New Effective Co-Management of Mental and Physical Chronic …qioprogram.org/sites/default/files/editors/141/National... · 2016. 11. 1. · Offer virtual training events focused

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National Learning & Action Network

Sharing Knowledge, Improving Health Care Series

November 1, 2016

Effective Co-Management of Mental and Physical Chronic Conditions

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Welcome and Reminders

Lindsay KirschQIN NCC

• Karen Ten Cate, from the QIN NCC, will be monitoring our WebEx CHAT board

• Please be prepared for sharing and open discussion!

• Slides and a recording from today’s session can be found on: http://qioprogram.org/national-learning-action-network-series-november-2016

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Agenda

• Purpose & Housekeeping • Speaker Presentations

o Christina Goatee, Centers for Medicare & Medicaid Services

o Eric Christian, Center of Excellence for Integrated Careo Dr. Paul Ciechanowski, Samepage Health

• Facilitated Discussion• Wrap-up

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Purpose of the Series

Audience: Patients, community and health care providers, local partners, federal partners and Quality Improvement Organization Program partners (*registration required)

Purpose: Offer virtual training events focused on health care quality improvement and hot topics in health care delivery transformation, and connect these national themes with related local services, resources and support available through the QIO Program

Expectations: Participants will gain knowledge that is directly applicable to their work in health care quality improvement and acquire information that can be easily shared among their own community, organization, or team

Topics: Topics will be aligned with the CMS Quality Strategy goals

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Learning Outcome

• The purpose of this session is to prepare healthcare quality improvement professionals to identify and implement effective healthcare strategies by exploring promising practices that integrate mental and physical chronic disease treatment and prevention.

• We expect that this experience will help participants demonstrate and promote successful delivery of care practices and identify opportunities for improvement, all of which may promote advances in care that impact the Medicare beneficiaries served by the work of the QIO Program.

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Things to Consider

Will you commit to being… • Attentive• Active participant• Actionable

Show your commitment by clicking the green “check”!

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Now Offering Continuing Education Credit

• Continuing education credit is available for:– Physicians & Physician Assistants– Registered Nurses & Nurse Practitioners– Dietitians– Pharmacists & Pharmacy Technicians– Certificate of Attendance

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CE Information

Physicians:This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of AKH Inc., Advancing Knowledge in Healthcare, CRW & Associates and Telligen. AKH Inc., Advancing Knowledge in Healthcare is accredited by the ACCME to provide continuing medical education for physicians.

AKH Inc., Advancing Knowledge in Healthcare designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Physician Assistants:NCCPA accepts AMA PRA Category 1 Credit™ from organizations accredited by ACCME.

Pharmacists:AKH Inc., Advancing Knowledge in Healthcare is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.AKH Inc., Advancing Knowledge in Healthcare approves this knowledge-based activity for 1.0 contact hour (0.1 CEU). UAN 0077-9999-16-095-L04-P; UAN 0077-9999-16-095-L04-T. Initial

Release Date: 11/1/2016

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CE Information

Registered Nurses:AKH Inc., Advancing Knowledge in Healthcare is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.This activity is awarded 1.0 contact hour.

Nurse Practitioners:AKH Inc., Advancing Knowledge in Healthcare is accredited by the American Association of Nurse Practitioners as an approved provider of nurse practitioner continuing education. Provider Number: 030803.This program is accredited for 1.0 contact hour which includes 0 hours of pharmacology. Program ID #21610-8.

This program was planned in accordance with AANP CE Standards and Policies and AANP Commercial Support Standard

Dietitians:AKH Inc., Advancing Knowledge in Healthcare is a Continuing Professional Education (CPE) Accredited Provider with the Commission on Dietetic Registration (CDR). Registered dietitians (RDs) and dietetic technicians, registered (DTRs) will receive 1.0 continuing professional education unit (CPEU) for completion of this program/material. CDR Accredited Provider #AN008. The focus of this activity is rated Level 2. Learners may submit evaluations of program/materials quality to the CDR at www.cdrnet.org.

