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Greater New Orleans Collaborative to Improve Behavioral Healthcare Access (C-IBHA) with support from the Robert Wood Johnson Foundation Harold Alan Pincus, MD Vice Chairman, Department of Psychiatry Columbia University Director of Quality and Outcomes Research New York-Presbyterian Hospital

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Greater New Orleans Collaborative to Improve Behavioral Healthcare Access (C-IBHA) with support from the Robert Wood Johnson Foundation

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Greater New Orleans Collaborative to Improve Behavioral Healthcare Access (C-IBHA)with support from the Robert Wood Johnson Foundation

Harold Alan Pincus, MD

Vice Chairman, Department of Psychiatry

Columbia University

Director of Quality and Outcomes Research

New York-Presbyterian Hospital

Senior Scientist

RAND Corporation

RWJF LPHI Kick-Off Meeting- July 29-30.2008 (New Orleans)








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Overall Plan (1) Healthcare Access

  • Introduction- Harold Pincus

  • Clinical/Provider- Steven Cole

  • Practice- Amy Kilbourne

  • Improvement Process- Karen Scott Collins

  • Patient Self-Management- Jeanie Knox-Houtsinger

RWJF LPHI Kick-Off Meeting- July 29-30.2008 (New Orleans)


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Overall Plan (2) Healthcare Access

  • Plenaries

  • Breakouts

  • In-Between

  • After

RWJF LPHI Kick-Off Meeting- July 29-30.2008 (New Orleans)


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Why Behavioral Health and Healthcare Access General Health Care?

  • Depression

  • Preventive / chronic illness care for people with Severe Mental Illness

  • Disaster response

RWJF LPHI Kick-Off Meeting- July 29-30.2008 (New Orleans)


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Why Depression? Healthcare Access

  • Prevalent

  • Significant personal, social and economic impact

  • Strong clinical science base

  • Strong evidence on care improvement interventions

  • Depression as a chronic disease

  • Large gap between evidence and action

RWJF LPHI Kick-Off Meeting- July 29-30.2008 (New Orleans)


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Ischaemic heart disease Healthcare Access

Unipolar major depression

Road traffic injuries

Cerebrovascular disease

Chronic obstructive pulmonary disease

Lower respiratory infections

Tuberculosis

War

Diarrhoeal diseases

HIV

2020 World Health Organization Burden of Disease (DALYs)

DALY = Disability-adjusted life year

Source: WHO, Evidence, Information and Policy, 2000

RWJF LPHI Kick-Off Meeting- July 29-30.2008 (New Orleans)


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Leading Causes of Years of Life Lived with Disability (YLD) in 15- to 44-Year-Olds(WHO, Mental Health: New Understanding, New Hope, 2001)

RWJF LPHI Kick-Off Meeting- July 29-30.2008 (New Orleans)


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Why Depression? in 15- to 44-Year-Olds

  • Prevalent

  • Significant personal, social and economic impact

  • Strong clinical science base

  • Strong evidence on care improvement interventions

  • Depression as a chronic disease

  • Large gap between evidence and action

RWJF LPHI Kick-Off Meeting- July 29-30.2008 (New Orleans)


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The State of Health Care Quality 2006 in 15- to 44-Year-Olds, NCQA

There are, however, disturbing exceptions to this pattern of [overall health care quality] improvement. The quality of care for Americans with mental health problems remains as poor today as it was several years ago. Patients on antidepressant medication are about as likely to receive appropriate care today as they were in 1999.

www.ncqa.org

RWJF LPHI Kick-Off Meeting- July 29-30.2008 (New Orleans)


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Antidepressant Medication Management: The Case for Improvement

RWJF LPHI Kick-Off Meeting- July 29-30.2008 (New Orleans)


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Antidepressant Medication Management: The Case for Improvement(cont’d.)

RWJF LPHI Kick-Off Meeting- July 29-30.2008 (New Orleans)


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Antidepressant Medication Management: The Case for Improvement(cont’d.)

RWJF LPHI Kick-Off Meeting- July 29-30.2008 (New Orleans)


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Prevalence of Major Depression Improvementin Patients with Physical Illnesses

General population

Up to 10%

Myocardial infarction

Up to 22%

Diabetes

Up to 27%

Hypertension

Up to 29%

Epilepsy

Up to 30%

Stroke

Up to 31%

Cancer

Up to 33%

HIV/AIDS

Up to 44%

Up to

46%

Tuberculosis

RWJF LPHI Kick-Off Meeting- July 29-30.2008 (New Orleans)

WHO, 2003.


