Integrated Health Matthew S. Duncan, MD Assistant Professor of Psychiatry Geisel School of Medicine at Dartmouth Dartmouth-Hitchcock Medical Center

SHOULD MENTAL

HEALTH BE A PRIMARY-CARE DOCTOR’S JOB?

POSTED BY SUZANNE KOVEN -a primary care doctor at Massachusetts

General Hospital in Boston Increasing Demand

Lack of Time

Lack of Training PCP’s

Medical Students

MH System/Insurance

PCMH Model

o HMS – Center for Primary Care MH staff in Primary Care

Teleconferencing

Ideal – on the spot, brief evaluation with PCP and Psychiatrist

OCTOBER 21, 2013

Collaborative/Integrated Care

(Heath et. al A Review and Proposed Standard Framework for Levels of Integrated Healthcare. SAMHSA-HRSA 2013)

Six Levels

Coordinated

Minimal Collaboration

Separate Facilities and Systems

No coordination and

communicate rarely

Basic Collaboration at

a Distance

Separate Facilities and Systems

Communication planned and

periodic

Co - located

Basic Collaboration on Site

Same facility but separate systems

Communicate regularly and

meet occasionally

Close Collaboration on Site with Some System Integration

Same facility and share some

systems

Communicate in person regularly

Integrated

Close Collaboration Approaching an

Integrated Practice

Shared space in same facility

Actively seek system solutions together and regular team meetings

Full Collaboration in a Transformed/Merged

Integrated Practice

Shared space in same facility

Resolved systems issues, function as one

team, communicate consistently at all levels

WHO

Psychiatrists:

5-30/100,000

Primary Care Physicians

100/100,000

Principles Policy

Fee for Service vs. Value Based HIPPA

Advocacy Training Limited and Doable Specialists

“New Yorkers to Find „No Wrong Door‟ to Public-Health Facilities” -

NY - Professional News October 21, 2013 Mark Moran

- 2005 – PHQ-9 screening

- 2007 – joining MH and substance abuse treatment

- 2007 - NY state agencies removed financial and regulatory barriers to integrated treatment

- provided funding to establish a Center for Excellence in Integrated Care

provide hands-on assistance in implementing best practices in at least half of the state’s 1,200 mental health and substance abuse treatment clinics.

- 2009, OMH required monitoring of cardiometabolic status and antipsychotic prescribing in all state-operated mental health facilities for adults, youth, and forensic populations.

- 2012 – IMPACT Model

Self-Assessment Interest/Goals

Triage sub-acute cases

Screen?

Care Coordination Social Work Behavioral Health

Treat Stabilization vs long-term Medications Counseling

Resources

Institution Support

Referral Network

External Virtual Team

Internal Team

Limited and Doable

Screening http://ibhp.org/uploads/file/IBHScreeningToolsRevFinal100313.pdf

Suicide: USPSTF/Annals of Internal Medicine – May 2013.

Unclear accuracy and no clear impact on outcomes

False Positives

Depression: 2010 Update of Previous USPSTF Recommendation In 2002, the USPSTF recommended:

screening adults for depression in clinical practices that have systems in place to assure accurate diagnosis, effective treatment, and follow-up.

The current recommendation:

staff-assisted depression care supports need to be in place. If such supports are not in place, the USPSTF does not recommend routine screening of adults.

IMPACT- Depression Care

PCP

Care Manager

Consulting Psychiatrist

Unutzer et al. JAMA 2002

Core Components

2 new processes Systematic diagnosis and outcomes tracking Stepped Care

2 new team members Care Manager Consulting Psychiatrist

Depression Care Model Usual

Pt’s therapist tells pt to tell PCP to start AD.

PCP reluctantly starts AD, arranges regular office visits

“crossed my fingers that the drug would be effective and wouldn’t cause side effects.”

IMPACT PHQ-9 Screening of all pt’s.

Immediate referral to a depression registry

Scheduled, frequent phone calls by depression care manager

Case- load supervision of DCM by Psychiatrist

1:1 Consultation if needed

Medications

- According to IMS Institute for Healthcare Informatics in 2009

Integrated Care

o Expand CM role o Systematize

Screening and Response Workflows

o Train, Educate, and Support

Key Components

Care Manager

Linkage

Support/Systems

LESSONS Advantages

Better Patient Care

Lower Healthcare costs

Less provider stress (if systems are in place)

Enhanced provider learning and confidence

Step toward a PCMH model

Cautions

Screening without Systems.

Systems without Training, Staffing and Specialist Support.

Ease of Access/PCMH can become CMHC.

Less can be More (but not optimal).

Trying to go Old School.