session # e6 integrated behavioral health at mayo ......primary care to ensure the delivery of...

Integrated Behavioral Health at Mayo –Bringing Together Mental Health Disciplines in Primary Care to Better Address a Population

William Leasure, MD

Craig Sawchuk, PhD

Angela Mattson, DNP, MS, RN, BC

Mark Williams, MD

Sarah Trane, PhD

Session # E6

CFHA 20th Annual ConferenceOctober 18-20, 2018 • Rochester, New York

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Faculty Disclosure

The presenters of this session have NOT had any relevant financial relationships during the past 12 months.

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Learning ObjectivesAt the conclusion of this session, the participant will be able to:

1. Describe a multidisciplinary model of integrated care that is developing to be applicable in a wide variety of settings, highlighting teamwork, translational methods, and learning from your population with retrospective research.

2. Identify key components in delivering high quality collaborative care coordination in primary care and key challenges to overcome both for outcomes and sustainability.

3. Describe a model of integration of evidence-based psychotherapy into primary care with the capacity to track outcomes.

Presenter

Presentation Notes

Include the behavioral learning objectives you identified for this session

1. Craner JR, Sawchuk CN, Mack J, LeRoy M. Development and implementation of a psychotherapy tracking database in primary care. Families, Systems, and Health, 2017;35(2):207-216.

2. Rossom RC, Solberg LI, Magnan S, Crain AL, Beck A, Coleman KJ, Katzelnick D, Williams MD, Neely C, Ohnsorg K et al: Impact of a national collaborative care initiative for patients with depression and diabetes or cardiovascular disease. Gen Hosp Psychiatry 2016.

3. Garrison GM, Angstman KB, O'Connor SS, Williams MD, Lineberry TW: Time to Remission for Depression with Collaborative Care Management (CCM) in Primary Care. J Am Board Fam Med 2016, 29(1):10-17.

4. Williams MD, Sawchuk CN, Shippee ND, Somers KJ, Berg SL, Mitchell JD, et al. A quality improvement project aimed at adapting primary care to ensure the delivery of evidence-based psychotherapy for adult anxiety. BMJ Open Qual, 2018;9:7(1).

5. Nathan D. Shippee, Angela Mattson, RoxAnne Brennan, John Huxsahl, Marcie L. Billings, and Mark D. Williams: Effectiveness in Regular Practice of Collaborative Care for Depression Among Adolescents: A Retrospective Cohort Study. Psychiatric Services, Published online February 15, 2018.

6. Katzelnick DJ, Williams MD: Large-Scale Dissemination of Collaborative Care and Implications for Psychiatry. Psychiatric services 2015, 66(9):904-906.

Bibliography / Reference

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Presentation Notes

Continuing education approval now requires that each presentation include five references within the last 5 years. Please list at least FIVE (5) references for this presentation that are no older than 5 years. Without these references, your session may NOT be approved for CE credit.

https://ps.psychiatryonline.org/doi/abs/10.1176/appi.ps.201700298

Learning AssessmentA learning assessment is required for CE credit.

A question and answer period will be conducted at the end of this presentation.

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Please incorporate audience interaction through a brief Question & Answer period during or at the conclusion of your presentation. This component MUST be done in lieu of a written pre- or post-test based on your learning objectives to satisfy accreditation requirements.

©2012 MFMER | slide-7

Outline

1. An introduction to Integrated Behavioral Health at Mayo

2. Our experience with care coordination

3. Imbedding evidence-based psychotherapy into primary care

4. Implementing new models, preserving teamwork, operational challenges

5. Adapting the model to rural settings – opportunities and challenges

6. Questions and answers

Presenter

Presentation Notes

Each talk 8-10 min – less on the theory of these topics and more on what we do in these areas – try to keep it to 10 slides or less?