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Disclosure of Financial Relationships & Commercial Support

• The faculty have the following relevant financial relationships to disclose: Karen Ten Cate, MA, RD, CDE: Nothing to disclose Christina Goatee, MSN, RN: Nothing to disclose Lindsay Kirsch, MPH: Nothing to disclose Paul Ciechanowski, MD, MPH: Nothing to disclose Eric Christian, MAEd, LPC, NCC: Nothing to disclose

• AKH Inc. , CRW & Associates and Telligen do not have any relevant financial relationships to disclose.

• No commercial support was received for this activity.

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Disclosure of Financial Relationships & Commercial Support

DisclosuresIt is the policy of AKH Inc. to ensure independence, balance, objectivity, scientific rigor, and integrity in all of its continuing education activities. The author must disclose to the participants any significant relationships with commercial interests whose products or devices may be mentioned in the activity or with the commercial supporter of this continuing education activity. Identified conflicts of interest are resolved by AKH prior to accreditation of the activity and may include any of or combination of the following: attestation to non-commercial content; notification of independent and certified CME/CE expectations; referral to National Author Initiative training; restriction of topic area or content; restriction to discussion of science only; amendment of content to eliminate discussion of device or technique; use of other author for discussion of recommendations; independent review against criteria ensuring evidence support recommendation; moderator review; and peer review.

Disclosure of Unlabeled Use and Investigational Product This educational activity may include discussion of uses of agents that are investigational and/or unapproved by the FDA. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer This course is designed solely to provide the healthcare professional with information to assist in his/her practice and professional development and is not to be considered a diagnostic tool to replace professional advice or treatment. The course serves as a general guide to the healthcare professional, and therefore, cannot be considered as giving legal, nursing, medical, or other professional advice in specific cases. AKH Inc. specifically disclaim responsibility for any adverse consequences resulting directly or indirectly from information in the course, for undetected error, or through participant's misunderstanding of the content.

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Method of Participation

• You must participate in the entire activity to receive credit.

• A statement of credit will be available upon completion of an online evaluation/claimed credit form.

• The link to the online evaluation will be provided after completion of the activity.

• If you have questions about this CME/CE activity, please contact AKH Inc. at [email protected].

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Who’s in the Room?

What entity or type of organization do you represent?

• CMS• Home Health Agency• Hospital• Nursing Home / Skilled Nursing Facility• Patient, Family or Caregiver Representative• Pharmacy / Pharmacist• Provider / Practice• QIN-QIO• Other (please specify in the comments field)

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Session Goals

By the end of today’s call you will be able to…

• Define integrated care on the continuum and identify action steps planning for integration and collaboration for your organization.

• Describe three models of behavioral health integration.

• Identify the core components of effective multi-condition collaborative care.

• Define clinical inertia and understand how collaborative care reduces its impact.

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Centers for Medicare & Medicaid Services (CMS)

Christina Goatee, MSN, RNNurse ConsultantCenter for Clinical Standards & Quality (CCSQ)

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CMS Quality Strategy

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Make Care Safer: Objectives

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Today’s Speakers

Commonalities:• Integrated physical care and behavioral health

treatment• Prevent and treat chronic conditions

Integrating Healthcare Journey• Where have we been?• Where are we now?• Where is the work going?

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Center of Excellence for Integrated Care

Eric Christian, MAEd, LPC, NCCTechnical Assistance Consultant

Effective Co-Management of Mental & Physical Chronic Conditions

Center of Excellence for Integrated Care, a program of The Foundation for Health Leadership and Innovation

Eric Christian, MAEd, LPC, NCC 11/1/2016

ObjectivesDefine integrated care on the

continuum

Describe three models of behavioral health integration

Basic Concepts and Theories of Integrated Care

Integrated care is “care that results from a practice team of primary

care and behavioral health clinicians, working together with

patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined

population.”

(Peek, 2013)

Whole Health Care

The majority of people have comorbid mental health and medical problems but do not receive care consistent with established practice guidelines (Institute of Medicine, 2006).

Treating the Whole Person

Whole-person care requires a more comprehensive approach (biopsychosocial model of assessment).

BiologicalPsychologicalCognitiveSocial InterpersonalDevelopmentalCulture and other

contextual factors

Why Do It?

71% of the most severe patients improved faster with IC than the less severe (Bryan et al., 2012).

Patients receiving just 2-3 visits showed broad improvement in functioning, well-being, with changes being robust and stable during 2-year follow-up (Bryan et al., 2009).

