Integrated CareThe Inseparability of the Mental and the Medical

CFHA SummitSan Diego, California

Frank deGruyOctober 22, 2009

“…responsible for providing for all the patient’s health care needs…”

“Care is coordinated and/or integrated across all elements…”

Joint Principles of the Patient Centered Medical Home

American Academy of Family Physicians (AAFP)American Academy of Pediatrics (AAP)American College of Physicians (ACP)American Osteopathic Association (AOA)

February 2007

A Medical Home is:

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Without mental and behavioral healthcare, the PCMH fails.

Fails!

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Mental DisordersSymptoms, Stress, Concerns

Substance Abuse

Health Behavior Change

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Mental Disorders

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6Number of physical symptoms

Personal Health CostsMedical CarePharmaceutical costsWorkers’ Compensation Costs

Productivity Costs

Presenteeism

OvertimeTurnover

Temporary StaffingAdministrative Costs

Replacement TrainingOff-Site Travel for Care

Customer DissatisfactionVariable Product Quality

Absenteeism

Short-term Disability Long-term Disability

The Full Cost of Poor Health to Employers

Iceberg of Full Costs to

Employers from Poor Health

Iceberg of Full Costs to

Employers from Poor Health

Sources: Loeppke, R., et al., "Health and Productivity as a Business Strategy: A Multi-Employer Study", JOEM.2009; 51(4):411-428. and Edington DW, Burton WN. Health and Productivity. In McCunney RJ, Editor. A Practical Approach to Occupational and Environmental Medicine. 3rd edition. Philadelphia, PA. Lippincott, Williams and Wilkens; 2003: 40-152

Sources: Loeppke, R., et al., "Health and Productivity as a Business Strategy: A Multi-Employer Study", JOEM.2009; 51(4):411-428. and Edington DW, Burton WN. Health and Productivity. In McCunney RJ, Editor. A Practical Approach to Occupational and Environmental Medicine. 3rd edition. Philadelphia, PA. Lippincott, Williams and Wilkens; 2003: 40-152

70

%3

0 %

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Top 10 Health Conditions Driving Med + Rx Costs per 1000 FTEs

Loeppke, R., et al., "Health and Productivity as a Business Strategy: A Multi-Employer Study“. JOEM. 2009;51(4):411-428.

Loeppke, R., et al., "Health and Productivity as a Business Strategy: A Multi-Employer Study“. JOEM. 2009;51(4):411-428. 8

Top 10 Health Conditions Driving Full Costs for Employers (Med + RX + Absenteeism + Presenteeism) Costs/1000 FTEs

Loeppke, R., et al., "Health and Productivity as a Business Strategy: A Multi-Employer Study“. JOEM. 2009;51(4):411-428.

Loeppke, R., et al., "Health and Productivity as a Business Strategy: A Multi-Employer Study“. JOEM. 2009;51(4):411-428. 9

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The Comorbidity Story

Robert Graham Center, “Why there must be room for mental health in the medical home; NBGH: An Employers’ Guide to Behavioral Health Services

Health Behavior Change

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12McGinnis JM, Foege WH. Actual Causes of Death in the United States. JAMA 1993;270:2207-12.Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual Causes of Death in the United States, 2000. JAMA 2004;291:1230-1245.

Myopia Psoriasis Hypothyroidism Allergies

Depression Multiple Sclerosis Epilepsy

Chronic Back PainInfertility Crohn’s Disease GERD

Ulcerative Colitis

Sickle Cell Disease

Type I Diabetes

Parkinson’s

Cystic Fibrosis CAD

Chronic Hep B

Osteoporosis Cerebrovascular Dz Hypertension Hyperlipidemia

Asthma CHFSchizophrenia Type II DM

Alzheimer’s Obesity

Bipolar Disorder Addictions

Requirement for behavior change

Moti

vatio

n to

cha

nge

So What Does A Comprehensive Medical Home Look Like?

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And where do we get the behavioralhorsepower we need for it?

The Shape Of Practices Today:

A solo doc in a micropractice A doc and a nurse

Three partners, four staff …joined by a care coordinator

…joined by a psychologist Eight partners, three care coordinators, a clinical pharmacist, two

psychologists, and a partridge in a pear tree Staff HMO office with a full complement of resources

FQHC with a different full complement of resources

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Possible Structuresfor Integrated, Comprehensive Care

A psychologist who does CBT both in her office and in the PCMH

A psychiatrist who is in the medical home one afternoon a week

A CMHC staff who are available any time by phone

An MFT who works part time in the practice

A Depression Center that consults by teleconferencing hookup

A psychiatrist who spends one long breakfast a week with the PCPs and the Care manager reviewing charts

A psychologist who works with the care coordinator .25 FTE on motivational interviewing and other health behavior change

modalities

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Principles

Specify the job to be donePay for outcomes

Offer ideas and options about meansEncourage local solutions

Support the cost of changeClosely evaluated case studies and demos

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