Integrated Behavioral Health (IBH) at Mayo William Leasure, MD

Co-Chair, Division of Integrated Behavioral Health

Mayo Clinic, Rochester, MN


Psychiatry at Mayo• Mayo started in late 1800’s

• Mayo brothers were surgeons• Other specialties needed• One of the first group practices

• Mayo Psychiatry roots in consultation-liaison• Excellent Psychiatric evaluations• Brief treatments in areas of excellence

• Addiction, mood, pain, etc.


Challenge – Specialty approach• Non-local patients

• Complex problems; in town for intensive work-up and an answer

• Fee-for-service payment

• Local community patient • Typically don’t have a rare condition

• Growing population insured by Mayo• Intensive work-up costly and often unnecessary• 2-3 month wait • High no show rate (waiting plus stigma)

• Need for a population-based approach

Presenter

Presentation Notes

Access and cost made the argument for change (not quality because no measures available)


Creation of IBH• One clinic using PDSA cycles then spread

• Therapy, Medications, Care coordination, etc.

• Work out system issues• Change ordering system, standardized tools• Clarify psychiatric emergency plan• Develop weekly huddle

• Clarify roles• MD and APRN • PHD and LICSW• RN care coordinator


The Multidisciplinary IBH Team

Care Coordinators

PsychiatristPsychologists

Social Work


Social Worker role change

• Triple role:• Evidence-based assessment

and psychotherapy• Triage visits; warm handoffs;

right-step level of care• General social work

resources


Roles on Our Team –all part of Primary Care

• Psychiatry (1/33,000) – plus academic responsibilities

• Direct patient care• Indirect patient care – curbsides, e-consults, reviewing cases for

care coordination• Supervision of care – nurses, residents

• Advance Practice Registered Nurse (1/23,000)

• Follow and stabilize patients needing meds

• Often have earlier access

• Backup by psychiatrist


Roles on Our Team• LICSW (1/8,000)

• Triage, CBT, traditional social work

• PHD (1/55,000)• Tougher cases, support LICSW, fellows• Pts with treatment resistant behaviors• Group therapy with LICSW

• RN Care coordinators (1/10,000)

• Others – desk staff familiar with schedules, secretarial support

• We also spend time on supporting teams

Presenter

Presentation Notes

Updated ratios on May 3, 2017


Our Population Based Program Development Process• Define population –most pressing need?• Find examples in literature of evidence-based treatment models

for that need• Adapt the model to one clinic and assess outcomes.

• Publish effort for peer review• Spread to other sites if achieving good results• Integrate programs to increase efficiency


Examples of IBH resources available to our patients (partial list) • Direct patient care (MD/APRN/LICSW/LP/PHD/RN)

• Care coordination (depression, bipolar, anxiety, medically complex)• Adults for all, adolescent patients focus on depression

• Short term evidence-based psychotherapy on-site• Group therapy

• Anxiety and Depression• Insomnia• Chronic Pain

• Link to local DBT program for borderline personality disorder

• Indirect support of their primary care providers (e.g. allows direct admission)


Integrated Behavioral Health Model (assume higher level has all features of lower levels)

Level Mental health team

Training Treatment Options

Registry Outcome tracking

Referral process

PopulationScreening

6 Specialty psychiatric programs and consults integration. Complex behavioral health coordination.

Specialty practice learn IBH model and IBH learn specialty practice

Intensive individualized treatments

Integrated registry Track appropriate additional outcomes including access to specialty care.

Easy transition between primary and specialty care

Additional mental health diagnoses

5 On site psychologists and/or psychiatrist

Working relationship with primary care providers. Psychologists participate in monthly therapy training.

Short term consultations/therapy and co-management. Close collaboration with social work and care coordinator

Integrated registry Same as level 4 LICSW helps coordinate mental health referrals

Same as level 4

4 On site CNS/NP and/or telepsychiatry

Working relationship with primary care providers. Spend time on site

Short term consultations and co-management

Integrated registry Same as level 3 and all level 2. Track access to providers

LICSW helps coordinate mental health referrals

All patients once a year. Includes all patients in practice

3 LICSW on site Expertise in triple Social work model: therapy, triage visit, and general social work consultation. Participate monthlytherapy training.

