Title: Eliminating Mental Health Disparities:
1 Eliminating Mental Health Disparities Behavioral
Health and Primary Care Integration is the
Solution National Policy Summit on the
Elimination of Mental Health Disparities in
Mental Health Care Center for Mental Health
Services SAMHSA New Orleans June 9, 2009
2Disparities in Mental Health Care Minority
Populations, the Uninsured and Residents of Rural
Areas
- Culturally relevant and appropriate services
- Insurance coverage
- Quality of care
- Access
- Distribution of Mental Health professionals
3Health Disparity Increased Morbidity and
Mortality Associated with Serious Mental Illness
- Increased Morbidity and Mortality Largely Due to
Preventable Medical Conditions - Metabolic Disorders, Cardiovascular Disease,
Diabetes Mellitus - High Prevalence of Modifiable Risk Factors
(Obesity, Smoking) - Epidemic within an Epidemic (e.g., Diabetes,
Obesity) - Some Psychiatric Medications Contribute to Risk
- Established Monitoring and Treatment Guidelines
to Lower Risk are Underutilized in SMI Populations
4Prevalence and Cost of Co-Occurring Disorders
- Co morbidities in Georgias Disabled Medicaid
Population - - 67 with diabetes had 3 or more co-occurring
disorders including one-third with either a
psychiatric or substance use diagnosis. - - 73 with a substance abuse diagnosis had 3 or
more co- occurring disorders - -George Rust, MD
- National Center for Primary Care
- Morehouse School of Medicine
- Healthcare expenditures for Medicare enrollees
with a mental - disorder are 22 higher than for other
Medicare enrollees - excluding all expenditures for mental
healthcare. - - Windsor Health Plan
- A California Study found it cost more to treat
chronic medical - condition in folks with SMI, excluding all
costs for treating the - psychiatric disorder.
- - Cheryl Cushin, Ph.D.
- CalMEND Project
-
5National Comorbidity Survey ReplicationGeneral
Conclusions
- About half of US Population will meet criteria
for a DSM-IV diagnosis in their lifetime
slightly over a quarter of the population in a
years time. - Half of all mental disorders begin by age 14 and
three-fourths by age 24. - Most people with mental disorders are untreated.
For those in treatment, more than half receive
less than adequate care. - Over half of those who receive treatment for
their disorders do so from a general medical
provider.
6Community Mental Health Centers What were they?
What are they? What happened?
- Historical roots Action for Mental Health
(1961), Community Mental Health Center Act
(1963), 1960s social activism - Community Mental Health Centers -- the initial
model - Federal block grants gave the States authority
over the program - Psychosocial rehabilitation and priority
populations - Managed care and behavioral health carve-outs
- Advocacy/consumer groups, peer support and
recovery models
7Trends in Locus of Mental Health Services for
Underserved Populations
- Restricted scope of CMHCs has led to diminished
access - Four-fold increase in patients treated for mental
health/substance abuse at FQHCs between
1998-2003
- Druss, Am J of Pub Health,
2006. - FQHCs had 1.4 million visits for depression in
2004, third most common presentation after
diabetes and hypertension - Are FQHCs becoming the nations community mental
health system?
