Integrating Mental Health into Advanced Primary Care – Why and

HowNeil Korsen, MD, MS

Medical DirectorMental Health Integration Program

MaineHealth

Outline

• Background – Why Integration?

• Screening for common mental health conditions

• Improving access to and communication with mental health specialists

• Building an integrated team

Why Integration?

1 in 4 people seeking primary health care services have a significant mental health condition.

Spitzer, JAMA 1999; Kessler, Arch Gen Psych 2005

>50% of people treated for depression receive all treatment in primary care.

Katon, Arch Gen Psych 1996

Only 41% with mental health conditions receive any treatment Wang, Lane, Olfsen et al; Arch Gen Psych, 2005

Management of common chronic illnesses often includes a need for changes in behaviors (e.g., diet & exercise).

People’s life problems and stresses affect their health and their health care.

Behavioral Health in PCMH

Behavioral health is integral to overall health as mind and body are inseparable.

– Patient Centered Primary Care Collaborative

Most people with poor mental health are cared for in primary care settings, despite many barriers. Efforts to provide everyone a medical home will require the inclusion of mental health care if it is to succeed in improving care and reducing costs.

– Petterson et al, American Family Physician 2008

Access

Standardized Screening & Assessment

Care Management

Support for Behavioral Change

Mental Health Treatment & Consultation

Patient Centered Medical Home mental/behavioral health components

Community Resources e.g., NAMI

Specialty Mental Health

Integrated Care – MHI Program Involvement

PCMH Pilot Sites

PCMH/MHI Collaborative Sites

MHI Collaborative Participants

MHI Mental Health Partners

Behavioral-Physical Integration

Participate in baseline assessment of current behavioral-physical health integration capacity

Take steps to make improvement(s), e.g., Implement a system to routinely conduct a standard

assessment for depression (e.g., PHQ-9) in patients with chronic illness

Incorporate a behavioral health clinician into the practice to assist with chronic condition management

Co-locate behavioral health services within the practice

  Level Attributes

Minimal Collaboration

I Separate site & systems Minimal communication

Basic Collaboration

from a distance

II Active referral linkages Some regular communication

Maximized off-site Collaboration

IIA Efficient and effective access to specialty mental health. Strong

consultative relationships. Links to community resources and providers.

Coordinated treatment.

Basic Collaboration

on site

III Shared site; separate systems Regular communication

Collaborative Care

partly integrated

IV Shared site; some shared systemsCoordinated treatment plans

Regular communication

Fully Integrated System

V Shared site, vision, systemsShared treatment plansRegular team meetings

Further modified from Doherty, McDaniel, and Baird - 1996

Levels of Integration

Screening for Common Mental Health Conditions

1. Emotional/ behavioral health needs (e.g., stress, depression, anxiety, substance abuse)

… are not assessed (in this site)

1

… are occasionally assessed; screening/assessment protocols are not standardized or are nonexistent

2 3 4

… screening/assessment is integrated into care on a pilot basis; assessment results are documented prior to treatment

5 6 7

… screening/ assessment tools are integrated into practice pathways to routinely assess MH/BH/PC needs of all patients; standardized screening/assessment protocols are used and documented.

8 9 10

Screening and Assessment

Screening and Assessment

• Addresses under-recognition of common mental health conditions

• Change ideas:– Choose

• a high risk population • one or more conditions for screening (depression,

anxiety, substance use)– Implement a process

• to routinely screen• to use screening results

Which condition(s)?

• Depression – recommended by US Preventive Services Task Force (USPSTF) to screen adults and adolescents

• Anxiety disorders - not recommended by USPSTF, but a common co-morbidity with depression

• Substance use – recommended by USPSTF for adults

Which Population(s) to Screen?

