Lifelong Personal Health Care (LPHC) team: Paul Block, Jeff Migneault, Kelly Madden

Lifelong Personal Lifelong Personal Health Care:Health Care:

Transforming health care throughTransforming health care throughintegration of behavioral health intointegration of behavioral health intothe patient-centered medical homethe patient-centered medical home

Lifelong Personal Health Care Lifelong Personal Health Care (LPHC) team:(LPHC) team:

Paul Block, Jeff Migneault, Kelly MaddenPaul Block, Jeff Migneault, Kelly Madden

Theresa Costello, Renee Rulin, Jen BowdoinTheresa Costello, Renee Rulin, Jen Bowdoin

Jonathan Leviss, Steve SchwartzJonathan Leviss, Steve Schwartz

Current RI Current RI transformation effortstransformation efforts

Rhode Island is a national leader in health Rhode Island is a national leader in health care reform, in large part because of efforts care reform, in large part because of efforts to transform primary care led by the Health to transform primary care led by the Health Insurance Commissioner, Chris Koller:Insurance Commissioner, Chris Koller: the the rule to increase primary care spending as a to increase primary care spending as a

percentage of all health care spendingpercentage of all health care spending Promotion of the medical home as the way Promotion of the medical home as the way

primary care should be delivered, through the primary care should be delivered, through the most comprehensive all-payer medical home most comprehensive all-payer medical home project in the country, the Chronic care project in the country, the Chronic care Sustainability Initiative (Sustainability Initiative (CSI))

What is the medical home What is the medical home that’s at the core of RI’s (& that’s at the core of RI’s (&

national) efforts?national) efforts? The medical home reorganizes primary care The medical home reorganizes primary care

practices, delivery and payment to improve practices, delivery and payment to improve health and reduce costs.health and reduce costs.

Many of the changes, including introduction Many of the changes, including introduction of a "care manager", are ultimately designed of a "care manager", are ultimately designed to change patient (and provider) behavior.to change patient (and provider) behavior.

Yet the patient-centered medical home does Yet the patient-centered medical home does not necessarily integrate behavioral health not necessarily integrate behavioral health expertise into the team offering primary expertise into the team offering primary care or into the design of care.care or into the design of care.

This slideshowThis slideshow Introducing a new patient-centered medical home Introducing a new patient-centered medical home

model, Lifelong Personal Health Care (LPHC)model, Lifelong Personal Health Care (LPHC)

LPHC divides care management into:LPHC divides care management into: Clinical, provided by a behavioral care provider (BCP), and Clinical, provided by a behavioral care provider (BCP), and Administrative, provided by a "care coordinator" (CC)Administrative, provided by a "care coordinator" (CC)

The BCP, like the PCP, evaluates every patient's The BCP, like the PCP, evaluates every patient's primary care needs and jointly develops treatment primary care needs and jointly develops treatment plans as part of a team including the patient, family plans as part of a team including the patient, family as relevant and desired, the PCP and CCas relevant and desired, the PCP and CC

The result is projected to be more successfully The result is projected to be more successfully transformed primary care practice, better health transformed primary care practice, better health outcomes, and significantly lower costs.outcomes, and significantly lower costs.

Primary care Primary care transformationtransformation

(rationale, evidence, and models)(rationale, evidence, and models) Rationale:Rationale:

Why primary careWhy primary care The medical home as an improved approach to The medical home as an improved approach to

providing primary careproviding primary care Evidence:Evidence:

Primary care makes health care more Primary care makes health care more affordable and effectiveaffordable and effective

The medical home seems obviously betterThe medical home seems obviously better Models:Models:

Nurse Care ManagerNurse Care Manager Chronic Disease ManagementChronic Disease Management Coordinated careCoordinated care Medical NeighborhoodsMedical Neighborhoods

Why primary care?Why primary care?Better qualityBetter quality

Why primary care?Why primary care?Lower costsLower costs

What is a medical home?What is a medical home? The patient-centered medical home (PCMH) The patient-centered medical home (PCMH)

[was] defined in a 2007 Joint Principles [was] defined in a 2007 Joint Principles document (American Academy of Family document (American Academy of Family Physicians (AAFP), American Academy of Physicians (AAFP), American Academy of Pediatrics (AAP), American College of Physicians Pediatrics (AAP), American College of Physicians (ACP), & American Osteopathic Association (ACP), & American Osteopathic Association (AOA), 2007) endorsed by the leading primary (AOA), 2007) endorsed by the leading primary care physician member organizations, care physician member organizations, championed by the Patient- Centered Primary championed by the Patient- Centered Primary Care Collaborative (PCPCC), and certified at Care Collaborative (PCPCC), and certified at three tiers of achievement by the National three tiers of achievement by the National Committee for Quality Assurance (NCQA)….Committee for Quality Assurance (NCQA)….

