the integration of behavioral health and primary care george rust, md, mph, faafp, facpm father of...
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The Integration of Behavioral Health and Primary Care
George Rust, MD, MPH, FAAFP, FACPMFather of Dan & Christina, Husband of Cindy,
Professor of Family Medicine and Director, National Center for Primary Care
National Center for Primary Care Morehouse School of Medicine
National Center for Primary Care at Morehouse School of Medicine
Promoting Excellence in Community-Oriented Primary Health Care and Optimal Health Outcomes for all Americans
What Is Primary Care?
•C First Contact Care
•C Comprehensive
•C Continuous
•C Coordinated
•C Context of Family & Community
What Is Primary Care?• Primary care is the provision of
integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.
Institute of Medicine, 1996
Primary Care is Relational Care
Personalismo y Confianza Trump Evidence-Based
Medical Advice
Behavioral Health Physical Health
• “Baseball is 90% mental -- the other half is physical."
-- Yogi Berra
Partnerships on Behavioral Health in Primary Care
Rollins School of Public Health
Southeast Regional Clinicians’ Network
Satcher Health
Leadership Institute
National Center for Primary Care
Carter Center
Federal Partners Senior Workgroup
Burden of Disease in Industrialized Nations
Percentof Total
All cardiovascular conditions 18.6
All mental illness including suicide 15.4
All malignant disease (cancer) 15.0
All respiratory conditions 4.8
All alcohol use 4.7
All infectious and parasitic disease 2.8
All drug use 1.5
WHO Global Burden of Disease
Murray CJL, Lopez AD, eds. The global burden of disease and injury series, volume 1: a comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. Cambridge, MA: World Health Organization and the World Bank, Harvard University Press, 1996. www.who.int/msa/mnh/ems/dalys/intro.htm
All Behavioral Health -- Mental Illness, Suicide, Alcohol, & Drug Use = 21.6%
Depression in Primary Care
• Survey of 1898 patients in 88 primary care practices
• Patients meeting DSM criteria for depression w/in past 30 days
•21.7% of women•12.7% of men
Rowe MG. Correlates of Depression in Primary Care. Journal of Family Practice, 1995.
18% Prevalence of Alcohol Abuse or Dependence in Primary Care
Why Primary Care?Why Primary Care?
McQuade et al; Detecting symptoms of alcohol abuse in primary care. Archives of Family Medicine, 2000.
Screening vs. Readiness to Change
• 7 VA Clinics --36% screened positive for alcohol misuse
Readiness to Change in Primary Care Patients Who Screened Positive for Alcohol MisuseWilliams et al. Ann Fam Med 2006;4:213-220.
• “About 70 percent of the population sees one of the 255,173 primary care physicians at least once every two years.”
BUT: • “94 percent of primary care physicians failed to include
substance abuse among the five diagnoses they offered when presented with early symptoms of alcohol abuse in an adult patient.”
• “Most patients (53.7 percent) said their primary care physician did nothing about their substance abuse: – 43 percent said their physician never diagnosed it– 10.7 percent believe their physician knew about their addiction
and did nothing about it.”
Missed Opportunity: National Survey of Primary Care Physicians and Patients on Substance Abuse. CASA- National Center on Addiction & Substance Abuse at Columbia University, April 2000.
Is Primary Care Failing?
Usual Care = Sub-Optimal Care
• Fail to screen / detect • Fail to diagnose• Fail to treat• Fail to treat adequately • Fail to treat to remission
“Typical” Primary Care Patient
A. A1C (Diabetes)
B. BP (Hypertension)
C. Cholesterol /LDL
D. Depression Plus – Osteoarthritis / Pain Mgt
(Self-medicating with sister’s Vicodin)
Plus – Social ComplexitiesHusband unemployed, now drinking heavily; teens caught up in juvenile justice system.
Co-morbidities Abound!