• Health maintenance visits• Chronic illnesses

– COPD– CVD– Diabetes

• Other high risk populations– Chronic pain– Children with home or school behavior problems– People who have been hospitalized

Developing a Screening Process

• Identify population to be screened

• Identify condition(s) to screen for

• Develop processes to get screening done– Assign roles to members of practice team

• Develop processes to take action for those who screen positive

PHQ-9

1. A validated tool for screening and diagnosing depression and for following response to treatment

2. Scoring parallels DSM-IV diagnosis for Major and Minor Depression

3. Can be administered in ‘interview’ style or completed by patient

PATIENT QUESTIONNAIRE (PHQ-9)

Name: Date: Over the last 2 weeks, how often have you been bothered by any of the following problems? (use “ ” to indicate your answer)

Not at all

Several days

More than half the days

Nearly every day

1. Little interest or pleasure in doing things 0 1 2 3

2. Feeling down, depressed, or hopeless 0 1 2 3

3. Trouble falling/staying asleep, sleeping too much 0 1 2 3

4. Feeling tired or having little energy 0 1 2 3

5. Poor appetite or overeating 0 1 2 3

6. Feeling bad about yourself – or that you are a failure or have let yourself or your family down

0 1 2 3

7. Trouble concentrating on things, such as reading the newspaper or watching television

0 1 2 3

8. Moving or speaking so slowly that other people could have noticed. Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual

0 1 2 3

9. Thoughts that you would be better off dead, or of hurting yourself in some way.

0 1 2 3

Add Columns: _____ + _____ + _____

(Healthcare professional: For interpretation TOTAL: of TOTAL, please refer to back of page)

_______

Not difficult at all _______

Somewhat difficult _______

Very difficult _______

If you checked off any problem on this questionnaire so far, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Extremely difficult _______

Patient Health Questionnaire (PHQ) Copyright© 1999 Pfizer Inc. All rights reserved. Reproduced with

permission. PRIME-MD ® is a trademark of Pfizer Inc.

Screening for Depression:

The first two questions of the PHQ-9 have been validated as a sensitive way to screen for depression– 96% of people with depression will say yes to one of

those two questions.– Consider an answer of ‘2’ or ‘3’ on either of those

questions a positive screen. – Administer the full PHQ-9 only to those who screen

positive

Scoring the PHQ-9

• Add columns vertically for the first 9 questions then tally across the bottom of the page

• Total score from 0 to 27• 10th question is a “Function Score” indicating to what

degree the depression symptoms have made it difficult for the patient to function in their everyday life

• The degree of functional difficulty can help you decide whether to start active treatment in people with mild symptoms.

Guideline for Using the PHQ-9 for Initial Management

Score/Symptom Level Treatment

0-4No depression

Consider other diagnoses

5-9Mild

Consider other diagnosesIf diagnosis is depression, watchful waiting is appropriate initial management

10-14Moderate

Consider watchful waitingIf active treatment is needed, medication or psychotherapy is equally effective

15-19Moderately Severe

Active treatment with medication or psychotherapy is recommendedMedication or psychotherapy is equally effective

20-27Severe

Medication treatment is recommended For many people, psychotherapy is useful as an additional treatmentPeople with severe symptoms often benefit from consultation with a psychiatrist

What is Watchful Waiting?

• It is estimated that a third of people with symptoms at this level will recover without treatment.

• Watchful waiting means you are seeing the patient about once a month and monitoring their PHQ-9 score, but not starting active treatment.

• Self-care activities such as exercise or relaxation are usually a component of watchful waiting.

• If the patient’s symptoms have not resolved after 2-3 months, active treatment ought to be considered.

How often should the PHQ be done for management of a patient with depression?

• Once a month until the patient reaches remission (score 0-4) or for the first 6 months of treatment

• Every 3 months after that while the patient is on active treatment

• Once a year for people with a history of depression who are no longer on active treatment

PHQ-9 - Change from last score, measured monthly

TreatmentResponse

Treatment Plan

Drop of 5 or more points each month

Good Antidepressant &/or PsychotherapyNo treatment change needed. Follow-up in 4 weeks.

Drop of 2-4 points each month

Fair Antidepressant: May warrant an increase in dose.

Psychotherapy: Probably no treatment change needed.

Share PHQ-9 with psychotherapist.

Drop of 1 point, no change or increase each month

Poor Antidepressant: Increase dose or augment or switch; informal or formal psychiatric consult; add psychotherapy.

Psychotherapy: 1. If depression-specific psychotherapy

discuss with supervising psychiatrist, consider adding antidepressant.

2. For patients satisfied in other psychotherapy consider adding antidepressant.

3. For patients dissatisfied in other psychotherapy, review treatment options and preferences.

Interpreting Follow Up Scores

Goals of Treatment

• Remission – score of 0-4 after an initial score of 10 or higher.

