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Discover collaborative care approaches to address depression in the aging population, learn about the essential elements of program implementation, and explore the relationship between IMPACT outcomes and emerging healthcare models.
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Caring for Our Aging Population: Improving Mood and Restoring Meaning in the "Wisdom" Years Speakers Mary Buttitta, MS, LPC, IMPACT Program Coordinator, CCWNC Allison McCarty, LCSW-A, IMPACT Care Manager, CCWNC Debra Moon, LCSW, IMPACT Care Manager , CCWNC Pamela Dunkin, MD, IMPACT Psychiatric Consultant Eric Christian, MAEd, LPC, NCC, Director of Behavioral Health Integration, CCWNC Session # D1 CFHA 18th Annual Conference October 13-15, 2016 Charlotte, NC U.S.A.
Faculty Disclosure The presenters of this session have NOT had any relevant financial relationships during the past 12 months.
Learning ObjectivesAt the conclusion of this session, the participant will be able to: • Describe collaborative care approaches to depression care • Identify the essential elements of program implementation • Discuss the relationship between IMPACT outcomes and its application in emerging healthcare models
Learning Assessment • A learning assessment is required for CE credit. • A question and answer period will be conducted at the end of this presentation.
Who’s in the Audience? • Who is currently working in an integrated care setting? • What role? • Therapists? • Care Managers? • Prescribers? • Nurses? • Others? • How many work in Primary Care? • Community Mental Health?
Caring for Our Aging Population:Improving mood and restoring meaning in the “Wisdom” years
LATE LIFE DEPRESSION • Profound effects on quality of life, functioning and healthcare costs. • 5 million out of 31 million adults over 65 in the U.S. have significant depressive symptoms • Few receive specialty mental health care compared to younger population • IMPACT – Improving Mood, Promoting Access to Collaborative Treatment • Designed to address the unmet needs of these older adults 1. Gellis, Kenaley, & McCracken, 2014
IMPACT: Evidence-Based Depression Care IMPACT has been shown in randomized controlled trials to double the effectiveness of usual care for depression while lowering long-term health care costs. Impact uses these 5 Key Components • Collaborative care is the cornerstone of the IMPACT model • Depression Care Manager • Designated Psychiatrist • Outcome measurement • Stepped care 2. Crain, Solberg, Unützer, et all 2013
IMPACT Study Results • 1998-2003 – 80 research studies show: • Less depression • Less physical pain • Better functioning • Higher quality of life • Greater patient and provider satisfaction • Cost effective • Effective with minority populations 3. & 4. Unützer, et all, 2002
Model Effectiveness • At 12 months, about half of the patients receiving IMPACT care reported at least a 50 percent reduction in depressive symptoms (19% in usual care i.e.: ANYTHING ELSE!) • A survey conducted one year after IMPACT shows that the benefits of the intervention persist after 1 year and last up to 4 years • IMPACT patients experienced more than 100 additional depression-free days over a two-year period than those treated in usual care. 3. & 4. Unützer, et all, 2002
What we are doing • CCWNC was invited by Kate B. Reynolds Charitable Trust to apply for a grant to implement the IMPACT model • 2 counties and in 2 practices each with 3 sites in Western North Carolina over a 3 year period • Pilot project to determine • Can we achieve the same outcomes as the studies • Can this model be expanded across the state • Is it sustainable
Behind the Scenes… • The Implementation Team • Comprised of key staff • Charged with making system wide changes • Staff training and orientation to the model • Changes to the EMR to accommodate referral flow • Patient Education Material • Designate space for the ICM to meet with patients • Develop the work flow
Work Flow All patients 60+ are given PHQ9 by clinical staff/ MA MA scores PHQ9 & notifies provider of scores 10+ Provider educates patient about IMPACT and makes referral through EMR
Work Flow Contact with Patient is made Initial Assessment conducted Begin treatment – Medications and/or Therapy Track progress in EMR and Registry Case Review with PCP champ, Psychiatrist and ICM for those not improving
Care Manager Role • Educates the patient about depression • Supports antidepressant therapy prescribed by the patient's primary care provider if appropriate • Offer a brief (six-eight session) course of counseling: Problem Solving Therapy and Behavioral Activation • Monitors depression symptoms for treatment response (PHQ-9) • Completes a relapse prevention plan with each patient who has improved • Regularly reviews patients with the consulting psychiatrist weekly
The Practice Champion • What is a “CHAMP”? • An Advocate • A Cheer leader • Communicator • Visionary • Change maker • Can make things happen • Yes, maybe a SUPERHERO!
