Behavioral Health and the Patient-Centered Medical Home PCMH

1. Behavioral Health and the Patient-Centered Medical Home (PCMH)

2. Six Reasons Behavioral Health Should be Part of the PCMH Reason 1: Prevalence of Behavioral Health Problems in Primary Care Reason 2: Unmet Behavioral Health Needs in Primary Care Reason 3: Cost of Unmet Behavioral Health Needs Reason 4: Lower Cost When Behavioral Health Needs are Met Reason 5: Better Health Outcomes Reason 6: Improved Satisfaction Behavioral healthcare is an umbrella term and refers to a continuum of services delivered by physicians and other licensed healthcare providers for individuals at risk of, or suffering from, mental, behavioral, or addictive disorders Substance abuse disorder refers to either substance abuse or substance dependence. Substance abuse is the problematic use of alcohol or drugs occurring when an individual’s use of alcohol or drugs interferes with basic work, family, or personal obligations. Source: NBGH: An Employers’ Guide to Behavioral Health ServicesBehavioral healthcare is an umbrella term and refers to a continuum of services delivered by physicians and other licensed healthcare providers for individuals at risk of, or suffering from, mental, behavioral, or addictive disorders Substance abuse disorder refers to either substance abuse or substance dependence. Substance abuse is the problematic use of alcohol or drugs occurring when an individual’s use of alcohol or drugs interferes with basic work, family, or personal obligations. Source: NBGH: An Employers’ Guide to Behavioral Health Services

3. Mental illness/behavioral health disorder (also known as mental disorder): is a health condition that is characterized by alterations in thinking, mood, or behavior (or some combination thereof), that is mediated by the brain and associated with distress and/or impaired functioning. Mental disorders cause a host of problems that may include personal distress, impaired functioning and disability, pain, or death. It is estimated that in any given year, one in five adults (20%), will experience a diagnosable mental illness or substance abuse disorder. Research from epidemiological catchment studies suggest that between 14%-20% of children and adolescents, about one in every five, have a diagnosable emotional or behavioral disorder Source: NBGH: An Employers’ Guide to Behavioral Health Services Mental illness/behavioral health disorder (also known as mental disorder): is a health condition that is characterized by alterations in thinking, mood, or behavior (or some combination thereof), that is mediated by the brain and associated with distress and/or impaired functioning. Mental disorders cause a host of problems that may include personal distress, impaired functioning and disability, pain, or death. It is estimated that in any given year, one in five adults (20%), will experience a diagnosable mental illness or substance abuse disorder. Research from epidemiological catchment studies suggest that between 14%-20% of children and adolescents, about one in every five, have a diagnosable emotional or behavioral disorder Source: NBGH: An Employers’ Guide to Behavioral Health Services

4. Patient-Centered Medical Home Reason Two: Unmet Behavioral Health Needs

5. Unmet Needs: Reasons People Die

6. Patient-Centered Medical Home Reason Three: Cost of Unmet Needs

7. The Cost of Poor Health to Employers

10. Patient-Centered Medical Home Reason Four: Lower Cost When Treated

11. Patient-Centered Medical Home Reason Five: Better Outcomes

12. Patient Centered Medical Home Reason Six: Improved Satisfaction

13. Including Behavioral Health in the Patient Centered Medical Home Helps Meet Core Principles Data and experience indicate that the goals of clinical quality, efficiency, and maximal ROI are aided when integrated care models are based on adaptation of principles of population health and chronic care management in the primary care setting – including, but not necessarily limited to: Screening, Timely access to services, Locus of service delivery in primary care medical home Treatment team – including primary care practitioners, care coordinators, and BH specialists Inclusion of pertinent BH interventions in a unified treatment plan Careful and systematic monitoring of treatment response Patient engagement, re-engagement, and active collaboration Reliance on evidence based BH practices and on defined clinical- and administrative workflows Data and experience indicate that the goals of clinical quality, efficiency, and maximal ROI are aided when integrated care models are based on adaptation of principles of population health and chronic care management in the primary care setting – including, but not necessarily limited to: Screening, Timely access to services, Locus of service delivery in primary care medical home Treatment team – including primary care practitioners, care coordinators, and BH specialists Inclusion of pertinent BH interventions in a unified treatment plan Careful and systematic monitoring of treatment response Patient engagement, re-engagement, and active collaboration Reliance on evidence based BH practices and on defined clinical- and administrative workflows

14. Integrating mental health into primary care involves more than just treating mental health. There exists a range of issues that extend from traditional mental health visits to visits solely for advanced health behavior change (e.g. weight loss, tobacco cessation). Within each of these broad categories, the three worlds of healthcare must simultaneously be examined (clinical, operational and financial) to comprehensively address the complexity of integration and collaboration. This slide represents the range of need involved in primary care that takes us from severe mental health visits to medical appointments, which address health behaviors. An integrated mental health clinician is capable of addressing each column in the context of primary care. As one can see, the functions of a mental health provider compliment the functions of primary care in each catgory. Integrating mental health into primary care involves more than just treating mental health. There exists a range of issues that extend from traditional mental health visits to visits solely for advanced health behavior change (e.g. weight loss, tobacco cessation). Within each of these broad categories, the three worlds of healthcare must simultaneously be examined (clinical, operational and financial) to comprehensively address the complexity of integration and collaboration. This slide represents the range of need involved in primary care that takes us from severe mental health visits to medical appointments, which address health behaviors. An integrated mental health clinician is capable of addressing each column in the context of primary care. As one can see, the functions of a mental health provider compliment the functions of primary care in each catgory.