- deGruy & Etz (2010)- deGruy & Etz (2010)

Patient Centered Medical Patient Centered Medical HomeHome

WHAT IS A MEDICAL HOME?WHAT IS A MEDICAL HOME?

AHRQAHRQThe Patient Centered Medical Home (PCMH)… is a way of The Patient Centered Medical Home (PCMH)… is a way of organizing service delivery in a coordinated manner organizing service delivery in a coordinated manner characterized by a “patient-centered” orientation; comprehensive characterized by a “patient-centered” orientation; comprehensive team-based care with coordination among providers; continuous team-based care with coordination among providers; continuous access to care; and a systems-based approach to quality and access to care; and a systems-based approach to quality and safety. safety.

NCQANCQAThe patient-centered medical home is a model for care provided The patient-centered medical home is a model for care provided by physician practices that seeks to strengthen the physician-by physician practices that seeks to strengthen the physician-patient relationship by replacing episodic care based on illnesses patient relationship by replacing episodic care based on illnesses and patient complaints with coordinated care and a long-term and patient complaints with coordinated care and a long-term healing relationship…. where each patient has an healing relationship…. where each patient has an ongoing ongoing relationship with a personal physician relationship with a personal physician who leads a team that who leads a team that takes collective responsibility for patient care. The physician-led takes collective responsibility for patient care. The physician-led care team is responsible for providing all the patient’s health care care team is responsible for providing all the patient’s health care needsneeds

Why the medical home?Why the medical home?

The The medical home as an improved as an improved approach to providing primary careapproach to providing primary care

Team careTeam care

Care managementCare management

Evidence-based practice (registries, Evidence-based practice (registries, guidelines, etc.)guidelines, etc.)

Why the medical home?Why the medical home? Evidence is developing: is developing:

“The findings from our updated review are entirely consistent with those of our 2009 report: Investing in primary care patient centered medical homes results in improved quality of care and patient experiences, and reductions in expensive hospital and emergency department utilization. There is now even stronger evidence that investments in primary care can bend the cost curve, with several major evaluations showing that patient centered medical home initiatives have produced a net savings in total health care expenditures for the patients served by these initiatives”

- Grumbach & Grundy, (2010). Outcomes of Implementing Patient Centered Medical Home Interventions: A Review of the Evidence from Prospective Evaluation Studies in the United States, Patient-Centered Primary Care Collaborative

Medical home modelsMedical home models

Team:Team:

NCM: Nurse Care ManagerNCM: Nurse Care Manager

CDM: Chronic Disease ManagementCDM: Chronic Disease Management

Coordinated care: High volume Coordinated care: High volume specialistsspecialists

Often with care managers coordinatingOften with care managers coordinating

Medical NeighborhoodsMedical Neighborhoods

Rationale for integration of Rationale for integration of behavioral health expertise behavioral health expertise into the core of the medical into the core of the medical

home teamhome teamBehavior- rather than medicine- is more likely to Behavior- rather than medicine- is more likely to determine someone’s health. The best determine someone’s health. The best prescription is one that urges people to follow a prescription is one that urges people to follow a few simple rules, such as exercising regularly (30 few simple rules, such as exercising regularly (30 minutes a day, 5 days a week), eating 5 servings minutes a day, 5 days a week), eating 5 servings of fruit and vegetables a day, avoiding tobacco, of fruit and vegetables a day, avoiding tobacco, illicit drugs and excessive alcohol, engaging only illicit drugs and excessive alcohol, engaging only in responsible sexual behavior and participating in responsible sexual behavior and participating daily in relaxing and stress-reducing activities.daily in relaxing and stress-reducing activities.