8Factors Compelling Integration for Safety Net
Providers
- MH/SU services system cant accommodate demand,
let alone need - Diminished scope of CMHCs
- More seek help for mental health problems in
primary care - Failure of referral
- Stigma endures
- Medical co-morbidities and premature mortality of
the SMI
9Safety Net Paradigm Shift
- Traditional Mental Health safety net (CMHCs)
- shifted course
- Health status of the seriously mentally ill a
- new health disparity (NASMHPD, 2006)
- Expanded mental health service capacity of
- FQHCs
- Recognition of the behavioral health nature of
- primary care
10Primary and Behavioral Health Care
IntegrationStrategies in Search of a Model
- Preferential Referral Relationship
- Formalized Screening Procedures
- Circuit Riding
- Co-Location of Services
- Disease Management
- Behaviorist on Primary Care Team
- Corporate Mergers
11Integration vs. Co-location Primary Goals
- Integrated
- Behavioral Health
- Supports primary care provider (PCP) decision
making - Builds on PCP interventions
- Educates patient in self management skills
through exposure - Monitors at-risk patients with PCP
- Specialty MH Treatment
- Co-location
- Therapy is the primary treatment to resolve
condition - Therapist may coordinate with PCP
- Teaches patient core self management skills
- Manages more serious mental disorders over time
as primary provider
12Integration vs. Co-location Intervention
Structure
- Integrated
- Behavioral Health
- Informal, revolves around PCP assessment and
goals - Less intensity, between session interval is
longer - Relationship generally not primary focus
- Visits timed around PCP visits
- Long term follow rare, reserved for high-risk
cases
- Specialty MH Treatment Co-location
- Formal, requires intake assessment and treatment
planning - Higher intensity, involving more concentrated
care - Relationship built to last over time
- Visit structure not related to medical visits
- Long term follow-up encouraged for most patients
13Integration vs. Co-location Information
Sharing/Documenting
- Integrated
- Behavioral Health
- Consultation report to PCP
- Part of medical record
- Notes filed in medical chart with physical health
notes
- Specialty MH
- Co-location
- Specialty treatment notes (i.e. intake or
progress notes - Part of a separate mental health record with
minimal notation to medical record
14Behavioral Health and Primary Care Integration as
a Disparity Reduction Strategy
- Access and Attitudinal Issues
- Disparities in mental health for Latinos
- (an example)
15- Latinos have the lowest rate of health insurance
coverage than any other ethnic group, greatly
limiting access to primary and behavioral health
care services (Vega and Lopez, 2001) - The longer Mexican immigrants stay in the U.S.,
the greater their chances of developing a
disorder (Vega et al., 1998) - More Latinos (particularly women) express
distress through somatic symptoms than whites
(Escobar et al., 1987, 2000) - Most commonly reported barriers to receipt of
mental health services are lack of health
insurance, lack of knowledge of where to seek
treatment, lack of proximity to treatment
centers, transportation problems and lack of
availability of Spanish speaking providers
(Aguilar-Gaxiola et al., 2002)
16La Clínica - Survey of 435 individuals
- Seniors 40
- Community Health Volunteers 32
- People who were denied specialty MH svcs 80
- General public 208
- Day laborers 75
17Survey Respondents
- Gender
- 61 Female
- 39 Male
- Primary language (n435)
- 98 Spanish
- 3 English
- 1 Mum (indigenous Guatemalan)
18Survey Question about MH
- Many people have experienced conditions of
nerves, anger, fear, depression, and/or sadness.
Have you or any person near to you had, any of
these conditions that affected your/their health
or emotional/mental well-being? - 77 yes
- 23 no
19Where do Latinos seek help?
- If you looked for help, where did you go?
(n242) - 42 doctor
- 27 agency/program
- 19 family
- 18 church
- 14 psychologist
- 13 close friend
- 3 healer
- 1 school
- 1 returned to country of origin
20Primary Care in the United StatesThe de facto
Behavioral Health System
- A variety of studies have concluded that 70 of
all health care visits have primarily a
psychosocial basis (Fries et al., 1993 Shapiro
et al., 1985) - General physicians prescribe 70 of all
psychotropic medications, including 80 of the
anti-depressants (Strosahl, 2001) - Studies have shown that
- Highest utilizers of healthcare commonly have
untreated/unresolved behavioral health needs
21Contributing factors to MH Disparities for Latinos
- General lack of MH health services in the
community, particularly for those without private
insurance - Existing publicly funded MH services primarily
limited to persons with severe mental illness - Lack of access to behavioral health providers for
consultation and immediate assistance - Even for those patients who are eligible for MH
services often do not receive them due to stigma,
location, cultural and linguistic barriers, etc.
