San Diego Long Term Care Integration Project (LTCIP)

Mental Health & Substance Abuse Workgroup

September 23, 2003

Community Planning Process

Grass-roots effort to improve system of care for long term care consumers and providers

From 50 to 550+ key stakeholders over past 4 years: 10,000+ hours

Agreement to use existing providers, assure fair compensation

Planning within state LTCIP authorization, AB 1040 (form follows funding)

San Diego County Board of Supervisors&

State Office of Long Term Care

Rodger G. Lum, Ph.D, DirectorCounty of San Diego, Health & Human Services

Agency, (HHSA)

Advisory Group:Goal: Make final decisions and

recommendations for inclusion in the plan.

Planning Committee:Goal: Guide the LTCIP planning process.

Suspended Workgroups pending service delivery

model decision

Suspended Workgroups pending service delivery

model decisionHealth Plan Workgroup

Health Plan Workgroup Finance/Data

Workgroup

Finance/DataWorkgroup Options Workgroup

Options Workgroup

Internet• Facilitates

communication• Provides broad public

education

Pamela B. Smith, Project DirectorEvalyn Greb, Project ManagerAging & Independence Services

Lead County Agency

Mental HealthWorkgroup

Mental HealthWorkgroup

Explore use of the Healthy SanDiego model for potentialService delivery system for LTCIP.

Determine the financialfeasibility of the proposedLTCIP for San Diego County.

Make recommendation to Planning Committee re: inclusion of mentalhealth and substance abuse services in LTCIP.

Incremental LTCI Strategies:1) Network of Care2) Physician Strategy3) Health Plan Pilots

Governance-Case Management-Info/Technology-Quality Assurance-Scope of Services-Workforce Issues-Community Network Development

Developmental DisabilitiesWorkgroup

Developmental DisabilitiesWorkgroup

Make recommendation to PC re: inclusion of persons with developmental disabilities in LTCIP.

Long Term Care Integration Project

Organizational Chart & Decision Tree

8/2003

Legislative Authority

AB 1040 in 1995 (revised in 1998) State Office of LTC:

– provides planning $$– provides “Center” resources– provides liaison with other state programs– approves local activity toward LTCI– will assist in procuring federal waivers

San Diego LTCIP Stakeholder Vision for Elderly & Disabled Develop “system” that:

– provides continuum of all health, social and support services that “wrap around consumer” w/prevention & early intervention focus

– pools associated (categorical) funding– is consumer driven and responsive– expands access to/options for care

Stakeholder Vision (continued)

– Fairly compensates all providers w/rate structure developed locally

– Engages MD as pivotal team member– Decreases fragmentation/duplication

w/single point of entry, single plan of care– Improves quality & is budget neutral– Implements Olmstead Decision locally– Maximizes federal and state funding

Why change?

Impact of demographics Cost containment vs. care management Consumer/outcomes not current focus Incentives for optimum care not aligned Health & support service fragmentation

Client Referral Patterns

From Vision to Service Delivery Model…

CUSTOMER ACCESS w ith LTCIP

Customer At Home/Community

Care Manager w/ Network of Care

IncomeAsst.

SeniorCntr.

In-homecare

HICAP

MedicalClinic/Health

Care

BloodPressure

Cks

ShoppingAsst. Mental

Health

Transp.

Escort

housingRehab

Intake Worker InformationProvided

From Vision to Service Delivery Model… Explore Healthy San Diego due to:

– Access, education, prevention– Advocacy– Cost-effectiveness– Population-based– Existing infrastructure– Stakeholder-designed, BUT

HSD Currently Does NOT…

Tailor the program for chronic care or aged and disabled persons

Provide “wraparound” services Provide chronic care management on a

population basis Receive adequate reimbursement for

chronic care Have much info on “duals”

Where are we now?

BOS: “come back with 3 options” Dr. Mark Meiners strategies/looking for

“consortium of funding”:– Network of Care– Physician Strategy – HSD Health Plan/Pilot Projects

Administrative Action Plan for FY 2003-04 State Development Grant

Establishment of Mental Health Workgroup

Why should mental health stakeholders get involved?