Former U.S. Surgeon General David Satcher, at Black Former U.S. Surgeon General David Satcher, at Black Health Forum, Brown UniversityHealth Forum, Brown University


home teamhome teamPeople are not likely to do anything that's hard, such People are not likely to do anything that's hard, such as… taking care of one's health — no matter how as… taking care of one's health — no matter how good the incentives are…. A new health care system good the incentives are…. A new health care system could use psychology to figure out ways to give better could use psychology to figure out ways to give better medical care, not just more health care.medical care, not just more health care.

Peter Orszag, director of the Office of Management and Peter Orszag, director of the Office of Management and BudgetBudget

Other supporters of integrating behavioral health into Other supporters of integrating behavioral health into primary care:primary care:

HRSA (Smith), 2004; Institute of Medicine, 2005HRSA (Smith), 2004; Institute of Medicine, 2005

Health behavior and lifestyle drive a large Health behavior and lifestyle drive a large proportion of medical concerns and proportion of medical concerns and presenting issues in primary care presenting issues in primary care e.g., Bakken, 1992; Kroenke & Mangelsdorff, 1989e.g., Bakken, 1992; Kroenke & Mangelsdorff, 1989

Inadequate identification and treatment of Inadequate identification and treatment of mental health/substance abuse problems in mental health/substance abuse problems in primary care have dramatic effects on primary care have dramatic effects on effectiveness and costs of medical careeffectiveness and costs of medical care e.g., Thomas, Waxmonsky, McGinnis, & Barry, e.g., Thomas, Waxmonsky, McGinnis, & Barry,

20062006


home teamhome team

Integrating behavioral health into medical care Integrating behavioral health into medical care improves outcomes and reduces costs for mental improves outcomes and reduces costs for mental health/substance abuse health/substance abuse andand medical problems, with medical problems, with potential for generating the largest untapped potential for generating the largest untapped healthcare savingshealthcare savings e.g., Blount, Kathol, O’Donohue, Peek, Rollman, e.g., Blount, Kathol, O’Donohue, Peek, Rollman,

Schoenbaum, & Thompson, 2007; Chiles, Lambert, & Hatch, Schoenbaum, & Thompson, 2007; Chiles, Lambert, & Hatch, 1999; Pincus, Pechura, Keyser, Bachman, & Huntsinger, 1999; Pincus, Pechura, Keyser, Bachman, & Huntsinger, 20062006

PCPs report deteriorating work satisfaction. Their PCPs report deteriorating work satisfaction. Their numbers are shrinking (e.g., National Resident numbers are shrinking (e.g., National Resident Matching Program, 2006), but satisfaction is Matching Program, 2006), but satisfaction is significantly higher among providers co-located with significantly higher among providers co-located with behavioral health specialists (Gallo et al., 2007)behavioral health specialists (Gallo et al., 2007)


home teamhome team

CLEARLYORGANIC

CLEARLYPSYCHOLOGICAL

OTHER

Kroenke and Mangelsdorff, 1989; Berkman and Breslow, 1983; Bridges and Goldberg, 1985

65-75%

15-20%

10-15%

74%

10%

16%

Causes of presenting complaints bringing patients to see their primary care doctor

Offering mental health treatment Offering mental health treatment reduces overall medical costs, reduces overall medical costs, especially when behavioral services especially when behavioral services are targeted at medical conditionsare targeted at medical conditions

- Lambert, Chiles, and Hatch, 1999; - Lambert, Chiles, and Hatch, 1999;

Cuffel, Goldman, & Schlesinger, Cuffel, Goldman, & Schlesinger, 19991999

(researchers from United Behavioral (researchers from United Behavioral Health)Health)

Mental health services Mental health services reducereduce costscosts

Medical home teams Medical home teams may not be ideally may not be ideally

designed to manage designed to manage health behaviors health behaviors

effectivelyeffectively(ethics: whose needs determine how care will be organized, payers’? Providers’? Or (ethics: whose needs determine how care will be organized, payers’? Providers’? Or

patients’?)patients’?)

Better: Integrated Team Better: Integrated Team CareCare

Integration is exquisitely difficult and is at Integration is exquisitely difficult and is at the heart of what makes primary care the heart of what makes primary care work. work.