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Comorbidities Among Depressed Patients Improvement

Source: http://www.medstat.com/healthcare/depression4.asp

RWJF LPHI Kick-Off Meeting- July 29-30.2008 (New Orleans)


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General Medical Comorbidity Improvementin severe mental illness

  • Diabetes: 20%

  • Cardiovascular disease: HBP 34%,

    Heart 15.6%

  • Weight gain and obesity (2x)

  • Smoking (2x)

  • Other: breast cancer (9.5x), HIV (8x),

    Hepatitis B (5x) and C (10x)

  • Reduced life span

RWJF LPHI Kick-Off Meeting- July 29-30.2008 (New Orleans)


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Mental-Health Challenge Emerges As Victims Face Multiple Traumas

BATON ROUGE, La. –

“…Post-traumatic stress disorder, depression and anxiety are common after major disasters, mental-health experts say, because disasters frighten people and disrupt their lives. But Hurricane Katrina poses special challenges…”

“…The hurricane’s upheaval also has exacerbated the symptoms of some people who suffer from developmental disabilities and mental illnesses such as schizophrenia…”

RWJF LPHI Kick-Off Meeting- July 29-30.2008 (New Orleans)


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Why Not? (Barriers) Traumas

  • Historical

  • Conceptual

  • Patients / Consumers

  • Providers

  • Practices / Delivery Systems

  • Plans – Managed Care Organizations (MCO)/ Managed Behavioral Health Organizations (MBHO)

  • Purchasers – Public / Private

  • Population / Community

RWJF LPHI Kick-Off Meeting- July 29-30.2008 (New Orleans)


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What’s Unique about Behavioral Health? Traumas

  • Mind-body dualism

  • Stigma

  • Role of the state

  • Legal / regulatory distinctions (e.g., privacy, competency)

  • Multiple complex systems intrinsically involved (e.g., social services, criminal justice, education, consumer-directed, etc.)

  • Different diagnostic systems

RWJF LPHI Kick-Off Meeting- July 29-30.2008 (New Orleans)


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What’s Unique about Behavioral Health? Traumas(continued)

  • Separate delivery systems

  • More heterogeneous work force / greater solo practice

  • Few procedures

  • Separate financing systems / different market structure

  • Less developed quality improvement / performance measures

  • Less linkage to IT innovations

RWJF LPHI Kick-Off Meeting- July 29-30.2008 (New Orleans)


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Conceptual Issues: Traumas

Primary Care vs. Mental Health Specialties

  • Different perspectives

    • Definitions / clinical measures (i.e., no lab tests)

    • Majority of literature comes from specialty (and often tertiary) care settings

    • Diagnostic systems such as DSM-IV often seen as too complex and specialty-focused

    • But DSM PC unsuccessful?

  • Linkages between and among various systems (SUD, social services, schools, consumer, directed, etc.)

RWJF LPHI Kick-Off Meeting- July 29-30.2008 (New Orleans)


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Provider Barriers Traumas

  • Time

  • Interest

  • Tools: DSM-PC, PHQ-9

  • Training

RWJF LPHI Kick-Off Meeting- July 29-30.2008 (New Orleans)


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Practices / Delivery System Issues Traumas

  • Organization does not enhance patient-provider interactions & promote successful outcomes

  • Who is responsible for care?

    • Limited communication and teamwork between primary care and mental health specialties

  • How should care be provided?

    • Consultative? Collaborative? Integrated?

  • When should care be provided?