22Addressing the Barrier of Stigma
- Integrating behavioral health into the primary
care setting serves the client where he/she is
already seeking care, provides a seamless
service. - Promotes emotional wellness in a non-stigmatizing
way treating the mind and body together
rather than treating these two aspects of a
person separately.building the neck - Is NOT a specialty service but rather a routine
component of medical care utilizes warm
handoff or personal introduction
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24Cherokee Health Systems A Federally Qualified
Health Center and Community Mental Health Center
Corporate Profile Founded 1960 Services Primar
y Care - Community Mental Health - Dental -
Corporate Health Strategies Locations 22
clinical locations in 15 Tennessee
Counties Behavioral health outreach at numerous
other sites including primary care clinics,
schools and Head Start Centers Number of
Clients 54,009 unduplicated individuals served
- 21,326 Medicaid (TennCare) New Patients
19,210 Patient Services 419,537
Number of Employees 588 Provider Staff
Psychologists - 39 Masters
level Clinicians - 67 Case Managers - 32
Primary Care Physicians - 30
Psychiatrists - 12 Pharmacists - 8
NP/PA (Primary Care) - 16 NP
(Psych) - 6 Dentists - 2
25Blending Behavioral Health into Primary
CareCherokee Health Systems Clinical Model
- Behaviorists on the Primary Team
- The Behavioral Health Consultant (BHC) is an
embedded, full-time member of the primary care
team. The BHC is a licensed Health Service
Provider in Psychology. Psychiatric consultation
is available to PCPs and BHCs - Service Description
- The BHC provides brief, targeted, real-time
assessments/interventions to address the
psychosocial aspects of primary care. - Typical Service Scenario
- The Primary Care Provider (PCP) determines that
psychosocial factors underlie the patients
presenting complaints or are adversely impacting
the response to treatment. During the visit the
PCP hands off the patient to the BHC for
assessment or intervention.
26The Behavioral Health Consultant (BHC) in Primary
Care
- Management of psychosocial aspects of chronic and
acute diseases - Application of behavioral principles to address
lifestyle and health risk issues - Emphasis on prevention and self-help approaches
- Build resiliency and encourage personal
responsibility for health - Consultation and co-management in the treatment
of mental disorders and psychosocial issues
27The Behavioral Health Consultant (BHC) in Primary
Care
- Psychological problems, such as anxiety and
depression - Substance use disorders and risk reduction
- Psychological components of physical illness,
both acute and chronic - Factors impacting health status stress,
nonadherence, health behavior, social support
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29Cherokee Health Systems Job Description Job
Title Behavioral Health Consultant Education/Li
cense Licensed Clinical Social Worker
(Masters) or a Licensed Clinical Psychologist
(Doctoral) Position Requirements Excellent
working knowledge of behavioral medicine and
evidence-based treatments for medical and mental
health conditions. Ability to work through
brief patient contacts as well as to make quick
and accurate clinical assessments of mental and
behavioral conditions. Should be comfortable with
the pace of primary care, working with an
interdisciplinary team, and have strong
communication skills. Good knowledge of
psycho-pharmacology Ability to design and
implement clinical pathways and protocols for
treatment of selected chronic conditions.
30The Integrated Care Psychiatrist
- Access and Population-Based Care
- Enhance the Skills of Primary Care Colleagues
- Treatment Team Meetings
- Telepsychiatry
- Stabilize Patients and Return to Primary Care
- Co-Management of Care
31Outcomes of Cherokees Behaviorist Enriched
Healthcare Home
- Penetration rate
- Efficient management of utilization
- Care coordination
- Focus on patient responsibility and behavioral
change - Improved health outcomes
32Cherokee Health SystemsPenetration into the
General and Medicaid Populations
- 3 year penetration into the general population
ranged from 4 in an urban county where there is
substantial competition up to 34 in one rural
county. - 3 year TennCare (Medicaid) penetration ranged
from 13 in two urban counties up to 48 in our
two most rural counties.