Inpatient Outpt Physician Other Rx Drugs Total
$218,460 $7,435 $28,984 $12,923 $13,444 $281,246
He’s just one patient, how bad could it be???• Diabetes• Arthritis• COPD• CHF• Stroke
• Pneumonia • Cancer• Depression• Alcohol / substance abuse
* 21 ER Visits * 139 hospital bed-days
Mental Health Co-Morbidities in the Disabled Medicaid Population
*mental health includes: anxiety, depression, dementia, severe mental illness35,165
CY-2005 total non-pregnant adult ABD members
52.5%22.5%47.5%69.0%0.1%40 Gynecologic
100.0%32.5%100.0%68.6%0.6%206 Dementia
50.2%35.0%35.3%78.6%0.9%331 Gastrointestinal
57.5%42.8%34.0%84.5%1.0%353 Hemophilia
60.9%48.7%38.7%84.7%1.4%501 Respiratory (not COPD
or asthma)
29.3%19.3%14.3%78.2%1.9%680 Renal
39.3%25.1%23.1%80.3%2.4%837 Stroke
57.6%41.1%35.3%76.1%2.6%898 Liver
42.1%31.2%21.4%90.4%3.8%1,333 CHF
29.4%11.9%22.8%58.3%4.2%1,468 Eye
49.0%28.0%35.7%52.5%5.1%1,798 Asthma
38.5%22.5%25.6%61.0%5.7%1,998 Cancer
47.1%29.2%30.7%77.6%6.0%2,099 Blood (not hemophilia)
44.0%30.7%25.1%87.3%6.1%2,130 Coronary Dz (CAD)
44.1%28.5%27.5%81.6%6.7%2,365 Vascular
41.9%28.4%24.9%78.4%7.2%2,530 Heart (not CHF/CAD)
56.1%38.2%35.7%75.4%8.4%2,944 COPD
100.0%100.0%48.5%72.7%10.6%3,735 Substance Abuse
32.9%14.2%25.0%67.1%14.8%5,187 Diabetes
39.4%17.8%29.7%63.2%21.6%7,613 Lipid / Metabolic
42.4%19.8%33.1%54.6%24.7%8,683 Musculoskeletal
36.5%17.6%26.7%60.2%30.0%10,545 Hypertension
% among Pop wth this Dx who also have
either Mental Health or
Substance Abuse (or both)
% among Pop with this Dx
who also have any
Substance Abuse
% among Pop with this Dx
who also have any Mental
Health Dx*
% among Pop with this Dx who also have at least 3 Other Co-Morbid Diseases
Prevalence of this
Diagnosis in adult,
non-pregnant
ABD Population n
Disease Diagnosis (Dx)
Diseases Associated with High Co-Morbidity Rates (> 50% with >3 comorbidities)
*mental health includes: anxiety, depression, dementia, severe mental illness35,165
CY-2005 total non-pregnant adult ABD members
52.5%22.5%47.5%69.0%0.1%40 Gynecologic
100.0%32.5%100.0%68.6%0.6%206 Dementia
50.2%35.0%35.3%78.6%0.9%331 Gastrointestinal
57.5%42.8%34.0%84.5%1.0%353 Hemophilia
60.9%48.7%38.7%84.7%1.4%501 Respiratory (not COPD
or asthma)
29.3%19.3%14.3%78.2%1.9%680 Renal
39.3%25.1%23.1%80.3%2.4%837 Stroke
57.6%41.1%35.3%76.1%2.6%898 Liver
42.1%31.2%21.4%90.4%3.8%1,333 CHF
29.4%11.9%22.8%58.3%4.2%1,468 Eye
49.0%28.0%35.7%52.5%5.1%1,798 Asthma
38.5%22.5%25.6%61.0%5.7%1,998 Cancer
47.1%29.2%30.7%77.6%6.0%2,099 Blood (not hemophilia)
44.0%30.7%25.1%87.3%6.1%2,130 Coronary Dz (CAD)
44.1%28.5%27.5%81.6%6.7%2,365 Vascular
41.9%28.4%24.9%78.4%7.2%2,530 Heart (not CHF/CAD)
56.1%38.2%35.7%75.4%8.4%2,944 COPD
100.0%100.0%48.5%72.7%10.6%3,735 Substance Abuse
32.9%14.2%25.0%67.1%14.8%5,187 Diabetes
39.4%17.8%29.7%63.2%21.6%7,613 Lipid / Metabolic
42.4%19.8%33.1%54.6%24.7%8,683 Musculoskeletal
36.5%17.6%26.7%60.2%30.0%10,545 Hypertension
% among Pop wth this Dx who also have
either Mental Health or
Substance Abuse (or both)
% among Pop with this Dx
who also have any
Substance Abuse
% among Pop with this Dx
who also have any Mental
Health Dx*
% among Pop with this Dx who also have at least 3 Other Co-Morbid Diseases
Prevalence of this
Diagnosis in adult,
non-pregnant
ABD Population n
Disease Diagnosis (Dx)
Diseases Associated with High Co-Morbidity Rates (> 50% with >3 comorbidities)
Complex Co-Morbidities• Among disabled Medicaid patients with HTN:
– 60% have at least 3 other serious physical conditions (on a billed claim within the past year)
– 26.7% have a mental health diagnosis– 17.6 % have a substance use disorder diagnosis– 36.5% have either a mental health or substance use
disorder diagnosis– 9.8% have both a mental health and
a substance use disorder diagnosis
Medical Chronic Dz
Mental Health Dx
Substance Use
Disorder
Prescription Drug Abuse
• 15.1 million Americans admit abusing prescription drugs
• The number of people who admit abusing controlled prescription drugs increased from 7.8 million in 1992 to 15.1 million in 2003.
