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GA-U Mental Health Pilot
Integrating primary care and mental health
Jurgen Unutzer, MD, MPH, MAProfessor & Vice Chair
Psychiatry & Behavioral SciencesUniversity of Washington
The Case for Integration
Mental disorders are common, disabling, and expensive
Primary care is the ‘de facto’ health care system for common mental disorders but only 20-40 % of patients get effective treatment.
Patients with severe mental illness (SMI) receive poor medical care and have high rates of mortality
Morbidity and Mortality in People with Serious Mental Illness
Persons with serious mental illness (SMI) are dying 25 years earlier than the general population
Suicide and injury account for about 30-40% of excess mortality, but 60% of premature deaths in persons with schizophrenia are due to medical conditions such as cardiovascular, pulmonary and infectious diseases– Need for improved care of chronic medical disorders
in specialty mental health care settings
Why treat mental disorders in primary care ?
Limited access to / use of mental health specialists
Treat mental health disorders where the patients are
- Established provider-patient relationship
- Less stigma in primary care
- Better coordination with medical care
Integrated care = working effectively ‘across silos’
Primary Care
Community Mental Health
Center
PC
CM
HC
Social services?
Alcohol & substance
abuse care?
J a m e s D . R a l s t o n
20 years of collaborative care research at UW
Depression in Primary Care
Depression in Diabetes (Pathways)
Late-life Depression (IMPACT)
Depression in Adolescents
- in Primary Care
- in Schools
Telemedicine Consultation in Child Psychiatry
Anxiety Disorders in Primary Care
PTSD & Substance abuse in Trauma Care
Moving towards integrated Care
Worst case scenario = compete
Usual situation = co-exist
Helpful but not sufficient = consult (or) co-locate
Ideal = collaborate effectively
Evidence for integrated care: depression
Meta-analysis by Gilbody et al, Archives of Internal Medicine; 2006
37 trials of collaborative care for depression in primary care (US and Europe)– CC is consistently more effective than usual care– Successful programs include
• active care management (not case management)• support of medication management in primary care• psychiatric consultation
1,801 primary care patients with depression and comorbid medical disorders
Funded byJohn A. Hartford Foundation California Healthcare Foundation
Example: IMPACTJürgen Unützer, MD
EffectiveCollaboration
Prepared, Pro-activePractice Team
Informed, ActivatedPatient
IMPACT Team Care Model
Practice Support
Integrated care DOUBLES the effectiveness of usual care for
depression
0
10
20
30
40
50
60
70
1 2 3 4 5 6 7 8
Usual Care IMPACT
% p
atie
nts
Participating Organizations
50 % or greater improvement in depression at 12 months
Unutzer et al., JAMA 2002; Psychiatr Clin N America 2005
42%
19%23%
14%
54%
43%
0%
10%
20%
30%
40%
50%
60%
White Black Latino
IMPACT Care
Care as Usual
Integrated Care BenefitsEthnic Minority Populations
Areán et al. Medical Care, 2005
50 % or greater improvement in depression at 12 months
Improved Physical Functioning
SF-12 Physical Function Component Summary Score (PCS-12)
P<0.01P<0.01 P<0.01
P=0.35
Callahan et al. JAGS. 2005; 53:367-373.
Lower long-term (4 year) healthcare costs
Other lessons from IMPACT
1) Co-location is NOT sufficient.
2) Initial treatments are rarely sufficient. Several changes in treatment are often necessary (stepped care). To accomplish this, we need - Systematic outcomes tracking (e.g., PHQ-9) to know when change in treatment is needed. - Active care management until patient is improved to facilitate changes in medication, behavioral activation.- Consultation with mental health specialist if patients not improving as expected.
