The number of elderly persons with severe mental illness (i.e., schizophrenia, major recurrent depression, bipolar disorder) is increasing, thereby creating a need to better understand the health care needs of this group of patients. Dr. Hendrie from the Indiana University Center for Aging Research and his colleagues recently published research examining health care utilization, health outcomes, and cost of care among the elderly patients with severe mental illnesses.
Their findings indicate that these patients are a major burden for our health care system. One study found that compared to age-matched primary care patients, patients with severe mental illnesses had higher rates of health care utilization, greater frequency of falls, and increased rates of substance abuse and alcoholism. Likewise, a second study that looked at a sample of patients with schizophrenia showed they had higher rates of comorbid chronic illnesses as well as increased mortality risk, health care utilization and cost of care compared to those without schizophrenia. These studies both highlight the challenges faced when providing health care for these patients and suggests that integrated models of health care can help meet the needs of elderly patients and decrease the burden on the health care system.
In a mid-January 2014 blog post, NIAC member, Kavita Patel, MD, MSHS and colleague Jeffery Nadel indicated that current efforts to improve the cost and quality of health care are aptly focused on primary care. According to the 2010 National Ambulatory Medical Care Survey, 560 million or 55.5% of the almost 1.1 billion physician office visits every year are to a primary care physician. Under the Affordable Care Act (ACA), numbers will continue to increase. In addition, primary care is often the point of entry to the vast medical system and offers a setting in which patients develop trusting, long-lasting relationships with their primary care physicians (PCPs) and focus on wellness.
Fortunately, the ACA has encouraged the development of Accountable Care Organizations (ACOs) which offer innovative care delivery and payment models that promote the transformation of primary care. One such model is the Patient-Centered Medical Home (PCMH) which is expected “to be an impactful first step in reforming U.S. health care”. According to the four major primary care societies, joint principles of the PCMH include “personal physician care”; “physician-directed medical practice”; “whole person orientation”; “coordinated and/or integrated care”; “high quality and safety in care, enhanced access to care”; and “payment that supports enhanced services.” Although more studies are needed, current evidence suggests that PCMHs have positive effects on both patients and the larger health system. Among the positive outcomes attributed to the PCMH are reduced costs, decreased emergency room visits (probably due to “increased access to the practice in off-peak hours and increased availability of next-day appointments”) and fewer in hospital admissions. Another benefit is increased availability of next day appointments with PCPs.
Widespread adoption and sustainability of PCMHs will require a “transitioning away from fee-for-service reimbursement to new payment models (that) can properly align financial resources with (delivered services).” Currently, many of the core principles of PCMHs are poorly reimbursed or not reimbursed at all by Medicare and commercial payers. As a result, upfront and ongoing costs deter practices from using the PCMH model. New payment models such as per-member per-month payment, bundled or episodic payments, shared savings arrangements, and full or partial capitation are all possible solutions. Payment reform along with patient satisfaction improvement, team-based care delivery, and robust physician leadership can all foster accountable, person-centered care.
Read the related article: http://www.brookings.edu/blogs/up-front/posts/2014/01/16-future-patient-centered-accountable-care-patel?utm_source=Patient+Centered+Primary+Care+Collaborative+List&utm_campaign=8e63ff6156-Week_in_Review_Jan_241_24_2013&utm_medium=email&utm_term=0_56f71f22
Over 70 randomized, controlled studies suggest collaborative care—the collaboration among primary care providers, primary care-based behavioral health providers, case managers, and psychiatrists to better target and deliver mental health treatment—improves outcomes and service cost-effectiveness. The passing of the Affordable Care Act is thought to quicken its adoption to meet the increasing population need. The Accreditation Council for Graduate Medical Education (ACGME) is aware of this demand, but how are psychiatry training programs shifting their focus from inpatient and specialty care to foster the development of integral members of multi-disciplinary primary care teams? In July 2014 the following ACGME objectives for psychiatry residency curricula will go into effect: consultation skills to engage with primary care providers and other skills related to effectively integrating behavioral health into primary care.