• In 2003, 2.3 million teens between the ages of 12 and 17 (9.3 percent) admitted abusing a prescription drug in the past year; 83 percent of them admitted abusing opioids.
• In 2002, controlled prescription drugs accounted for 23 percent of all drug-related emergency department mentions in the U.S
-- Under the Counter: The Diversion and Abuse of Controlled Prescription Drugs in the U.S. (July 2005); CASA – The National Center on Addiction and Substance Abuse at Columbia University
Pain Management vs Opioid Addiction
Achieve
Adequate
Pain Control
Prevent Prescription Drug
Addiction
You are now entering . . .
. . . the No-Win Zone!
• Screening• Brief Intervention• Motivational Interviewing• Referral• Care Management• Medication-Assisted Recovery • Recovery-Oriented Systems of Care
Strategies to Address At-Risk Substance Use and SUDs in Primary Care Setting
Primary Care without A Team Approach
Preventive Services = 7.4 hrs / day
Chronic Dz (well-controlled panel) = 3.5 hrs/day
Chronic Dz (poorly-controlled panel) = 10.6 hrs/day
Østbye T, Yarnall KS, Krause KM, Pollak KI, Gradison M, Michener JL. Is there time for management of patients with chronic diseases in primary care? Ann Fam Med. 2005 May-Jun;3(3):209-14.
Screening in Primary Care
CAGE
CAGE-AID
AUDIT-C
ASSIST
DAST
CRAFFT
PHQ-9
Hamilton-D
GAD-7
Beck Anxiety Inventory
HITS (domestic violence)
Epworth Sleepiness Scale
Screening & Brief Intervention in Primary Care
• AHRQ Evidence Review does recommend alcohol screening & brief intervention
• After primary care brief, multi-contact interventions, patients reduced average drinks per week by 13%–34% and increased the proportion drinking at moderate or safe levels by 10%–19% compared with controls.
Whitlock EP, Green CA, Polen MR, Berg A, Klein J, Siu A, Orleans CT. Behavioral Counseling Interventions in Primary Care to Reduce Risky/Harmful Alcohol Use. Rockville (MD): Agency for Healthcare Research and Quality (US); 2004 Mar.
BUT, . . . the USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening adolescents, adults, and pregnant women for illicit drug use.
Brief Intervention -- FRAMES• Feedback
– “I am specifically concerned about your substance use because…”
• Responsibility– “What you do with your substance use is up to you.”
• Advice– “In my medical opinion, you can best minimize your health risks by…”
• Menu– “What do you think would work for you
if you decided to make a change?”
• Empathy– “It is not easy to change.”
• Self-Efficacy – “I can see that you are a strong person.”
Primary Care Needs the Partnership with Behavioral Health !!!
“ Seven Characteristics of the Patient-Centered Medical Home”
• Personal Relationship with Physician
• Team Approach
• Comprehensive Whole Person Approach
• Coordination and Integration of Care
• Quality and Safety as Hallmarks
• Expanded Access to Care
• Added Value Recognized
http://pcpcc.net/files/pcmhpurchasersummary.pdf
Does the Mental Health Sector Need More Primary Care?