Evidence-based psychotherapy for patients. Collaborate with Care Coordinators.

Integrated registry: includes coordinator panel, contacts, care plan and outcomes.

Track psychotherapy progress and treat to target. Also track access.

LICSW helps coordinate mental health and community referrals.

Patients having general social work and triage visits.

2 Supervising psychiatrist (does not need to be on site)

Psychiatrist trained to participate in SCR and use registry

SCR process with recommended adjustments to treatment

Treat to target. Document SCR reviews

Add GAD-7, AUDIT, and MDQ

Psychiatrist can recommend referrals

Same as level 1

1 Hybrid Model Coordinator and primary care teams

Understand depression treatment options and Motivational Interviewing (MI) and Behavioral Activation (BA).

Antidepressant prescribed by primary care provider. MI and BA. Self-management. Computer CBT. Emergency behavioral health plan in place.

Track depression outcomes if possible in same registry as medical illnesses.

Longitudinally track PHQ-9 scores for patients diagnosed with depression and hospitalizations and ER visits

Electronic list of mental health resources updated and available to providers.

Screen all hybrid model patients for depression. Population wide screening not recommended.


Care coordination

Mark Williams, MD

Associate Professor

Division of Integrated Behavioral Health



Definitions – Care Coordination• Over 40 definitions in literature• For this presentation:

• Care coordination (or care management)• Time limited/goal directed based on self management targets

• Improved health outcome (e.g. Blood pressure)• Improved experience of care• Improved efficiency of care (?)

• Case management• Ongoing support for a patient who for whatever reason cannot

or is not likely to return to self management of health burden


Evidence for Collaborative Care: Cochrane Systematic Review• 79 Randomized Controlled Trials involving 24,308 patients worldwide testing

collaborative care models vs. usual care

• Depression outcomes for adults• Short-term (6m) RR 1.32 (1.22 - 1.43)• Medium-term (7-12m) RR 1.31 (1.17 - 1.48)• Long-term (13-24m) RR 1.29 (1.18 - 1.41)• Very long term (25 m +) RR 1.12 (0.98 – 1.27)*

• Anxiety outcomes for adults• Short-term RR 1.50 (1.21 - 1.87)• Medium-term RR 1.41 (1.18 - 1.69)• Long-term RR 1.26 (1.11 - 1.42)• Very long term unavailable

Archer J, et all, Cochrane vol. 10, 2012

Presenter

Presentation Notes

Tom stops here


• Depression Initiative Across Minnesota, Offering a New Direction (2007-2010)

• Modeled after collaborative care work (Katon/ Unutzer).

• Created by the Institute for Clinical Systems Improvement (ICSI)• Implemented in over 80 clinics in Minnesota

Unutzer, J. et al. Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial, JAMA 2002.


How does it work?

• Patient see by Primary Care• PHQ-9 given – score ≥ 10 (moderate)

• Patient introduced to RN care coordinator• Data gathered from patient

• GAD7, MDQ, AUDIT, WPAI• Past history, social situation, meds, etc.

• Data entered into a registry and presented to Psychiatrist (meet once/week)• Access to mental health input reduced from 2-3 months (face-to-face visit) to 1-2

weeks.

Measure and track

outcomes

Treat to target of remission

on the PHQ-09


Registry: Reviewing Cases in Supervision –Attending to the Absent Patient:

A simple column sorting tool lets the supervising physician sort by patients with (in this example) a PHQ-9 of 10 or more to make sure to review them all and make suggestions.Same concept with LDL/HgBA1C etc.


Secrets of success of this model

• Do not slow down the primary care system!!• Respect the team (primary care provider, nurse, patient, etc.)