Most patients who attend 2, 3 or > 4 visits show clinically significant change (Cigrang et al., 2006).

(Courtesy of Reiter, 2013)

Why Do It?

Up to 70% of appointments with PCPs are for problems stemming from psychosocial issue (Gatchel & Oordt, 2003).

Behavioral problems and unhealthy lifestyle choices are responsible for most of the top ten causes of morbidity and mortality (US Department of Health and Human Services, 2000).

(Frank deGruy, 2009).

Outcomes

Decreases depression levels Improves quality

of life Decreases stress Increases higher

functioning Promotes greater

adherence to medical recommendations and lifestyle change –prevention as well as treatment

Reduces hospitalization readmissions Lowers rates of

hospitalization and Encourages

movement toward value-based care for better overall health outcomes and wellness

(IBHP, 2009; Kim, et al., 2012; O’Donnell, et al., 2013).

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The Continuumof Integrated Care

Team-based Care

Mental health and medical care providers work together to coordinate the detection, treatment, and follow-up of both the physical and mental health needs of their patients. Assumes that health is a shared

community responsibility and can be achieved through the dissolution of barriers that result in silo-style service provision (Mauer & Jarvis, 2010). Strategic workflows stressing that

support individuals in their whole-person health needs and goals.

Behavioral Health Integration Models

Have a clear definition of practice, personnel rolesHave an evidence baseThree exist: Collaborative Care,

SBIRT & PCBHAre not mutually exclusive and can

run simultaneously in a practice setting given that two are vertical models (CC, SBIRT) and one is a horizontal model (PCBH)Differ in which populations they

are applicable to (Four Quadrants)

Horizontal vs Vertical

Integration

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Side-By-Side Comparison

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Population-Based Health Approaches

PCBH: Distributes the skills of a behavioral health consultant across provider panels by eliminating the concept of a ”case load” and providing for more strategic contact between the mental health professional, PCP and patient across visits (e.g. more patients impacted per behavioral health professional than in caseload model)

SBIRT: Uses a behavioral health professional trained in motivational interviewing to provide interventions to the portion of a primary care population that screens positive for substance use issues in a brief format with strategic follow-up

Collaborative Care/IMPACT: Uses a registry and care manager to change the practice habits of primary care providers with regard to prescribing while also tracking depressed patients so that they are not lost to follow-up

Bidirectional Integration

Primary health care providers integrated into specialty mental health settings.

The focus is on targeted medical issues for the population in the setting (Mauer & Jarvis, 2010).

Levels of bidirectional integration are also on a continuum.

Primary Care services do not replace the need for more intensive specialty care.

References

Bryan, C.J., Morrow, C.E., & Appolonio, K.A.K. (2009). Impact of behavioral health consultant interventions on patient symptoms and functioning in an integrated family medicine clinic. Journal of Clinical Psychology, 65, 281-293.

Bryan, C.J., Corso, M.L., Corso, K.A., Morrow, C.E., Kanzler, K.E., & Ray-Sannerud, B. (2012). Severity of mental health impairment and trajectories of improvement in an integrated primary care clinic. Journal of Consulting and Clinical Psychology, 80, 396-403.

Cigrang, J. A., Dobmeyer, A. C., Becknell, M. E., Roa-Navarrete, R. A., Yerian, S. R. (2006). Evaluation of a collaborative mental health program in primary care: Effects on patient distress and health care utilization. Journal of Community and Primary Care Psychiatry, 11, 121-127.

deGruy, F. (2009, October). Integrated Care: The Inseparability of the Mental and the Medical. Presentation at the Collaborative Family Healthcare Association Policy Summit, Sandiego, CA.

Gatchel, R. J., & Oordt, M. S. (2003). Clinical health psychology and primary care: Practical advice and clinical guidance for successful collaboration. Washington, DC: American Psychological Association

Institute of Medicine. 2006. Improving the quality of health care for mental and substance-use conditions. Washington, DC: National Academies Press.

