Eliminating Mental Health Disparities: - PowerPoint PPT Presentation

1 / 61
About This Presentation
Title:

Eliminating Mental Health Disparities:

Description:

Integration is the Solution. National Policy Summit on the ... Jump aboard the Healthcare Home bandwagon. How can you incent providers to integrate? ... – PowerPoint PPT presentation

Number of Views:90
Avg rating:3.0/5.0
Slides: 62
Provided by: jho137
Category:

less

Transcript and Presenter's Notes

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
2
Disparities 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

3
Health 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

4
Prevalence 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

5
National 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.

6
Community 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

7
Trends 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?

8
Factors 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

9
Safety 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

10
Primary 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

11
Integration 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

12
Integration 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

13
Integration 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

14
Behavioral 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)

16
La 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

17
Survey Respondents
  • Gender
  • 61 Female
  • 39 Male
  • Primary language (n435)
  • 98 Spanish
  • 3 English
  • 1 Mum (indigenous Guatemalan)

18
Survey 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

19
Where 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

20
Primary 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

21
Contributing 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.

22
Addressing 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

23
(No Transcript)
24
Cherokee 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
25
Blending 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.

26
The 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

27
The 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

28
(No Transcript)
29
Cherokee 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.
30
The 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

31
Outcomes of Cherokees Behaviorist Enriched
Healthcare Home
  • Penetration rate
  • Efficient management of utilization
  • Care coordination
  • Focus on patient responsibility and behavioral
    change
  • Improved health outcomes

32
Cherokee 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.

33
Cherokee 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.

34
Impact 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

35
Behavioral 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)

36
(No Transcript)
37
Outcomes 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

38
Forks 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)

39
Cherokees 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

40
Measuring 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

41
La 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
42
La 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

43
Who 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
44
The 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.

45
La 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

46
Current 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

47
Self 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)

48
Screening 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

49
Summary Screen Results by Question
The Avisa Group
49
50
Summary Screen Results by Category
51
Measures over time
  • Symptom Improvement
  • Decrease in emotional distress
  • Primary Care Utilization pattern
  • Chronic Disease Management

52
(No Transcript)
53
Policy 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)

54
(No Transcript)
55
Policy 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

56
Barriers 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

57
(No Transcript)
58
Impacting 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.

59
Impacting 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?

60
Contact 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

61
Contact 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
Write a Comment
User Comments (0)
About PowerShow.com