue, WT, & Ferguson (Editors). Behavioral Health as Primary Care: Beyond Efficacy to Effectiveness Reno, NV: Context Press © 2003

Books (cont.)

Frank, R., McDaniel, S., Bray, J., Heldring, M.  Primary Care Psychology, Washington, DC: APA Press. © 2003

James, LC & Folen, RA (Editors). The Primary Care Consultant: The Next Frontier for Psychologists in Hospitals and Clinics, Washington, DC: APA Press. © 2005

Books (cont.)

O'Donohue;, WT, Michelle R. Byrd, MR, Cummings, NA, & Henderson, DA (Editors). Behavioral Integrative Care: Treatments That Work in the Primary Care Setting New York: Routledge. © 2005.

Blount, Alexander (Editor). Integrated Primary Care: The Future of Medical and Mental Health Collaboration  New York: W. W. Norton. © 1998.

Good Web Sites

www.integratedprimarycare.com/www.integratedprimarycare.com/Blount.htm (Blount Link)

www.behavioral-health integration.com/news.php(Strosahl’s site, Mountainview Consulting)

www.healthpsych.com/practice/ipc/primarycare1.html(a little dated, but a good basis for understanding evolution of IPC)

Discussion