Rodger Kessler Ph.D. ABPPDirector, Primary Care Behavioral HealthFletcher Allen Health Care Assistant Professor, University of Vermont College of MedicineDirector, Collaborative Care Research Network, NRN/AAFPFellow, Jeffords Center for Health Care Policy

Mental Health, Substance Use and Health Behavior Services in the Patient Centered Medical Home: A National Survey

PCPCC Behavioral Health Working Group, December 2011

Additional authors

• Wilson Pace M.D., Debbi Graham M.P.H.

National Research Network• Benjamin Miller Psy.D.

Collaborative Care Research Network• Sarah Scholle Ph.D.,Manasi Tiradkar Ph.D. NCQA• Benjamin Littenberg M.D., Amanda Kennedy

Pharm.D.,Charles Maclean M.D. University of Vermont

Background

• Primary care practices are increasingly integrating mental health, substance abuse, and health behavior services.

• The American Academy of Family Practice recently adopted principles for integrating behavioral health care into the patient-centered medical home (PCMH).

• We currently know very little about how PCMHs integrate behavioral health care.

Research Questions

• Do Patient Centered Medical Homes have organizational and clinical systems to provide behavioral and health behavior care?

• How does this compare to practice systems for other health care and health care providers?

• What are the key identified barriers?

• Is level of NCQA certification associated with organizational or clinical systems?

Method

• NCQA and CCRN developed a 20 item survey of clinical leaders concerning organizational and clinical activities related to Behavioral Health in PCMH.

• Sampling frame: All 447 NCQA certified practices as of March 2010 were identified. One practice per multi site organization was selected leaving a sample of 238 surveyed.

• The survey was administered via email then mail with phone follow-up.

• Approved by AAFP IRB

Sample

• N= 123 (52%)*• PCMH level

• 1 =37%• 2 =07%• 3 =56%LocationEast =67%Midwest =20%South =06%West =06%

*No significant differencesbetween responders and non responders

• <5 providers =55%• Multi site =17%• FQHC =06%

• Practice Specialty Category• IM =22%• FM =41%• Peds =06%• Adult Peds =14%• FP & Peds =12%• Other =05%

Results - PCMH Support Systems for MH, SA & Health Behavior • Clinician part of practice

Psychiatry 16%Psychology 22%Social Work 25%

SA 09%Care Manager 62%

• Scheduling same as other providers 36%

• Same day appointments 28%

• Evidence Based protocols for Mental Health, Substance Abuse

20%

• EB protocols for Health Behavior rated as working well

Headaches 11%Insomnia 13% Obesity 23%Smoking 37%

• MH,SA, HB results inEHR rated as working well

35%

Results - How Processes Compare with Other Specialties

Standard process for referrals that works well• Cardiology 73%• Endocrinology 69%• MH SA 50%Standard process to track referrals that works well• Cardiology 50%• Endocrinology 45%• MH SA 33%Standard process to share information that works well• Cardiology 72%• Endocrinology 71%• MH SA 56%

Results - How Processes Compare with Other Specialties

Standard process for receiving consultation reports that works well• Cardiology 71%• Endocrinology 60%• MH SA 34%

Standard process to schedule appointments that works well• Cardiology 69%• Endocrinology 66%• MH SA 40%

Results - Identified Barriers

• 92% Lack of Time

• 91% Reimbursement Issues

• 74% Lacked Expertise

Results - Does NCQA certification level Affect Behavioral Health Clinical and Organizational Improvements?

MH organizational index Mean=12.3

Level 3=12.4 Level 1/2 =12.2 p= .086

MH clinical index Mean=07.6

Level 3=08.2 Level 1/2 =06.7 p= .11

DiscussionKey findings and observations having nothing to do

with data (in Vermont, opinions carry more weight than data)

• There is no level playing field

• There has not been structural carrot to attend to behavior

• Behavioral health and medicine are still separate

• Barriers, barriers, barriers

• Behavioral issues in primary care recent phenomena

Bothersome Key Findings That Need To Be Addressed In Addition To The Other Findings That Need To Be Addressed

• Within the field(s) we have silos

• Behavioral Health and Health Behavior are functionally two different universes

• Substance Abuse and Mental Health are two different planets

• Silos

Mental Health Substance

Abuse

Health Behavior

• Within the field(s) we have silos• Behavioral Health and Health Behavior are functionally two different universes

• Substance Abuse and Mental Health are two different planets

• Silos• Survey findings suggest these divisions exist in primary care behavioral health

• Right now NIH is equally stuck

Bothersome Key Findings That Need To Be Addressed In Addition To The Other Findings That Need To Be Addressed

Limitations and Future DirectionsLimitations

• Sample constraints• Survey instrument• Variation in who filled out survey• PCMHs are not necessarily representative

Future Directions

•NCQA engagement survey•Further Analysis•Robust Resurvey

Thank You

PCPCC for Funding Support

We approve of this presentationAnd don’t forget to drink milk!...