GAU Mental Health Pilot

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GA-U Mental Health Pilot

• Integrating primary care and mental health
• Jurgen Unutzer, MD, MPH, MA
• Professor Vice Chair
• Psychiatry Behavioral Sciences
• University of Washington

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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

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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

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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

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Integrated care working effectively across
silos
Primary Care
PC
Social services?
Alcohol substance abuse care?
Community Mental Health Center
CM HC
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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

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Moving towards integrated Care

• Worst case scenario compete
• Usual situation co-exist
• Helpful but not sufficient consult (or)
  co-locate
• Ideal collaborate effectively

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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

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1,801 primary care patients with depression and
comorbid medical disorders
Example IMPACT Jürgen Unützer, MD
Funded by John A. Hartford Foundation California
Healthcare Foundation
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IMPACT Team Care Model
Effective Collaboration
Prepared, Pro-active Practice Team
Informed, Activated Patient
Practice Support
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Integrated care DOUBLES the effectiveness of
usual care for depression
50 or greater improvement in depression at 12
months
patients
Participating Organizations
Unutzer et al., JAMA 2002 Psychiatr Clin N
America 2005
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Integrated Care Benefits Ethnic Minority
Populations
50 or greater improvement in depression at 12
months
Areán et al. Medical Care, 2005
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Improved Physical Functioning
SF-12 Physical Function Component Summary Score
(PCS-12)
Plt0.01
Plt0.01
Plt0.01
P0.35
Callahan et al. JAGS. 2005 53367-373.
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Lower long-term (4 year) healthcare costs
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Other lessons from IMPACT

• 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.

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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

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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)

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GA-U Mental Health Pilot

• Community Health Plan of Washington
• GA-U Mental Health Pilot Steering Committee
• UW Department of Psychiatry

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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
OConnor Amnon Schoenfeld Anne Shields Rose
Soohoo Karen Spoelman
Doug Stevenson Tom Trompeter Jurgen
Unutzer Richard Veith Steve Vervalin Grace Wang
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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

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Co-occurring diagnoses
DSHS GA-U Clients Challenges and Opportunities
August 2006
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Most common Dx and Rx
DSHS GA-U Clients Challenges and Opportunities
August 2006
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GA-U Mental Health Pilot

• Based on experiences with managed medical care
  pilot
• - difficulty managing medical care without
  addressing mental health issues

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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

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Goal Integrated care
Level II Care
GA-U Client
PCP
CSO
Consulting Psychiatrists
Care Coordinator
DVR
Other clinic-based mental health providers
CD Treatment
Level I Care ( 1,500)
Available in some clinics
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Goals

• Integrated physical health, mental health and
  substance abuse services to GA-U clients where
  they seek care
• Goals
• - improve patient outcomes
• - reduce costs

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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

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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

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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)

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Intensive mental health services (Level 2)

• Community Mental Health services
• CMHC case manager coordinates with Level-1 Care
  Coordinator to insure continuity of care

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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)

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Integrated care
Level II Care
GA-U Client
PCP
CSO
Consulting Psychiatrists
Care Coordinator
DVR
Other clinic-based mental health providers
CD Treatment
Level I Care ( 1,500)
Available in some clinics
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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

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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

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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

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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