    • Lack of longitudinal focus

RWJF LPHI Kick-Off Meeting- July 29-30.2008 (New Orleans)


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Policy (Public and Private) Traumas

  • Depression not on radar

  • Stigma, bias, misinformation

  • Fragmentation encouraged

  • Quality not a factor

  • Change is coming fast

RWJF LPHI Kick-Off Meeting- July 29-30.2008 (New Orleans)


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Who? Responsibility for Care Traumas

PCP

BHS

RWJF LPHI Kick-Off Meeting- July 29-30.2008 (New Orleans)


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How? Traumas

Integrated Team

CollaborativeCare

Consultative Care

Referral

Independent

Autonomous (PCP)

Autonomous (MHS)

RWJF LPHI Kick-Off Meeting- July 29-30.2008 (New Orleans)


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When? Traumas

RWJF LPHI Kick-Off Meeting- July 29-30.2008 (New Orleans)


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How? Strategies Traumas

  • Chronic (Planned) Care Model

  • The Robert Wood Johnson Foundation’s national program on Depression in Primary Care: Linking Clinical Systems and Strategies

  • Models of linkage/integration

  • Institute of Medicine / Crossing the Quality Chasm

RWJF LPHI Kick-Off Meeting- July 29-30.2008 (New Orleans)


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Evidence-Based Chronic (Planned) Care Approaches for Treating Depression

Are Effective

Community

Health System

Resources and Policies

Health Care Organization

ClinicalInformationSystems

Self-Management Support

DeliverySystem

Design

Decision

Support

Productive Interactions

Patient-Centered Coordinated

Timely and Evidence- Efficient Based and Safe

Informed, Empowered

Patient and Family

Prepared, Proactive

Practice Team

Improved Outcomes

RWJF LPHI Kick-Off Meeting- July 29-30.2008 (New Orleans)


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Chronic Disease Clinical Models Treating Depression

  • Hypertension

  • Congestive heart failure (CHF) / Coronary artery disease (CAD)

  • Stroke

  • COPD (Chronic Obstructive Pulmonary Disease)

  • DM (Disease Management)

  • Asthma

  • Multiple comorbidities

  • Transitional care management

RWJF LPHI Kick-Off Meeting- July 29-30.2008 (New Orleans)


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Depression Clinical Models Treating Depression

  • Chronic (planned) care model – Wagner

  • Collaborative care – Katon

  • Partners in Care (AHRQ) – Wells

  • PROSPECT – Alexopoulous, Katz, Reynolds

  • Telephone care management – Simon, Hunkeler

  • IMPACT (Hartford) – Unutzer

  • RESPECT (MacArthur) – Dietrich

  • Quality Improvement for Depression (NIMH) – Rost, Ford, Rubenstein

  • Child models – Campo, Asarnow, GLAD-PC

  • Other models for anxiety/PTSD

RWJF LPHI Kick-Off Meeting- July 29-30.2008 (New Orleans)


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A national program supported by The Robert Wood Johnson Foundation

www.depressioninprimarycare.org

National Program Office

Harold Pincus, MD, Director

Jeanie Knox Houtsinger, BA, Deputy Director

Gail Wrobleski, Administrative Specialist

Susanne Salem-Schatz, ScD, Quality Improvement Consultant

John Bachman, PhD, Communications Consultant

Donna Keyser, PhD, Communications Consultant

The Robert Wood Johnson Foundation

Constance Pechura, PhD, Senior Program Officer

Clinical Model Team

Bruce L. Rollman, MD, MPH

Bea Herbeck Belnap, PhD

Amy M. Kilbourne, PhD

Herbert C. Schulberg, PhD

Economic Team

Richard Frank, PhD

Haiden Huskamp, PhD

Tom McGuire, PhD

Colleen Barry, MPP

Evaluation Team

Daniel E. Ford, MD, MPH

Lisa A. Cooper, MD, MPH

Gail L. Daumit, MD, MHS

Michael J. Kaminsky, MD, MBA

Darrel Gaskin, PhD

Laura L. Morlock, PhD

Alan Langlieb, MD

National Advisory Committee

Frank deGruy, MD, Chair

RWJF LPHI Kick-Off Meeting- July 29-30.2008 (New Orleans)


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“6 P” Conceptual Framework Foundation

  • Enhance self-management / participation

  • Link with community resources

  • Evaluate preferences and change behaviors

Patient /

Consumer

  • Improve knowledge / skills

  • Provide decision support

  • Link to specialty expertise and change behaviors

Providers

  • Establish chronic care model and reorganize practice

  • Link with improved information systems

  • Adapt to varying organizational contexts

Practice /

Delivery Systems

  • Enhance monitoring capacity for quality / outliers

  • Develop provider / system incentives

  • Link with improved information systems

Plans

  • Educate regarding importance / impact of depression

  • Develop plan incentives / monitoring capacity

  • Use quality / value measures in purchasing decisions

Purchasers (Public / Private)