• S Brown. Excess mortality of schizophrenia. A meta-analysis The British Journal of Psychiatry 171: 502-508 (1997)
• 25-year survival deficit -- Schizophrenia Excess Mortality• 28% due to suicide
• 12% due to accidents
• 60% due to everything else
Uncoordinated Care – When We Just Don’t Talk
• Jane Doe -- 37 y/o F w/ Bipolar Disorder– Lithium (Lithobid®)
– Aripiprazole (Abilify®)– Divalproex Sodium (Depakote®)
• Jane Doe – 37 y/o fertile female smoker with HTN & two-weeks of productive cough– Azithromycin (Zithromax Z-Pack®)– ACE + HCTZ (Vaseretic®)– OCP’s (Yaz®)– Bupropion (Zyban® or Wellbutrin®)
Three-Way Integration – Mental Health, Substance Abuse, & Primary Care
• 40 percent of those with an alcohol use disorder also had an independent mood disorder and 60 percent of those with a drug use disorder had an independent mood disorder (Grant, Stinson, Dawson, Chou, Dufour, Compton, et al., 2004).
• Integrated treatment for both problems is the standard of care for clients with substance abuse and depressive symptoms or any co-occurring mental disorder.
– TIP 48:Managing Depressive Symptoms in Substance Abuse Clients during Early Recovery. SAMHSA/CSAT Treatment Improvement Protocol Series; 2008.
Clinical Scenarios
MENTAL HEALTH
• Schizophrenia patientgains 100 lbs and develops diabetes
• Bipolar patient on lithium has hypothyroidism and high blood pressure
PRIMARY CARE
• Diabetic patient with depression
• Insomnia patient using increasing doses of Xanax®
• CHF patient who self-treats PTSD with alcohol
• Chronic back pain patient develops opioid addiction
SUBSTANCE ABUSE TREATMENT
• Alcohol patient in detox with HTN and chest pain
• Sickle cell patient with heroin addiction has painful crisis
• Obese, smoking diabetic worried that he is addicted to the Darvocet® he takes for neuropathic pain.
Status Quo = Fragmentation• Silos:
– Public health– Medical care– Behavioral Health– Mental health– Substance Abuse– Faith Communities – Employers– Legislators
policymakers– Payors / Funders
How’s that
workin’ for ya???
Choices Real People Make
54 yr old Depressed, Alcoholic, Diabetic Man
Agree to Accept Referral and then Don’t Go
Accept Referral to Behavioral Practice
Deal with Alcohol & Mental Health Problems in Primary Care Setting Only
Get Help X Avoid Stigma X Get Optimal Treatment X XCoordinate Medical & Behavioral Rx
X ?
• Screening for Medical Co-Morbidities
• Treatment of Co-Morbid Medical Conditions – Asthma/COPD, Blood Pressure, Diabetes, etc.
• Coordination / Care Management with Medical Specialty Providers– Infectious Disease
(HIV-AIDS, Hepatitis C, Tuberculosis)– Gastroenterology / Hepatology
(Liver Failure, Cirrhosis, Hepatitis)
• Coordination / Care Management with Mental Health Specialty Providers
Roles for Primary Care in Specialty Substance Abuse Treatment Setting
• Survey of 2878 patients in 52 treatment programs – At 12-month follow-up, patients who attended programs with on-site
primary medical care (compared with patients who attended programs with no primary medical care) experienced : • Significantly less addiction severity• No significant difference in medical severity .
• Referral to off-site primary care exerted no detectable effects on either addiction severity or medical severity.
Can Primary Care Improve SA Treatment Effectiveness?
Friedmann PD, Zhang Z, Hendrickson J, Stein MD, Gerstein DR. Effect of primary medical care on addiction and medical severity in substance abuse treatment programs. J Gen Intern Med. 2003 Jan;18(1):1-8.
• DESIGN: Randomized controlled trial conducted between April 1997 and December 1998.
• SETTING AND PATIENTS: Adult men and women (n = 592) who were admitted to a large health maintenance organization chemical dependency program in Sacramento, Calif.
• INTERVENTIONS: Patients were randomly assigned to receive treatment through an integrated model, in which primary health care was included within the addiction treatment program (n = 285), or an independent treatment-as-usual model, in which primary care and substance abuse treatment were provided separately (n = 307). Both programs were group based and lasted 8 weeks, with 10 months of aftercare available.
Primary Care Impact on SA Treatment
Weisner C, Mertens J, Parthasarathy S, Moore C, Lu Y. Integrating primary medical care with addiction treatment: a randomized controlled trial. JAMA. 2001 Oct 10;286(14):1715-23.
• RESULTS: – Both groups showed improvement on all drug
and alcohol measures.
– Overall, there were no differences in total abstinence rates between the integrated care and independent care groups (68% vs 63%, P =.18).
