Psychiatry in an ACOAn Example from the Frontlines
Arthur E. Kelley, MDMedical Director, Partnership for Community Care (CCNC)
Psychiatric Consultant, Cornerstone Healthcare, High Point, NC
The Context
Source: naviglinlp.blogspot.com
Primary Care: the De Facto Mental Health SystemNational Comorbidity Survey Replication
Treated in Primary Care 23%
Treated in
MH System 18%
Wang et al, Arch. Gen. Psychiatry, 63, June ,2005
Untreated59%
Co-Morbidity Percentages 2001-2003
University of Washington AIMS Center
DEPRESSION
Chronic Pain
40-60%
CANCER10-20%
NEUROLOGIC
DISORDERS10-20 %
GERIATRIC SYNDROME
S20-40 % HEART
DISEASE20-40%
DIABETES10-20 %
No Health Without Mental HealthFrom: Center for Health Care Strategies, 2010
LACK OF ACCESSHalf of the Counties in US Have No Practicing Psychiatrist or Psychologist
Source: Unutzer, Psychiatric News, November 1, 2013
Changing Healthcare Environment
Source: www.wcorha.org
PCMHThe main vehicle for the coming change.
PCSPThe medical
“neighborhood”
Impact Model for Collaborative Care of Depression in Primary Care
Source: www.uwaims.org
Core Components of Collaborative Depression Care
Two Processes Care Manager Role Consulting Psychiatrist Role
Systematic diagnosis and
outcomes tracking (facilitated by PHQ-
9)
1.Diagnostic Assessment2.Patient Education/self management support
3.Close follow-up to prevent patients from “falling through the cracks”
Caseload consultation
Diagnostic consultation on difficult cases
Stepped CareChange treatment
according to evidence based algorithm if
patient not improving
Relapse prevention once patient is
improved
Support antidepressant treatment by the PCP
Brief Counseling
Facilitate treatment change
Triage to community
Relapse prevention
Consultation is focused on patients who are not
improving as expected
Recommendations for additional
treatment/referral according to
evidence-based guidelines
Adapted from AIMS Center, Univ. of Washington
Collaborative Care Improves Outcomes
“ Comparative Effectiveness of Collaborative Care Models For Mental Health Conditions Across Primary, Specialty and Behavioral Health Settings: Systematic Review and Meta-Analysis” Am. J. Psych.,169(11), Aug 2012
Statistically Significant Effects Across All Mental Disorders For:
1. Clinical Symptoms2. Mental Quality of Life3. Physical Quality of Life4. Social Role Functioning WITH:
NO NET INCREASES IN TOTAL HEALTH CARE COSTS
Lowers Healthcare Costs for Patients with Depression
Impact Study : $841 per annum/per patient over 4 years
Diamond Study: $1300 per annum/per patient over 4 years
Unutzer, Harbin, Schoenbaum. and Druss, CMS Information Resource Center Brief,, 2013
Lowers Costs for Other Disorders
Diabetes and Depression
Panic Disorder
SPMI Patients
Katon et al, Diabetes Care. June 2008:31(6): 1155-1159Katon et al, Archives of General Psychiatry. December 2002: 59(12): 1098-1104Druss et al, American J. of Psychiatry. November 2011: 168(11): 1171-1178
Cornerstone Care Outreach ClinicOur Team
David Talbot, MD, DirectorEileen Weston, NP, Clinician Mary Keever, LCSWA, Behavior Health Care Mgr.Art Kelley, MD, Consulting Psychiatrist
Our Patients: Medicaid, Medicare, or Dually Eligible Current Enrollment: 360 (10/31/2013)
Other Clinicians
Our Experience
Importance of our tweaked EHR (Allscripts)
Screening Issues
The Registry
Triage Issues
Our Statistics: Definitions
Positive PHQ-9 : score of > 10
Response: 50% improvement in PHQ-9 score
Remission: PHQ-9 score of < 5
Usual care: 20% of treated patients achieve a response.
Source: Rush et. al., Biological Psychiatry. 2004: 56(1): 46-53
Our Results
# ACHIEVING RESPONSE 7 (21%)# ACHIEVING REMISSION 9 (27%)# ACHIEVING NEITHER 17 (51%)
PROTOCOL PATIENTS (N=33)
48% achieved response or remission
Non-Protocol Patients88 (73%) of patients with positive PHQ-9 did
not enter the depression protocolReasons:
1. Depression comorbid with another disorder too complicated for primary care
2. Already under psychiatric care3. Refused4. Lost to follow-up
Future Issues for CCOCIs response/remission in 48% good enough?
How to improve medication/psychotherapy adherence.
What are the characteristics of good community partners in terms of referral?
Can we improve our numbers in regard to patients accepting Impact Model care?
Can we improve the medical numbers?