DIAMOND Initiative in Minnesota
Integrated care management for depression supported by 8 large commercial payors and the state Medicaid plan in Minnesota- Organized by the Institute of Clinical Systems Improvement (ICSI)
- Common payment code for integrated care / care management
State-wide implementation- First group of 14 clinics trained in March 2008
- Goal to have evidence-based depression care management available in ~ 90 primary care clinics state-wide, reaching ~ 1.4 million Minnesotans by 2010
Evidence for integrated care: anxiety, alcohol/substance abuse
Anxiety disorders:- Roy-Byrne, et al: Integrated care for anxiety disorders
- Zatzick, et al: Trauma-center-based care for alcohol / substance abuse problems and PTSD
Alcohol / substance abuse: SBIRT (Substance use Brief Intervention Referral and Treatment)
GA-U Mental Health Pilot
Community Health Plan of Washington
GA-U Mental Health Pilot Steering Committee
UW Department of Psychiatry
Steering Committee
Graydon Andrus
Marc Avery
Amandalei Bennett
Esther Bennett
Jane Beyer
Teri Card
Abie Castillo
Mervyn Chambers
Ann Christian
Frances Collison
Mark Dalton
David DiGiuseppe
David Dula
Stephanie Earhart
Trudi Fajans
Sharon Farmer
David Flentge
Harvey Funai
Mark Johnson
Rebecca Kavoussi
Earl Long
Barbara Mauer
Linda McVeigh
Evan Oakes
Virginia Ochoa
Ed O’Connor
Amnon Schoenfeld
Anne Shields
Rose Soohoo
Karen Spoelman
Doug Stevenson
Tom Trompeter
Jurgen Unutzer
Richard Veith
Steve Vervalin
Grace Wang
GA-U Program
State-only funded program that provides:
- cash grants (up to $339/mo)
- limited medical care
- no mental health care
For adults who are: - physically or mentally disabled
- unemployable for more than 90 days
Co-occurring diagnosesDSHS | GA-U Clients: Challenges and Opportunities August 2006
Most common Dx and RxDSHS | GA-U Clients: Challenges and Opportunities August 2006
GA-U Mental Health Pilot
Based on experiences with managed medical care pilot:
- difficulty managing medical care without addressing mental health issues
GA-U Mental Health Pilot Overview
2 year demonstration pilot– Pierce & King counties– Partnership between CHP, Community Health Centers,
Community Mental Health Centers, and UW Department of Psychiatry
Goals of Mental Health Pilot– Build on success of GA-U medical pilot
Structure of Mental Health Pilot– Level I: MH Treatment in Primary Care– Level II: Community Mental Health Care for severely mentally ill– Goal: Improved access, coordination of care & outcomes
Goal: Integrated care
GA-UClient
Level II Care
Care Coordinator
Consulting Psychiatrists
CSO
CD Treatmen
tLevel I Care (~ 1,500)
PCP
DVROther clinic-based mental
health providers*
* Available in some clinics
Goals
Integrated physical health, mental health and substance abuse services to GA-U clients where they seek care
Goals:
- improve patient outcomes
- reduce costs
Level 1 mental health care
Clients with behavioral health needs are treated by primary care providers with:
- support from care coordinators and other practice-based mental health staff (if available)
- support from consulting psychiatrist
Psychiatric Consultation in Level 1
Ongoing case consultation with care managers re: Level 1 mental health treatment
- scheduled and ad hoc consultation to care managers and PCPs
- systematic, based on clinical needs and outcomes
- In-person evaluation, if needed
Participating Health Systems
• Community Health Care (Pierce)• Community Health Centers of King County• Country Doctor Clinic (King)• Puget Sound Neighborhood Health Centers
(King)• Harborview Medical Center (King)• International Community Health System (King)• SeaMar (Pierce, King)
Intensive mental health services (Level 2)
Community Mental Health services
CMHC case manager coordinates with Level-1 Care Coordinator to insure continuity of care
Participating CMHCs
Greater Lakes (Pierce)
Community Psychiatric Clinic (King)
Downtown Emergency Service Center (King)
Harborview Mental Health (King)
Highline-West Seattle (King)
SeaMar (Pierce, King)
Sound Mental Health
Therapeutic Health Services (King)
Valley Cities (King)
Integrated care
GA-UClient
Level II Care
Care Coordinator
Consulting Psychiatrists
CSO
CD Treatmen
tLevel I Care (~ 1,500)
PCP
DVROther clinic-based mental
health providers*
* Available in some clinics
Mental Health Integrated Tracking system (MHITS):
Helps CHP, CHCs, CMHCs, and care coordinators keep track of and care for client population
Facilitates communication between providers (e.g., CHC and CMHC), referrals, and mental health consultation
How does MHITS help?
Keeps track of all GA-U Mental Health clients• Up to date client contact information to facilitate
contact and follow-up• Who is being treated in level 1 and 2?• Who has been referred for services (e.g., CD,
CSO, DVR, level 2 care) and who is getting services?
Tells you quickly who needs additional attention• Who is improving or not improving?• Reminders for clinicians & managers• Customized caseload reports
How does MHITS help?(cont.)
Facilitates mental health specialty consultation
Facilitates communication between treating providers
Supports care and care coordination across settings of care (e.g., level 1 and 2)
Provides updates on program developments, clinical tools, etc.
Facilitates management decisions
J a m e s D . R a l s t o n
Integrated mental health care: a vision
WA could be the 1st state with a truly integrated MH care system
Improved access and capacity in primary care
Less stigma
Better medical care for patients with SMI
Improved communication between mental health, primary care,
Information systems to facilitate cost-effective care across systems.
Improved population health