33Cherokee Health SystemsPenetration into the
African-American and Hispanic Populations
- Penetration rate into these minority populations
exceeds penetration into the general population. - African-American patients are twice as likely to
receive a mental health intervention if seen in
primary care. - Hispanic patients are four times more likely to
receive a mental health service if they are a
primary care patient. - Refugee populations rarely seek out mental health
services.
34Impact of BHC on Subsequent CHS Service
Utilization
- 28 decrease in medical utilization for Medicaid
patients - 20 decrease in medical utilization for
commercially-insured patients - 27 decrease in psychiatry visits
- 34 decrease in psychotherapy sessions
- 48 decrease in mobile crisis team encounters
35Behavioral Interventions Enhance Primary Care
Outcomes
- CHS Rate Tenn MCD Rate-2008
Natl MCD Rate-2007 - Control of Diabetes 54
34
30 - (Hgbalc lt7)
- Control of BP 67
52
53 - (Goal lt140/90)
- Depression 100
unknown unknown - Substance Screening
- (Initial visit)
- Postpartum 76
unknown unknown - Depression Screening
- (Edinburgh)
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37Outcomes Blue Cross Blue Shield Comparison of
CHS Service Utilization Data with Other Regional
Providers
- Higher primary care utilization
- Lower specialist utilization
- Lower ER utilization
- Lower hospital admissions
- Lower overall costs per enrollee
38Forks in the Road
- Committing to provide primary care
- Choosing the primary care culture
- Providing open access, every patient our priority
- Retaining a biopsychosocial care model
- Sticking with population-based care
- Becoming a Federally Qualified Health Center
(FQHC)
39Cherokees Blended Behavioral Health and Primary
Care Clinical Model A Behaviorally Enhanced
Health Care Home
- Embedded Behaviorist on Primary Care Team
- Real time behavioral and psychiatric consultation
to PCP - Focused behavioral intervention in primary care
- Behavioral medicine scope of practice
- Encourage patient responsibility for healthful
living - A behaviorally enhanced Healthcare Home
40Measuring the Impact of the Behavioral Health
Consultant in Primary Care
- Increases the efficiency of primary care
- Provides alternatives to psychoactive
pharmaceuticals - Improves patient adherence
- Decreases referrals to specialty mental health
care - Increases provider and patient satisfaction
41La Clínica de La Raza, Inc A Federally Qualified
Health Center
Organizational Profile Founded
1971 Services Primary Care - Community Mental
Health - Dental - Optical - Health Ed
Preventive Medicine Locations 27 locations in 3
Northern California Counties 4 Primary Care sites
with Integrated Behavioral Health
Programs Number of Clients in 2008 54,000
unduplicated individuals served - 262,000 visits
Number of Employees 750
42La Clínica de La Raza, Inc.
- Founded in 1971
- Federally Qualified
- Health Center (FQHC)
- Non-profit, 501(c) (3)
- Governed by an 18-member Consumer-Majority Board
of Directors - Operating Budget of 63 million
- 27 sites in three counties in CA
- 750 employees
- Largest community health center in the San
Francisco Bay Area
43Who does La Clínica serve?
73 Latino 8 African American 7 Asian/Pacific
Islander 4 White 76 are non-English
Speaking 49 Uninsured 55 Public Health
Insurance 6 Private Insurance
44The Landscape.
- General lack of MH health services in the
community, particularly for those without private
insurance - Existing publicly funded MH services primarily
limited to persons with severe mental illness - Lack of access to behavioral health providers for
consultation and immediate assistance - Even for those patients who are eligible for MH
services often do not receive them due to stigma,
location, cultural and linguistic barriers, etc.