– Patients with SA-related medical conditions (SAMCs) were more likely to be abstinent in the integrated care group than the independent care group (69% vs 55%, P =.006; odds ratio [OR], 1.90)
– This was true for both those with medical (OR, 3.38) and psychiatric (OR, 2.10) SAMCs.
Impact on Outcomes
Four-Quadrant
Model (~2004)
Four-Quadrant Clinical
Integration Model (~2010)
--National Council, B. Mauer
Men
tal H
ealt
h / S
ubst
ance
Use
Com
plex
ity
Continuum of Integration
Separate Referral Coordinated Collaborative Integrated
Separate Co-Located Common
INTEGRATING APPROPRIATE SERVICES FOR SUBSTANCE USE CONDITIONS IN HEALTH CARE SETTINGS
An Issue Brief on Lessons Learned and Challenges Ahead
2010
http://www.niatx.net/pdf/ARC/Integrating_Appropriate-Services_TRI.pdf
Coordinated Care• Tracking & Confirmation
of Referrals & Follow-up• Sharing of Medical Records• Sharing of Prescribing
Changes & Medication Lists• Inter-Operable
Electronic Health Records• Mutual Participation in Effective
Health Information Exchange
Collaborative Care• All of the Above plus . . . • Team-Based Case Conferences• Frequent Interaction on Therapeutic Strategy• Patient-Centered, Shared Decision-Making• Shared Care Management• Joint Decision-Making on
Medication Changes• Frequent, secure communication by
phone, e-mail, & videoconferencing
Continuum of Integration
Separate Referral Coordinated Collaborative Integrated
Separate Co-Located Common
National Collaborations
• http://www.niatx.net/Content/ContentPage.aspx?PNID=4&NID=245
Baby Steps
• NIATx / NACHC Collaborative
NIATx Resource Links
http://www.niatx.net/Content/ContentPage.aspx?NID=249#skip3
Resources
Review of Evidence (& Best-Practices)
“Best-Practices” Integrating Behavioral Health & Primary Care
• Cherokee Health System
Cherokee Health Systems
• “CHS follows a generalist approach even for behavioral health issues. The PCP has to deal with everyone that walks in the door, and the BHC should be able to as well.”
Integration of Mental Health, Substance Abuse, & Primary Care; AHRQ, 2008.http://www.ahrq.gov/downloads/pub/evidence/pdf/mhsapc/mhsapc.pdf
Haight Ashbury Integrated Care
“Haight Ashbury’s vision of integrated care follows an “any door is the right door” philosophy. The integrated care clinic on Mission Street provides primary care, substance abuse treatment services, mental health services, and intensive case management (which can include referrals to other organizations for assistance with housing, food, clothing, and employment) within a unified team service delivery model.” -- AHRQ Evidence Report
Over 200 paid staff and 500 volunteers provide services at over 15 facilities to over 19,000 clients, with the vast majority served by the substance abuse programs.
Haight Ashbury• Lessons Learned:
– Patients are socially and clinically complex – HIV, homelessness, and addiction commonly co-occur. A team approach is essential.
– Weekly team meetings include front desk staff since they are the first point of contact and thereby necessarily involved in the triage process.
– Clients meet initially with a case manager and “are literally walked from office to office” by the case manager as they move through the system.
– Warm hand-offs have been instrumental in patient adherence with treatment plans.
• Obstacles to Overcome: – Each of the three services, primary care, mental health, and substance
abuse treatment, have their own traditional charting cultures and legal requirements. Combining the three into one comprehensive charting system has involved legal counsel along with cultural and process considerations of the three services.
Behavioral Expert Working in Primary Care
Personal Perspectives (cont.)
Integration Allows us to Triangulate Interventions
Patient
Systems Change
Primary CareTeam
Family &Community
Psychologists & Behavioral Health
The Power of Integration
What would happen if all the health professionals came together and created a therapeutic community of healers for whole people?
Faith Communities
Mental Health
Substance Abuse
Treatment Primary Care
Community-Level Teamwork – A Real System of Care
Inpatient Programs Primary Care
Mental Health
Substance Abuse Treatment
Behavioral Health
Community-Level Teamwork – A Therapeutic Community
Faith Communities
Family
Recovery-Oriented Systems of Care
• No one can whistle a symphony.
It takes a whole orchestra to play it.
-- H.E. Luccock
Embracing One Another, Soaring Together
“We are all as angels, with only one wing;
We can only fly when we embrace each other. -- Luciano de Crescenzo