15. Changes Need to occur However,

16. Payment Reform Needed

17. PCPCC Payment ModelMay 2007

18. Integrated care focuses on all patient populations utilizing a team-based management approach to care for the full range of patient needs including behavioral needs/problems that surface in primary care. In addition to traditional mental health presentations like depression and anxiety, integrated care also focuses on behavior medicine areas such as tobacco use, obesity, chronic pain, sleep disturbance, health risk behavior, and medical non-adherence. From the PCMH team perspective – they communicate and work collaboratively (process) to deliver comprehensive co-ordinated patient-centered care (outcome). From the patient’s perspective – they feel like they are being treated as a whole person and their experience is that of integrated (vs fragmented) care.Integrated care focuses on all patient populations utilizing a team-based management approach to care for the full range of patient needs including behavioral needs/problems that surface in primary care. In addition to traditional mental health presentations like depression and anxiety, integrated care also focuses on behavior medicine areas such as tobacco use, obesity, chronic pain, sleep disturbance, health risk behavior, and medical non-adherence. From the PCMH team perspective – they communicate and work collaboratively (process) to deliver comprehensive co-ordinated patient-centered care (outcome). From the patient’s perspective – they feel like they are being treated as a whole person and their experience is that of integrated (vs fragmented) care.

19. Medical and behavioral health providers share patient information, working from a shared medical record, treatment plan, and standard of care. The behavioral health provider is embedded with the primary care team (physically or virtually) and serves as a team member in the assessment, intervention and healthcare management of the patient. Integrated care is more systematic than the simple co-location of two distinct services since it requires interdisciplinary communication, collaboration, coordination of service delivery, and the shared goal of improved total health for patients. The patient is likely to perceive this behavioral health care as part of his or her routine medical care. Flexibility is essential when adapting and implementing these models in particular primary care medical home settings; allowing integrated services to be customized to fit with settings’ patient populations, payer mixes, practitioner cadre and perspective(s) and other local factors Medical and behavioral health providers share patient information, working from a shared medical record, treatment plan, and standard of care. The behavioral health provider is embedded with the primary care team (physically or virtually) and serves as a team member in the assessment, intervention and healthcare management of the patient. Integrated care is more systematic than the simple co-location of two distinct services since it requires interdisciplinary communication, collaboration, coordination of service delivery, and the shared goal of improved total health for patients. The patient is likely to perceive this behavioral health care as part of his or her routine medical care. Flexibility is essential when adapting and implementing these models in particular primary care medical home settings; allowing integrated services to be customized to fit with settings’ patient populations, payer mixes, practitioner cadre and perspective(s) and other local factors

20. Behavioral healthcare skills and practice are a core component of the delivery of comprehensive and integrated care in a team-based patient centered medical home. Evidence exists that comprehensive integrated patient-centered care in primary care improves patient outcomes and reduces total healthcare costs. Payment for comprehensive and integrated care including behavioral healthcare practice needs to be accomplished, and payment reform that permits and incents it needs to be encouraged. Removing barriers and creating blended payment systems would help improve BH treatment in primary care Behavioral healthcare skills and practice are a core component of the delivery of comprehensive and integrated care in a team-based patient centered medical home. Evidence exists that comprehensive integrated patient-centered care in primary care improves patient outcomes and reduces total healthcare costs. Payment for comprehensive and integrated care including behavioral healthcare practice needs to be accomplished, and payment reform that permits and incents it needs to be encouraged. Removing barriers and creating blended payment systems would help improve BH treatment in primary care

21. The Need for Integration and Transformation

23. System Redesign Needed Patients same single identifier Payment Pool separate single bucket Network of Providers separate all in one Practice Locations separate co-location (can be virtual) Approval Process separate uniform Information Systems separate unified Collaboration & Communication rare routine Coding and Billing separate consistent process Outcome Accountability disciplinary total health Clinical/Cost Data Warehousing separate consolidated Administrative Oversight separate coordinated workflows

25. Selected Resources/Websites

26. Acknowledgements This PowerPoint presentation was developed by the members of the PCPCC Behavioral Health Task Force. Thank you to all the members of the Task Force for their contribution to the content. The PCPCC (Patient Centered Primary Care Collaborative) is a coalition of major employers, consumer groups, patient quality organizations, health plans, labor unions, hospitals, clinicians and many others who have joined together to develop and advance the patient centered medical home. Special thanks to the following people who served on the sub-group: Chris Hunter, DoD: TRICARE Management Activity, Office of the Chief Medical Officer Gene Kallenberg, Division of Family Medicine, Department of Family and Preventive Medicine,UCSD Rodger Kessler, Collaborative Care Research Network; University of Vermont College of Medicine Susan McDaniel, Department of Family Medicine, University of Rochester Medical Center Benjamin Miller, Collaborative Care Research Network , University of Colorado Denver School of Medicine Nancy Ruddy, Mountainside Family Practice Residency, New Jersey 26