  • Engage community stakeholders; adapt models to local needs

  • Develop community capacities

  • Increase demand for quality care enhance policy advocacy

Populations

and Policies

RWJF LPHI Kick-Off Meeting- July 29-30.2008 (New Orleans)


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Incentives Demonstration Foundation

  • Partnerships of health plans (Health Management Organizations [HMO] and Managed Behavioral Health [MBHOs]) and practice groups (and purchasers)

  • 8 sites

  • Commercial, Medicaid

  • Implementation of:

    • Clinical Model

    • Economic Model

RWJF LPHI Kick-Off Meeting- July 29-30.2008 (New Orleans)


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Clinical Model: Major Components Foundation

RWJF LPHI Kick-Off Meeting- July 29-30.2008 (New Orleans)


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Leadership Foundation

A Clinical Framework for Depression Treatment in Primary Care; Psychiatric Annals 32:9; September 2002

RWJF LPHI Kick-Off Meeting- July 29-30.2008 (New Orleans)


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Delivery System Design Foundation

A Clinical Framework for Depression Treatment in Primary Care; Psychiatric Annals 32:9; September 2002

RWJF LPHI Kick-Off Meeting- July 29-30.2008 (New Orleans)


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Clinical Information System Foundation

A Clinical Framework for Depression Treatment in Primary Care; Psychiatric Annals 32:9; September 2002

RWJF LPHI Kick-Off Meeting- July 29-30.2008 (New Orleans)


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Decision Support Foundation

A Clinical Framework for Depression Treatment in Primary Care; Psychiatric Annals 32:9; September 2002

RWJF LPHI Kick-Off Meeting- July 29-30.2008 (New Orleans)


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Self-Management Support Foundation

A Clinical Framework for Depression Treatment in Primary Care; Psychiatric Annals 32:9; September 2002

RWJF LPHI Kick-Off Meeting- July 29-30.2008 (New Orleans)


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Community Resources Foundation

RWJF LPHI Kick-Off Meeting- July 29-30.2008 (New Orleans)


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Functions of Care Managers Foundation

A Clinical Framework for Depression Treatment in Primary Care; Psychiatric Annals 32:9; September 2002

RWJF LPHI Kick-Off Meeting- July 29-30.2008 (New Orleans)


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Functions of Care Managers Foundation(cont’d)

A Clinical Framework for Depression Treatment in Primary Care; Psychiatric Annals 32:9; September 2002

RWJF LPHI Kick-Off Meeting- July 29-30.2008 (New Orleans)


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Phases of Depression Treatment Foundation

Recovery

Remission

Relapse

Recurrence

No Depression

Response

Symptoms

Syndrome

Treatment Phases

Acute

Continuation

Maintenance

Kupfer DJ. J Clin Psychiatry. 52(5s):28-34,1991.

RWJF LPHI Kick-Off Meeting- July 29-30.2008 (New Orleans)


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Systems/ Economic Model Foundation

  • Reinforce clinical model

  • Realign financial and non-financial incentives

  • Alter contractual / organizational arrangements

  • Pay for:

    • PCP depression care

    • MHS consultation

    • Care management

    • Distinguished performance

  • Unique issues in local context

RWJF LPHI Kick-Off Meeting- July 29-30.2008 (New Orleans)


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Models of Linkage / Integration Foundation

Embedded PCP in BHSCo-location of BHS in PCP

B

P

P

B

Unified Coordination / Collaboration

B

P

B

P

RWJF LPHI Kick-Off Meeting- July 29-30.2008 (New Orleans)


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Components of Linkage Foundation

  • Formal agreements

  • Referral

  • Consultation

  • Information flow

RWJF LPHI Kick-Off Meeting- July 29-30.2008 (New Orleans)


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PCASG Strategies Foundation

  • Medical Home

  • Flexibility

  • Quality Incentives

RWJF LPHI Kick-Off Meeting- July 29-30.2008 (New Orleans)


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“Crossing the Quality Chasm” Foundation

RWJF LPHI Kick-Off Meeting- July 29-30.2008 (New Orleans)


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Studies Documenting the “Quality Gap” Foundation