Integration should not be confused with Integration should not be confused with coordination. Coordination implies coordination. Coordination implies ordering and sequencing, while integration ordering and sequencing, while integration implies creating something new - in this implies creating something new - in this case, something fitted to a particular case, something fitted to a particular individual patient.individual patient.


What is integrated primary careWhat is integrated primary care??Building on descriptions by Blount, Kathol, O’Donohue, Peek, Building on descriptions by Blount, Kathol, O’Donohue, Peek, Rollman, Schoenbaum, & Thompson (2005), the Allied Rollman, Schoenbaum, & Thompson (2005), the Allied Advocacy Group for Collaborative Care (2002), the Rhode Advocacy Group for Collaborative Care (2002), the Rhode Island Policy Roundtable on Collaborative Care (2003), and Island Policy Roundtable on Collaborative Care (2003), and Block, Costello, & Fine (2004):Block, Costello, & Fine (2004):

Integrated care is based on the Integrated care is based on the principle that mental, social, and principle that mental, social, and physical are indivisible, and physical are indivisible, and accordingly that health care must accordingly that health care must target the whole person.target the whole person.


Integrated services routinely define Integrated services routinely define all healthcare issues in terms of all healthcare issues in terms of physical, social, and behavioral physical, social, and behavioral components.components.


The integrated healthcare team includes The integrated healthcare team includes medical and behavioral providers who medical and behavioral providers who mutually design one treatment plan for mutually design one treatment plan for each person receiving care.each person receiving care.


Integrated healthcare services are Integrated healthcare services are offered concurrently by all members of offered concurrently by all members of the team as relevant, each addressing the team as relevant, each addressing every issue for which their perspective every issue for which their perspective and expertise can make a significant and expertise can make a significant contribution.contribution.


Integrated healthcare interventions are Integrated healthcare interventions are actively coordinated and presented to the actively coordinated and presented to the patient as a single treatment approach patient as a single treatment approach designed to best serve their needs.designed to best serve their needs.

Is anything like this Is anything like this realistic?realistic?

Or only fantasy?Or only fantasy?

Later is hereLater is here

““It is inconceivable that whole person care can It is inconceivable that whole person care can occur absent attention to and incorporation of occur absent attention to and incorporation of the full psychosocial dimension of health and the full psychosocial dimension of health and healthcare— mental healthcare, family and healthcare— mental healthcare, family and community contexts, substance abuse, and community contexts, substance abuse, and health behavior change (here collectively health behavior change (here collectively referred to as behavioral healthcare). Any referred to as behavioral healthcare). Any PCMH that neglects this dimension is PCMH that neglects this dimension is incomplete and will be ineffective. It will fail. A incomplete and will be ineffective. It will fail. A solid edifice of empirical evidence supports solid edifice of empirical evidence supports this rather uncompromising assertion.”this rather uncompromising assertion.”

Later is hereLater is here

““Comprehensive Primary Care Requires Comprehensive Primary Care Requires Negotiation Of Team Roles With Other Clinicians. Negotiation Of Team Roles With Other Clinicians. We call this horizontal collaboration, which means We call this horizontal collaboration, which means collaboration with clinicians of more or less equal collaboration with clinicians of more or less equal status… to produce functional team-based care….status… to produce functional team-based care….

Integration of behavioral healthcare into the PCMH is Integration of behavioral healthcare into the PCMH is difficult…. The wins - for the health of our citizens, the difficult…. The wins - for the health of our citizens, the restoration of our workforce, the effectiveness of our restoration of our workforce, the effectiveness of our healthcare system, the advances in our science, and healthcare system, the advances in our science, and the health or our nation’s economy - far outweigh [the] the health or our nation’s economy - far outweigh [the] costs.”costs.”


An effective, complete An effective, complete PCMH model:PCMH model:

Lifelong PersonalLifelong Personal

Health CareHealth Care(LPHC)(LPHC)

Give me a break!Give me a break!

The LPHC modelThe LPHC model

A fully integrated patient-A fully integrated patient-centered medical home with centered medical home with behavioral care managementbehavioral care management

For more information about LPHC, contact:For more information about LPHC, contact:

[email protected]@lphc.info

Documents

Lifelong Personal Health Care (LPHC) team: Paul Block, Jeff Migneault, Kelly Madden