45La Clinicas Response Behavioral Health
Integration Project BHIP
- Lack of access to behavioral health services for
the vast majority of La Clínicas patient
population - Provider experience that behavioral health issues
are commonly presented during primary care visits
(mirrors the research) - La Clínica's overall commitment to adopt best
practices and utilize culturally based treatment
approaches
46Current Status Primary Care Behavioral Health
Integration
- 4 Primary Care Clinics have behavioral health
integration programs (to date) - Behavioral Health Consultant nested in the exam
area - Psychiatry Consultation (Phone)
- Annual Screening
47Self Administered BH Screening
- Adult Screening 13 Questions
- Rating Options Never, Sometimes, A Lot, Always
or Y/N - Depression (2Qs)
- Anxiety/Nervios (1Q)
- Trauma (3Qs)
- Pain (1Q)
- Sleep (1Q)
- Drugs (2Qs)
- Alcohol (2Qs)
- Domestic Violence (2Qs)
48Screening Results
- 68.3 of patients who completed a BHIP Screen
responded Yes, A Lot or Always to one or
more of the thirteen questions - Sleep troubles and Pain were the BHIP Screen
items that were most likely to elicit a positive
response 26.5 of respondents answered A Lot
or Always to each of these questions
49Summary Screen Results by Question
The Avisa Group
49
50Summary Screen Results by Category
51Measures over time
- Symptom Improvement
- Decrease in emotional distress
- Primary Care Utilization pattern
- Chronic Disease Management
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53Policy Barriers to Behavioral Health and Primary
Care Integration
- Service Codes/Allowable Costs (FQHCs)
- No billing codes approved for psychiatric
consultation or care management - No billing codes approved for BH Screening
- Group visits are not eligible for reimbursement
- Most states prohibit FQHCs from billing for same
day visits (more than one visit per day)
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55Policy Barriers to Behavioral Health Primary
Care Integration
- Service/Provider Type
- Licensed Clinical Psychologist (PhD) or Licensed
Clinical Social Worker (LCSW) - MFT/MFCC/LPC (in most states) do not qualify as
allowable providers - MSWs, PhDs, etc cannot bill until they are
independently licensed. Supervisory signature
verifying oversight of service does not qualify
service to be reimbursable
56Barriers to Behavioral Health and Primary Care
Integration
- Workforce Issue/ Provider Type
- Limited number of PhDs and LCSWs trained to
provide behavioral health services within an
integrated model - Even fewer bilingual PhDs and LCSWs
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58Impacting Mental Health Disparities Policy
Considerations Strategies
- Jump aboard the Healthcare Home bandwagon.
- How can you incent providers to integrate?
- Encounter-based reimbursement is a barrier to
consultation-based integrated care. - Behavioral health carve-outs increase
disparities carve-ins dont assure integration.
59Impacting Mental Health Disparities Policy
Considerations Strategies
- Enhance the diagnostic and behavioral health
intervention skills of PCPs. - Prepare behavioral health providers to work in
primary care. - Is reverse integration (primary care into mental
health settings) viable? - Whither CMHCs?
60Contact Information
- Dennis S. Freeman, Ph.D.
- Chief Executive Officer
- Cherokee Health Systems
- 2018 Western Avenue
- Knoxville, Tennessee 37921
- Phone (865) 934-6734
- Fax (865) 934-6780
- dennis.freeman_at_cherokeehealth.com
- Leslie Preston, LCSW
- Behavioral Health Director
- La Clinica de La Raza
- 1515 Fruitvale Avenue
- Oakland, California 94601
- Phone (510) 535-6200
- Fax (510) 535-4167
- Lpreston_at_laclinica.org
61Contact Information
- Dennis S. Freeman, Ph.D.
- Chief Executive Officer
- Cherokee Health Systems
- 2018 Western Avenue
- Knoxville, Tennessee 37921
- Phone (865) 934-6734
- Fax (865) 934-6780
- dennis.freeman_at_cherokeehealth.com
- Leslie Preston, LCSW
- Behavioral Health Director
- La Clinica de La Raza
- 1515 Fruitvale Avenue
- Oakland, California 94601
- Phone (510) 535-6200
- Fax (510) 535-4167
- Lpreston_at_laclinica.org