  • Literature reviews conducted by RAND

    • Over 70 studies documenting quality shortcomings

  • Large gaps between the care people should receive and the care they do receive

    • true for preventive, acute and chronic

    • across all health care settings

    • all age groups and geographic areas

  • Only 50% chance of getting appropriate care

    (Schuster et al, MMFQ,1998; updated 2000; McGlynn et al, NEJM 2003)

RWJF LPHI Kick-Off Meeting- July 29-30.2008 (New Orleans)


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To Err Is Human: FoundationBuilding A Safer Health System

  • First Report

  • Committee on

  • Quality of Health Care

  • in America

  • To order: www.nap.edu

RWJF LPHI Kick-Off Meeting- July 29-30.2008 (New Orleans)


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Crossing the Quality Chasm Foundation

  • Second Report

  • Committee on

  • Quality of Health Care

  • in America

  • To order: www.nap.edu

RWJF LPHI Kick-Off Meeting- July 29-30.2008 (New Orleans)


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Committee’s Conclusion Foundation

The American health care delivery system is in need of fundamental change. The current care systems cannot do the job. Trying harder will not work. Changing systems of care will.

RWJF LPHI Kick-Off Meeting- July 29-30.2008 (New Orleans)


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Safe Foundation

Effective

Patient-centered

Six Aims For Improvement

  • Timely

  • Efficient

  • Equitable

RWJF LPHI Kick-Off Meeting- July 29-30.2008 (New Orleans)


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What People Should Expect from the Health Care System (10 rules)

  • Continuous healing relationships

  • Safety

  • Cooperation

  • Science

  • Individualization

  • Control

  • Information

  • Anticipation

  • Transparency

  • Value

RWJF LPHI Kick-Off Meeting- July 29-30.2008 (New Orleans)


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Evidence-Based Chronic (Planned) Care Approaches for Treating Depression

Are Effective

Community

Health System

Resources and Policies

Health Care Organization

ClinicalInformationSystems

Self-Management Support

DeliverySystem

Design

Decision

Support

Productive Interactions

Patient-Centered Coordinated

Timely and Evidence- Efficient Based and Safe

Informed, Empowered

Patient and Family

Prepared, Proactive

Practice Team

Improved Outcomes

RWJF LPHI Kick-Off Meeting- July 29-30.2008 (New Orleans)



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Six Problems in the Quality of M/SU Health Care Treating Depression

  • Problem 1: Obstacles to patient-centered care

  • Problem 2: Weak measurement and improvement infrastructure

  • Problem 3: Poor linkages across MH/SU/GH

  • Problem 4: Lack of involvement in National Health Information Infrastructure (NHII)

  • Problem 5: Insufficient workforce capacity for QI

  • Problem 6: Differently structured marketplace

RWJF LPHI Kick-Off Meeting- July 29-30.2008 (New Orleans)


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Overarching Recommendation 1 Treating Depression

The aims, rules, and strategies for redesign set forth in Crossing the Quality Chasm should be applied throughout M/SU health care on a day-to-day operational basis but tailored to reflect the characteristics that distinguish care for these problems and illnesses from general health care.

RWJF LPHI Kick-Off Meeting- July 29-30.2008 (New Orleans)


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Preparing for the Future Treating Depression

Consumer Participation

Standardize Practice Elements

  • Clinical assessment

  • Interventions

  • IT infrastructure

    Develop Guidelines

  • Mental health

  • Substance use

  • General health

    Measure Performance

  • For each “6P” level

  • Across silos

    Improve Performance

  • Learn

  • Reward

    Strengthen Evidence Base

  • Document stakeholder value

  • Evaluate effective strategies

  • Translate from bench to bedside to community

Leadership (PCP/MH/SUD) Support

Clinical (PCP/MH/SUD) Perspectives

Integrative Processes

RWJF LPHI Kick-Off Meeting- July 29-30.2008 (New Orleans)


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Overarching Recommendation 2 Treating Depression

Health care for general, mental, and substance-use problems and illnesses must be delivered with an understanding of the inherent interactions between the mind / brain and the rest of the body.

RWJF LPHI Kick-Off Meeting- July 29-30.2008 (New Orleans)


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Don’t Split Mind and Body Treating Depression

RWJF LPHI Kick-Off Meeting- July 29-30.2008 (New Orleans)


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