• Improve access to psych (input in 1 week vs 2-3 months)

• Weekly review of patients is critical to success• Better triage – who needs more care and match to service• Allows patients to start on any reasonable plan as long as we follow up

• Treat to target – brainstorming and cheerleading• Patient inertia - depressed• Clinical inertia – too busy


Collaborative care (DIAMOND) was better than practice as usual at 3 & 6 months

Shippee et al. 2013 J Ambulatory Care Manage Vol. 36, No. 1, pp. 13–23

Presenter

Presentation Notes

Practice as usual included patients in clinics with care coordination who did not participate, and patients in clinics with no care coordination but who would have been eligible for care coordination


DIAMOND and Time to Remission

Garrison JABFM 2016


IMPACT of DIAMOND for IBH• Data from DIAMOND demonstrated outcomes to primary care

• more resources offered- creation of IBH

• Nursing invested in care coordinator role• Requires ongoing training on motivational interviewing

• Data in a registry allowed us to see which patients were not improving• Those with anxiety for example*

• Led to development of therapy resources in primary care

Angstman et al. DEPRESSION AND ANXIETY 30:143–148 (2013)


Mayo IBH Experience in Evidence to PracticeProblem/Population

RCT research trial Real world implementing

Depression in adults IMPACT (elderly) DIAMOND (all adults)

Adolescent depression Richardson 2014 JAMA EMERALD

Anxiety CBT in PC CALM trial (adults) Mayo CBT (all ages)

Diabetic/CVD Depressed TEAMcare (adults) COMPASS (adapting to other chronic illnesses)

Also available: Research examples for primary care models for PTSD (VA based research), alcohol misuse (SBIRT), bipolar disorder in adults, telemedicine models, etc.


Imbedding Evidence-Based Psychotherapy in Primary CareCraig N. Sawchuk, PhD, ABPP

Professor

Co-Chair, Division of Integrated Behavioral Health



Advantages to Primary Care CBT Evidence-based Goal-oriented and time limited Emphasis on collaboration and coaching Durable effects of treatment – reduces relapse Highly preferable to patients Can be delivered in self-help, individual, and

group formats Easy* to learn; easy* to teach


Challenges to Primary Care CBT Doing CBT vs. doing CBT – quality and fidelity Negative beliefs (patients and providers) Between-session engagement with homework Limited resources to assist in tracking outcomes Salaried vs. fee-for-service models Not everyone needs the same treatment

Translation from research to practice


Laying the Groundwork Finding space Recruiting the right provider Training, experience, specialty certification

Constructing the schedule and continuing education to prevent drift

Educating primary care colleagues Gaining infrastructure support to show outcomes Screening, materials, database development


Ongoing Challenges Balancing the needs of the population Keeping up with the evidence-base Navigating the witness relocation program Differing opinions on quantity vs. quality metrics Killing innovation


Operational OpportunitiesAngela Mattson, DNP, MS, RN, NE-BC

Nurse Administrator


Department of Nursing


Model Planning & Implementation

• Understand the problem and opportunity• It may not be what you think

• Utilize Plan-Do-Study-Act cycles

• Address systems concerns

• Start where you are, do what you can

• Clarify collaborative team roles

• Build a burning platform

and ignite support


Original IBH Model Outcomes• Start small and disseminate

• One provider > Care Team > Clinic > Region

• Multiple PDSAs – e.g. order type of service versus type of provider

• Results• High provider satisfaction• Improved access

Vickers et al. 2013 General Hospital Psychiatry


Selecting the Team

• Seek out individuals who can:• Tolerate ambiguity • Build relationship• Resist rigid bounds• Want to do the work

• Relevant work experiences to support collaborative care

• Willingness to grow beyond traditional norms

• Don’t rush identifying the right person


Patient Reported Outcomes• Measurement matters

• Clinical outcomes support growth• Look for shared measurement opportunities

• MIPS and insurance contracts• Minnesota Community Measures & Wisconsin Collaborative for

Healthcare Quality• Anticipate challenges

• Time• Intervention for concerning results• Available support• Imbedding in culture

Presenter

Presentation Notes

Handout on a list of patient reported outcomes that we use?