PCP ROLE • Oversees all aspects of patient care at the primary care clinic • Makes/confirms diagnoses for depression using PHQ-9 • Starts pharmacotherapy as indicated (writes and refills all prescriptions). • Collaborates with team to make treatment adjustments as clinically indicated
Registry Functions • Tracks patient success • Makes sure patients don’t fall in between the cracks • Determines clinical decision making at key milestones • Ensures that 70% of patients are receiving Psychiatric consult • Helps with oversite work load balance and referrals by team members
Did we succeed – did our patients’ improve? • I am here to say YES! • Our Patients say YES! • The Providers say Yes! • RESULTS after 1 year: • 141 patients were referred • Of those 141 - 107 were Enrolled in the program (75%) • And 64% of those patients Improved – or 58 • Improvement is defined by a reduction of the PHQ-9 score by 5 points or 50% • In addition to numbers I’d also like to tell you about our patients stories of hope and recovery 12. Bauer, et.al, (2011)
Patient Perspective • “I was shocked and overwhelmed with grief. That grief only got worse as I went through the holiday season. I finally sought help through my primary care physician……Over the three months I saw Allison, I could see a definite improvement in my emotions. I felt that I was getting control of my life again and that I could move forward.”
Patient Perspective • 73 year old woman • Artist, athletic woman who was a competitive billiard player, and active grandmother • Care giver for chronically ill husband for 6 years • After the loss of her husband she struggled to find purpose/meaning • PCP referred to Impact • Behavioral Activation – renewed engagement in LIFE!
Patient Perspective “Having Debra to talk to and work out problems helps me so much . Each day I feel better about myself.…I had no idea that talking to someone could help this much.” 82 yr old IMPACT Participant Informed consent for medical photograph on record with CCWNC
Provider Perspective • “IMPACT IS A REAL SAFETY NET.” • Patients can go unscreened and undiagnosed • More likely to receive mental health services if offered at the doctor’s office • “IMPACT offers a fuller picture of the patient.” • Extra set of eyes and ears makes a huge difference • “The psychiatric consultant supports me beyond the usual scope of my practice when it comes to difficult mental health issues. I learn so much more about the BH meds I am prescribing ……which helps me be a better doctor.”
So What is taking us so long? 2011 2012 2013 2014 2015 2016 2017 2018 2019 2021 2020
COLLABORATIVE CARE THE WAY FORWARD • Increased excitement and interest in Integrated Care • Several different models of integrated care out there • Collaborative Care is strongest evidence based approach 6. Auxier, Runyan, Mullin, et all, 2012
Collaborative Care is gaining momentum • APA has received a grant from CMS to train 10% of its members free, in the collaborative care model. • APA is supporting adoption of the CoCM as a Federal policy option. • CMS proposing a rule to reimburse for psychiatric collaborative care 7. Valenstein, et. al., (2016).
IMPACT in a FQHC • FQHC – • 2/3 of the patients served are below poverty line • 55% are uninsured • Insurance provides only 10% of operating revenue 8. Article WNC Woman 2016
Consulting Psychiatrist Role • Supports care managers and PCPs • Provides regular (weekly) consultation on a caseload of patients, focusing on patients who are not improving clinically • Provides education and training for primary care-based providers
My Experience • Successes • Patient gets psychiatric help at their doctor’s office • Patient does not have to navigate BH systems • Challenges • Balance thoroughness with brevity • Shifting my role to trust others’ reports instead of seeing patient directly • Choosing your words wisely: • Suggestions – not orders • Busy PCPs – little time to build trust
Integrated Care Team Medical Providers Administrators Behavioral Health Providers Residents Patients “Consumers”/Families Nurses and medical assistants Front Desk Medical Records Pharmacists Care Managers Psychiatrists Nutritionist Practice Manager Health Care Entity (ACO- MCO, PLE, CCO) Accountable Care State and Regional Partners 9. Adapted from Mendenhall, Lamson, & Hodgson, 2010 EC
Cost Effectiveness • Average cost ~ $580./participant • Cost of IMPACT to an insured older population ~ $1 /member/month (PMPM) • Overall Health care in 4 yr period (IMPACT included) was ~ $3,300. less 3. & 4. Unützer, et all, 2008
Sustainability • Fee for service • Current code set does not cover all IMPACT activities such as non-face-to-face therapy and case management. • Proposed CMS codes for 2017 could help bridge the gap with payment reform. • Crossovers w/ IMPACT activities and Medicare Chronic Care Management services
Sustainability • Payment reform to capitated value-based care • Accountable Care Organizations: forming but data outcomes and realized savings at the practice-level are far off • Intermountain Study: 113, 452 Patients. NCQA influenced practices (have PCMH activities and team-based care) who also have BH integration have significantly better cost and health outcomes than those without Team-Based Care. In addition, the cost of implementation and support needed to build these routines is covered by the financial savings realized by Team-Based care. • Cost Effectiveness continued: Kaiser Permanente results are encouraging for value based care. 10. Reiss-Brennan B, Brunisholz KD, Dredge C, et al., 2016