To influence planning and decisions To impact delivery of acute & LTC

needs of individuals (support+services) To recommend to include mental health

and substance abuse service integrated with primary, acute, and social support

Mental Health Today Current Medi-Cal carve-out (UBH) Limited Medicare reimbursement LTCIP stakeholders want no carve-outs Mental health problems under-diagnosed &

under-treated Quality of life and cost impact of untreated

mental illness/substance abuse is huge Most state integration projects do not enroll

disabled w/primary MH diagnosis Seniors do not self-identify as having MH

need; don’t use MH Centers

Mental Health and LTCIP

Establishment of Mental Health Workgroup to:– hear from broad array of stakeholders (132 invited!)– focus on consumer as “whole” in system– develop plan specific to San Diego and LTCIP

How do we “mainstream” mental health services for aged and disabled?– parity w/physical health for treatment– age-, disease-specific treatment– delivered as “part of the whole”– viewed within greater context of health

LTCIP Mental Health Workgroup Goal Process… Make recommendation to Planning

Committee on inclusion of mental health programs, populations, and services

Importance of consensus on a recommendation

Forward to Planning Committee by February 2004

Why do we even talk about Integrating primary medical care

and mental health care?

Margaret E. McCahill, M.D.

Clinical Professor, UCSD School of Medicine

Director of Clinical Services, St. Vincent de Paul Village

Diplomate, American Board of Family Practice

Diplomate, American Board of Psychiatry and Neurology

How do we think about diagnoses?

Axis-I: what major mental illness does the patient have?

Axis-II: what kind of patient has the illness? (P.D.’s, developmental disorders, etc.)

Axis-III: what general medical conditions does the patient have?

Axis-IV and Axis-V: interesting, and have some prognostic value, but not generally used by primary care practitioners

It takes awareness of the proper treatment of all THREE axes to treat the patient effectively The personality-disordered patient will act

out more if the major depression is not treated

The diabetic will be out of control if the personality disorder or psychosis is not managed

The psychosis will be worse if the asthma, diabetes, pneumonia, etc., is not treated

Multidisciplinary teams Bring a wealth of comprehensive

skills and service to the patient are essential in many settings to be

sure that the patient is receiving the correct treatment that he/she needs

However…they need to be well coordinated, and someone needs to be aware of the big picture…the overall view of the patient’s health care needs--all 3 axes.

Integration is not new:From the AAFP, 11/94:

“White Paper on the Provision of Mental Health Care Services by Family Physicians” AAFP Reprint no. 714

“After replacing its managed care firm (i.e., a “carve-out” model) with a collaborative mental health care model, a large health care delivery system reduced by 33% its overall medical and mental health costs, while retaining high consumer and provider satisfaction.”

Expertise in psychiatric diagnosis Most primary care physicians can

recognize most mood disorders, anxiety disorders, psychoses

personality disorders and substance use disorders can be more difficult to recognize at first

but remember...

Even for the “experts:” Psychiatric diagnosis is always a work in progress

For example, major depression is only major depression until the first episode of mania, and now its bipolar disorder

“Schizophrenia” may be an initial impression until the UDS comes back positive for amphetamines…

The challenge: how to treat the patient when the diagnosis might change…

Is this our field of expertise? Who treats patients for depression? (Rx only)

general and family physicians ? %

internists ? % other specialists ? %

psychiatrists ? %

Is this our field of expertise?

Who treats patients for depression? (Rx only)

general and family physicians 56%

internists 11% other specialists 10%

psychiatrists 23%

Kroenke and Price. Kroenke and Price. Arch Intern MedArch Intern Med. 1993;153:2474.. 1993;153:2474.

0 20 40 60 80 100

Insomnia

Fatigue

Constipation

Fainting

Headache

Palpitations

0 20 40 60 80 100

Insomnia

Fatigue

Constipation

Fainting

Headache

Palpitations

Physical Symptoms often attributed to Psychiatric illness

Kroenke et al. Kroenke et al. Arch Fam MedArch Fam Med. 1994;3:774.. 1994;3:774.

