Lifelong Personal Health Care: Transforming Healthcare through Full Integration of Behavioral Health into the Patient-Ce

1. Lifelong Personal Health Care:Transforming health care throughfull integration of behavioral health intothe patient-centered medical home Lifelong Personal Health Care (LPHC) team: Paul Block, Jeff Migneault, Theresa Costello Kelly Madden, Renee Rulin Jen Bowdoin, Jonathan Leviss, Steve Schwartz, RTI Primary Care Research Team Development funded by grant from Rhode Island Foundation (a community foundation)

2. Patient care is team based with a central role given to a behavioral care provider (BCP, a health psychologist) for all patients Lifelong Primary Health Care (LPHC): • Fully integrated Patient-Centered Medical Home practice model

3. U.S. healthcare reform: • Vs. the IHI’s “Triple Aim” Mess” Poor health Ineffective care Unaffordable care

4. Current RI transformation efforts Rhode Island is a national leader in health care reform, in large part because of efforts to transform primary care led by the Health Insurance Commissioner, Chris Koller: the rule to increase primary care spending as a percentage of all health care spending by 1% per year for 5 years, from 5-10% Promotion of the medical home as the way primary care should be delivered, through the most comprehensive all-payer medical home project in the country, the Chronic care Sustainability Initiative (CSI)

5. Current reform strategies for changing behavior

6. Healthcare reform efforts will succeed by changing behavior • Patient • Provider • The healthcare “system” Ready! Fire! Aim!

7. Rationale for integration of behavioral health expertise into the core of the medical home team Behavior- rather than medicine- is more likely to determine someone’s health. The best prescription is one that urges people to follow a few simple rules, such as exercising regularly (30 minutes a day, 5 days a week), eating 5 servings of fruit and vegetables a day, avoiding tobacco, illicit drugs and excessive alcohol, engaging only in responsible sexual behavior and participating daily in relaxing and stress-reducing activities. Former U.S. Surgeon General David Satcher, at Black Health Forum, Brown University

8. If you want to change behavior, involve a behaviorist

9. Integrated Team Care Integration is exquisitely difficult and is at the heart of what makes primary care work. Integration should not be confused with coordination. Coordination implies ordering and sequencing, while integration implies creating something new - in this case, something fitted to a particular individual patient. - deGruy & Etz (2010)

10. All care plans are collaboratively developed Lifelong Primary Health Care (LPHC): • Care management in LPHC is divided between Administrative and Clinical • Administrative care management is provided by a specialized Care Coordinator (vs. a Nurse Care Manager or Medical Assistant) • Clinical care management is provided by the BCP (vs. a Nurse Care Manager)

11. LPHC care

12. How LPHC differs from standard PCMH team models

13. Most "integrated care" designs offer limited availability of behavioral health specialists: Services include immediate consultation and brief, well-coordinated interventions Behavioral targets are identified based on physician referral or patient match to criteria in care protocols Behavioral health is typically an adjunctive service Lifelong Primary Health Care (LPHC): • Compared to other medical home models that co-locate behavioral health services, LPHC: • Focuses on health behavior in addition to mental health and substance abuse • builds behavioral health into all care without requiring physician or other prior identification • addresses health behavior for every patient, as clinically relevant

14. Modest pmpm funding: supports implementation of the team model and integration of the behavioral perspective into routine care with additional flexibility and coordination among team members Without pmpm funding: The practice is still able to offer fully integrated behavioral care and care management as part of routine care Projected savings: Behavioral care management as part of routine care for all patients is expected to improve management of the health-related behaviors that are drivers of inefficiency and ineffectiveness of health care as it is now practiced Financial models available in Rhode Island LPHC is financially sustainable under existing funding models

15. Rationale for integration of behavioral health expertise into the core of the medical home team “Any PCMH that neglects… the full psychosocial dimension of health and healthcare— mental healthcare, family and community contexts, substance abuse, and health behavior change… is incomplete and will be ineffective. It will fail. A solid edifice of empirical evidence supports this rather uncompromising assertion.” - deGruy & Etz (2010)

16. Thank you for following along Presenting Presenting • Next steps: • Exploring collaboration with a FQHC, and • Seeking funding for oversight & piloting the model in a new practice • We have an evaluation partner with funding • Federally guaranteed loans are sufficient to open the practice Presenting For more comprehensive description of LPHC, please visit: http://LPHC.wordpress.com