Reporting Structures & Training

• Formal supervision (HR) can look different than clinical supervision

• Create culture of openness that all disciplines and can learn form and teach each other

• Create space for ongoing discussions with formal and clinical supervisors

• Interprofessional huddle• Case consultation• Observation and feedback• Systematic case review


Maintaining Access

• How target population is defined can impact access• Implement evidence based models• Short term vs long term interventions• Alignment with organizational priorities• Collaboration with community partners and specialty practice

• Build clinical calendars with defined standards for visit and non-visit care time

• Set access targets


Dissemination & Integration

• Model consensus• Functions vs individual roles

• Fidelity and adaptation• Rural Settings• Resource constraints• Outcome targets

• Clinical and administrative outcomes• Can be competing priorities

• Understanding who the decision makers are


Productivity• Value based or fee-for-service environment• Define standard set of metrics

• Access metrics• Standard patient contact hours • Fill Rates

• Non-Visit Care workload• Triage, resource referral, EHR messaging

• Clinical outcomes• Response and remission

• Financial metrics • Billing and utilization


Sustainability

• Define outcomes from the beginning

• Utilize population based registries, access dashboards, etc. for ongoing evaluation

• Consider tele options for expanding reach

• Support primary care teams in outcomes they are impacted by

• Use data for clinical and administrative decision making at point of care

• Influence contracting and policy


Ideas That Did Not Work• Simply educating the primary care providers, care team, and RN care

coordinators on psychiatric issues

• Put out algorithms for everyone to use

• Integrating substance abuse program into a small town clinic

• Trust that resources would be made available based on models from the literature alone

• Need to develop internal data from your own practices


Adapting the model to rural settings –opportunities and challenges

Sarah Trane, PhD

Assistant Professor


Mayo Clinic Health System, La Crosse, WI


Presenter

Presentation Notes

Rural health care can feel like a lot of open empty space. e.g., about 100,000 in MN, 1 mental health counselor in Dept of AG.


Rural Healthcare Quarterly, 2017. http://ruralhealthquarterly.com/home/2017/12/15/u-s-rural-health-report-card-2017/

2017 US RURAL HEALTHCARE REPORT CARD

Presenter

Presentation Notes

Research from TX Tech using CDC census data with focus on health care access including mental health care.


What we learned along the way

Laying Groundwork

• Start as sociologist• Needs assessment• Local resources are creative

by necessity – Learn from them. Use them.

• Champion Teams!

Presenter

Presentation Notes

Understand local culture and players. Don’t be shy. Locate champion PCP/RN. Reg/sched. Voicemail. Start SMALL – just a few providers. Get established. Then try to work out growth. Keep data.


How to Call or Page in LASK


What we learned along the way

Becoming part of the team

• Daily huddle• Lunch and learn• Shared record

Ongoing opportunities

• Becoming the best generalist• Using colleagues and

consultation• Remembering to set

boundaries• Self care

Presenter

Presentation Notes

Understand local culture and players. Don’t be shy. Locate champion PCP/RN. Reg/sched. Voicemail.


FHC PHQ9M Screening Rates2017-2018

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17-Apr 17-Jun 17-Aug 17-Dec 18-Mar

LaX PedsFM LaXBLUEGOLDGREENREDSILVER

Presenter

Presentation Notes

A little friendly competition among the FM residents


Remember - You are not alone

https://www.ruralhealthinfo.org/toolkits/services-integration/2/primary-care-behavioral-health


Thanks to our IBH colleagues!!!

Questions??

[email protected]

mailto:[email protected]

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session # e6 integrated behavioral health at mayo ......primary care to ensure the delivery of...

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