• Clinical response – score of less than 10 after an initial score of 10 or higher

Improving Access and Communication

2. Coordination of referrals and specialists

does not exist

1

is sporadic, lacking systematic follow-up, review or incorporation into the patient’s plan of care; little specialist contact with primary care team

2 3 4

occurs through teamwork & care management to recommend referrals appropriately; report on referrals sent to primary site; coordination with specialists in adjusting patients’ care plans; specialists contribute to planning for integrated care5 6 7

is accomplished by having systems in place to refer, track incomplete referrals and follow-up with patient and/or specialist to integrate referral into care plan; includes specialists’ involvement in primary care team training and quality improvement

8 9 10

Mental health referrals

Mental health referrals

• Improve communication & coordination with mental health specialists within or outside your practice

• Change ideas include:– ID mental health specialists who care for many of your

patients and meet with them– Develop templates for communication, include patient

consent– Improve tracking for patients referred for mental health

care

Building an Integrated Team

3. Patient care team for implementing integrated care

does not exist

1

exists but has little cohesiveness among team members; not central to care delivery

2 3 4

well defined, ea. member has defined roles/responsibility; good communication & cohesiveness among members; members are cross-trained, have complementary skills5 6 7

is a concept embraced, supported and rewarded by the senior leadership; “teamness” is part of the system culture; case conferences and team meetings are regularly scheduled 8 9 10

Integrated Team Function

Developing an Integrated Team

Change ideas include:• Regular team meetings• Morning huddles to anticipate and plan for patient needs that day• Use warm handoffs to onsite mental

health staff

Team Roles in Integrated Primary Care

Mental HealthSpecialist

Diagnose, Treat

Care Manager Follow up,

Family Adherence Patient Education

Primary Care Clinician Support Staff

Screen, Diagnose, Treat

PsychiatristOr APRN

Consult, Train

NAMI Community

Resources,Family Support

Patient and Family

Team Effectiveness Model

Mission

Goals

Processes/Procedures

Interpersonal Relationships

Roles

Cul

ture

– P

rim

ary

Car

e Culture – M

ental Health

Beckhard, R. Optimizing Team-Building Efforts. Contemporary Journal of Business, Summer 1972.

Mental Health Specialist in Primary Care:

How about those differences?

The Questions for Integrated Care Settings

– Who will be delivering the service? – What service will be delivered and what code will be

used? – Who are the partners doing integration?– Where will the service be delivered?– What is the “facility”? Under what license? – Who will “employ” staff?– Who will do the billing?– How will the reimbursement work? Which insurance will

be billed? What are the rules for that insurer?

Start where you are

Use what you’ve got

Do what you canArthur Ashe

Resources:Websites www.integratedprimarycare.com – National clearinghouse site for information on

integrated care out of U Mass. www.nationalcouncil.org - The unifying voice of America’s behavioral health

organizations. Includes resources for providers and a link to the National Council’s journal.

www.ibhp.org - Integrated Behavioral Health Project. Good general information on integrated care site out of California.

www.pcpcc.net - Patient Centered Primary Care Collaborative. National resource devoted to developing and advancing the patient centered medical home.

Books Blount, A. ed.(1998). Integrated Primary Care: The Future of Medical and Mental

Health Collaboration. New York: Norton Hunter, L., Goodie, J., Oordt, M., & Dobmeyer, A. (2009). Integrated Behavioral

Health in Primary Care. Washington, D.C: American Psychological Association Robinson, P. & Reiter, J. (2006) Behavioral Consultation and Primary Care: a

Guide to Integrating Services. New York: Springer Publications Butler M, Kane RI, McAlpine D, Kathol, RG, Fu SS, Hagedorn H, Wilt TJ.

Integration of Mental Health/Substance Abuse and Primary Care No. 173 (Prepared by the Minnesota Evidence-based Practice Center under Contract No. 290-02-009.) AHRQ Publication No. 09-E003. Rockville, MD. Agency for Healthcare Research and Quality. October 2008.

Contact info:

Cynthia Cartwright, MT RN MSEd, cartwc@mainehealth.org, 662-3529

Neil Korsen, MD MS, korsen@mainehealth.org, 662-6881

Mary Jean Mork, LCSW, morkm@mmc.org, 662-2490