0 10 20 30 40 50 60 70

Fainting

Insomnia

Chest Pain

Abdominal Pain

Headache

Fatigue

Mood Disorder Anxiety Disorder

0 10 20 30 40 50 60 70

Fainting

Insomnia

Chest Pain

Abdominal Pain

Headache

Fatigue

Mood Disorder Anxiety Disorder

Somatic Symptoms In Mood And Anxiety Disorders

0

20

40

60

80

100

0 to 1 2 to 3 4 to 5 6 to 8 >9

Anxiety Disorder Mood Disorder Any Phychiatric Disorder

0

20

40

60

80

100

0 to 1 2 to 3 4 to 5 6 to 8 >9

Anxiety Disorder Mood Disorder Any Phychiatric Disorder

%%

Kroenke et al. Kroenke et al. Arch Fam MedArch Fam Med. 1994;3:774.. 1994;3:774.

Physical Symptoms (#)Physical Symptoms (#)

Physical Symptoms & Risk of Psychiatric Disorder

0

10

20

30

40

50

60

Any Anxiety Depression Somatoform Multiple

0

10

20

30

40

50

60

Any Anxiety Depression Somatoform Multiple

Prev.Prev.(%)(%)

**PP<.05<.05O’Malley et al. O’Malley et al. Arch Intern MedArch Intern Med. 1998;158:2357.. 1998;158:2357.

Psychiatric DisorderPsychiatric Disorder

**

**

ConnectiveConnective Articular orArticular orPeriarticularPeriarticular

Nonarticular orNonarticular orOtherOther

Psychiatric Disorders In Rheumatology Referrals

Cumulative Mortality For Depressed And Non-depressed Patients Following Heart Attack

Frasure-Smith et al. Frasure-Smith et al. JAMAJAMA. 1993;270:1819.. 1993;270:1819.

0

5

10

15

20

25

30

0 1 2 3 4 5 6

Months After Heart Attack

Mortality(%)

Depressed (N = 35)

Nondepressed (N = 187)

0

5

10

15

20

25

30

0 1 2 3 4 5 6

Months After Heart Attack

Mortality(%)

Depressed (N = 35)

Nondepressed (N = 187)

Prevalence Of Depression In Patients With Cancer

McDaniel et al. Arch Gen Psychiatry. 1995;52:89.

Cancer SiteCancer Site

PancreasPancreas

OropharynxOropharynx

BreastBreast

ColonColon

GynecologicalGynecological

Reported RatesReported Rates

50%50%

22% - 40%22% - 40%

10% - 32%10% - 32%

13% - 25%13% - 25%

23%23%

Anticancer Drugs Associated With Depression

Massie et al. J Pain Symptom Manage. 1994;9:325.

Corticosteroids

Interferon

Asparaginase

Cyproterone

Vinblastine

Vincristine

Procarbazine

Tamoxifen

HIV Disease

Initial presentation of illness may be psychiatric symptoms

Untreated mental disorders worsen the primary illness

The medications used in treatment of HIV disease may exacerbate/cause mental illness

A presentation unto itself

Katon et al. Katon et al. Gen Hosp PsychiatryGen Hosp Psychiatry. 1990;12:355.. 1990;12:355.

PatientsPatients(%)(%)

0

25

50

75

100

MajorDepression

PanicDisorder

GeneralizedAnxiety

Disorder

SomatizationDisorder

AlcoholAbuse/

Dependence

0

25

50

75

100

MajorDepression

PanicDisorder

GeneralizedAnxiety

Disorder

SomatizationDisorder

AlcoholAbuse/

Dependence

Psychiatric Disorders &High Medical Utilizers (n=119)

Special problems:

Drug interactions abuse potential of medications compliance issues diversion of medications follow-up issues interaction between mental illness

and general medical conditions—both current and those that develop with time…..others…

Next Steps Sign-up to be considered for smaller

stakeholder work committee 15 stakeholders will be selected by

LTCIP staff and Dr. McCahill Formal invitation to participate in

working committee by October 10 First meeting: Oct. 21, 2003 from 2:30-

4:00 at Aging & Independence Services

November 2003 Mental Health Workgroup Meeting Staff and committee work to-date presented Option discussion by full group Ideas for further option development Refer back to staff and committee Consensus development at January MH

Workgroup meeting Forward recommendation to LTCIP Planning

Committee

How can you influence planning?

Get on LTCIP mailing list for updates

Participate in Planning Committee and Mental Health Workgroup meetings

Log onto website for background & info: www.sdcounty.ca.gov/cnty/cntydepts/health/ais/ltc/

Call 858-495-5428 or e-mail on-going input/ideas: evalyn.greb@sdcounty.ca.gov