Integrated Behavioral Health Project. (2013). Partners in health: Mental health, primary care and substance use interagency collaboration tool kit (2nd ed.). [PDF document]. Retrieved from http://ibhp.org/uploads/file/IBHPIinteragency%20Collaboration%20Tool%20Kit%202013%20.pdf

References

Kim, J.Y., Higgins, T.C., Esposito, D., Gerolamo, A.M., & Flick, M. (2012). SMI innovations project in Pennsylvania: Final evaluation report. Report prepared for the Center for Health Care Strategies. Princeton, NJ: Mathematica Policy Research. Available at http://www.chcs.org/usr_doc/Mathematica-RCP-FinalReport-2012.pdf.

Mauer, B., & Jarvis, D. (2010). The business case for bidirectional integrated care. Retrieved from http://www.thenationalcouncil.org/galleries/policy-file/CiMH%20Business%20Case%20for%20Integration%206-30-2010%20Final.pdf

O’Donnell, A.N., Williams, B.C., Eisenberg D., & Kilbourne A.M. (2013). Mental health in ACOs: missed opportunities and low hanging fruit. American Journal of Managed Care, 19(3):180–4.

Peek, C. J. (2013). Lexicon for behavioral health and primary care integration: Concepts and definitions developed by expert consensus. Rockville, MD: Agency for Healthcare Research and Quality.

Reiter, J. (2013). The future is now. Presentation at the Integrated Behavioral Health Conference Co-sponsored by Virginia Community Health Care Association, Radford University and Southwest Virginia Community Health Systems, Incorporated, Richmond, VA.

United States Department of Health and Human Services (2000). Healthy people in 2010: Understanding and improving health (2nd ed.). Washington DC: U.S. Government Printing Office.

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Let’s Take a Poll

Where does your organization lie in their implementation of Behavioral Health Integration (BHI)?A. Precontemplation: No interest in BHIB. Contemplation: Would like BHI but not sure how to

beginC. Preparation: Planning to take action towards BHID. Action: Active in implementing BHIE. Maintenance: Mature systems of BHI are in placeF. Relapse: Started BHI but failed and may try again

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Facilitated Discussion

Chat in your questions and comments.

Press *1 on your telephone key pad to enter the teleconference queue.

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Samepage Health

Paul Ciechanowski, MD, MPHCMO / Founder

Integrating CareCollaborative Teams for Behavioral Health and Medical Conditions

Paul Ciechanowski, MD, MPHCMO, Samepage Health

Clinical Inertia

• defined as lack of treatment intensification in a patient not at evidence-based goals for care.

• a major factor that contributes to inadequate chronic disease care in patients with diabetes mellitus, hypertension, dyslipidemias, depression, coronary heart disease, and other conditions.

Study: 161,697 Patients

Schmittdiel et al., J Gen Intern Med. 2008; 23(5): 588–594.

✗ Glucose control✗ Blood pressure ✗ Cholesterol

“Bundled benchmark”

81% of those with diabetes

FAIL TO ACHIEVE

the bundled benchmark

Casagrande et al., Diabetes Care, 2013

✗ Glucose control✗ Blood pressure ✗ Cholesterol

“Bundled benchmark”

Achieving the bundled benchmark, healthcare systems…“…will require improved methods to increase adherence to prescribed medications, physical activity, healthy dietary choices, and access to support, including motivation and maintenance of behavior change.”

Casagrande et al., Diabetes Care, 2013

What Is It Costing You?

Adapted from: Oliver Wyman Analysis, Kaiser, CMS, Census Bureau, CSC, Oliver Wyman Health Innovation Center. Exec. Summary. Convergence: Consumer & Patient-Centered Business Designs. Oct 2013 Ideation Session. Found online. Note: Data excludes the uninsured and VA populations, year = 2012

Adapted from: Oliver Wyman Analysis, Kaiser, CMS, Census Bureau, CSC, Oliver Wyman Health Innovation Center. Exec. Summary. Convergence: Consumer & Patient-Centered Business Designs. Oct 2013 Ideation Session. Found online. Note: Data excludes the uninsured and VA populations, year = 2012

Collaborative Care:A team with a shared mission, using improved clinical systems to deliver improved care to a patient population supported by operational and financial systems.

Such care is continuously evaluatedthrough improvement processes and effectiveness measurement.

ahrq.gov

A1c

Blood pressure

Cholesterol (LDL)

Depression

Outcome domain

Collaborative Care Focusing on

Multiple Conditions

Comparison Studies

Focusing on One Outcome

Description

Depression Effect size: 0.65 Effect size: 0.25 37 Collaborative Depression Trials

HbA1c Change: 0.58% Change: 0.42% 66 Diabetes Trials

Systolic BP Change: 5.1 mmHg

Change: 4.5 mmHg 44 Trials

• A significant change in LDL of 6.9 mg/dL in the Collaborative Care Study

• $1116 lower outpatient costs per Medicare patient at 24 months

Katon et al. N Engl J Med 2010; 363:2611-2620

One or More Med Adjustments in 12 mo.

Katon et al. N Engl J Med 2010; 363:2611-2620

Clinical and Utilization Outcomes in 17 Weeks

• Patients were enrolled into the Multi-Condition Collaborative Care program implemented by Samepage in a large Health Delivery Network

• Patients had an average of 9.6 chronic conditions and the majority had depression and out-of-target diabetes or hypertension.

• Patients were enrolled for a median duration of 17 weeks.

Collaborative Care Cycle

IdentifyGoals

BehavioralStrategies

MonitorProgress

Treat-to-Target

SystematicCase Review

PCP Participation

Comprehensive Collaborative Care Solution

Systematic Case Review

Registry with recent values for each patient: PHQ-9, A1c, BP, LDL, GAD-7, etc.

Detailed action steps for each patient shared immediately with PCP• Weekly systematic case review lasts 1-2 hours

• 40-60 patients reviewed per 1 FTE care manager equivalent• Population management: all patients’ outcomes/treatment discussed• Detailed outcome values/detailed action steps shared by team

members• Process: Treat-to-target and measurement-based care

Fortney et al., 2013

Addressing Depression & Co-Morbidities

• Psycho-education• Administering screens (PHQ-9, GAD-7, PCL-C)• Screening for co-morbid conditions• Screening for self-harm• Reviewing and titrating meds• Addressing side effects• Problem solving treatment• Behavioral activation• Decisional balance• Relapse prevention

Summary• Addresses depression and anxiety in setting of

comorbid medical conditions• Addresses the “how” to the analytics “what”• Addresses health behavior as well as behavioral

health • Population health approach vs. being indexed to

admission/discharge• Benefits: rapid improvement; reduced silos of care; a

bio-psycho-social approach; inclusion of PCP every step of the way; built-in “curbside consultation” from psychiatry and internal medicine (+ pharmacy and social work).

Thank You!

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Facilitated Discussion

Chat in your questions and comments.

Press *1 on your telephone key pad to enter the teleconference queue.

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Individual Reflection

What are your key takeaways?

What did you hear that you could apply to your efforts to address healthcare acquired infections?

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Call to Action

• Consider if one or more models of integration might fit your organization’s practice site(s). – What resources and adjustments would be needed for

this model (i.e., culture change, quality improvement support, training of clinicians and clinical staff, EMR adjustments, financing, population data to make decisions, etc.)?

• Do you have a story to share? What has worked? What are you challenges?– Share your story with the QIN NCC

([email protected]).

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Call For Future Topics

• We want to hear from you!• Do you have a need or desire to hear about a certain

topic?• Submit your ideas in chat or email us at

[email protected]

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12/6/16 - Save the Date!

• Join us for the Follow-up Event to today’s National Learning & Action Network (LAN) Call– Tuesday, December 6, 2016– 3:00-4:00 PM ET– Registration is required!▪ Register at:

https://qualitynet.webex.com/qualitynet/onstage/g.php?MTID=e82007e7c8a02bcaded14a50cc3790c0d

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2/7/17 - Save the Date!

• Join us for the next National Learning & Action Network (LAN) Event • The topic will be aligned with the CMS Quality Strategy goal to work

with communities to promote best practices of healthy living.

– Tuesday, February 7, 2017– 3:00-4:00 PM ET– Registration is required!

https://qualitynet.webex.com/qualitynet/onstage/g.php?MTID=e1bf32469f9004a5be452d436dd4cbdb2

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Post-Event Assessment

• Provide your feedback!

Post-event assessment: https://www.surveymonkey.com/r/ZPKTPPC

• Contact Nikki Racelis ([email protected]) with any questions.

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Thank you!

This material was prepared by Telligen, the Quality Innovation Network National Coordinating Center, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 11SOW-QINNCC-00987-09/07/16