As leaders in developing the collaborative care model, the University of Washington’s Advancing Integrated Mental Health Solutions (AIMS) Center has created such a curriculum for dissemination of the collaborative care model. Within only two sessions, psychiatry residents will learn these consultation skills, how to track outcomes using valid measures, and how to provide stepped care. Curricula to implement these skills within an integrated primary care rotation are also available, given the availability of this type of rotation at each training site. The role of psychiatry is changing and the AIMS approach provides an evidence-based, APA-supported, and direct method to equip the next generation to competently deliver collaborative care. With emerging structural changes in the health care delivery system, trainees need to be prepared to meet the new challenges so they can thrive as essential team members in integrated care models such as Accountable Care Organizations and the Patient Centered Medical Home.
Read the original article: http://psychnews.psychiatryonline.org/newsarticle.aspx?articleid=1827559
Although “integrating primary and behavioral health has been recognized as having significant potential to prevent behavioral health issues from becoming severe,” it is often difficult to achieve in rural areas where behavioral health providers are scarce. Fortunately, telehealth (or telemedicine)—described as “the use of medical information exchanged from one site to another via electronic communications to improve patients' health status”—can address this problem. According, to the Agency for Healthcare Research and Quality (AHRQ) Health IT Portfolio, telehealth is valuable “in regions where physician-to-patient ratios are inadequate or where there are not enough medical specialists available to meet the population’s needs.”
Larson et al. (2003) reveal several ways in which telehealth offers solutions to rural health care issues. First, telehealth can bridge the gap between rural and urban health care availability “by providing access to more health care services for rural residents.” Secondly, it can provide services virtually and allow urban health care professionals to serve rural patients. In addition, to attend to the “often older, sicker, and less educated” rural population, telehealth can offer geriatric care and education to rural patients and providers. It can also address problems with the “misdistribution of providers.” Finally, telehealth can bring specialty care to rural populations, particularly for Native Americans and other isolated communities.
Other benefits of telehealth include fewer medical errors, increased availability of clinical supervision, reduced travel time and costs for rural residents, and attention to “issues of privacy and stigma for patients and caregivers in rural communities.” Many studies have shown that telehealth specifically “(facilitates) collaborative care to patients without onsite specialists” by offering “direct intervention with the patient by a distant specialist,” “consultation between a primary care and behavioral health provider” and “education and training in diagnosis and care for behavioral health.” Additional ways in which telehealth is used includes “transmission of data or images for analysis, “remote monitoring (of patients by providers),” and “telepharmacy.”
Unfortunately, there exist many barriers to fully adopting telehealth. Some barriers specific to care coordination include “lack of reimbursement and/or incentives for providers,” “lack of training for primary care providers in assessing behavioral health”, poor treatment of behavioral health conditions, and lack of co-located behavioral health and primary care services. Patients and providers are reluctant to adopt collaborative behavioral health care due to “lack of understanding of the value of behavioral health care services,” “lack of technical support for collaboration,” concerns about practice workflow, additional time for new assessments, and poor and low “communication among primary and behavioral health care practitioners.” With training and education of providers, outreach to patients, collaboration between behavioral health and primary care providers, support for telehealth and Integration, online tools for collaborative care and operating manuals/guidelines, our rural population and overall health system can reap the benefits of telehealth and Integration.
Take a look at the following funding opportunities:
Health Resources and Services Administration (HRSA), Bureau of Primary Care
The Health Resources and Services Administration (HRSA), Bureau of Primary Health Care, is accepting applications for fiscal year (FY) 2014 Mental Health Service Expansion – Behavioral Health Integration (BHI). The purpose of this grant opportunity is to improve and expand the delivery of behavioral health services through the establishment/enhancement of an integrated primary care/behavioral health model at existing health centers. The source of funding for this competitive, supplemental opportunity is the Patient Protection and Affordable Care Act (P.L. 111-148), Section 10503.
ACA Provides Opportunities to Improve Care Through the Integration of Behavioral Health and Primary Care
Over 20 years of research suggests integrating behavioral health and primary care services improves mental health outcomes. With the implementation of the Affordable Care Act, states are now opportunely positioned to implement integrated care, particularly to address the needs of the underserved. Wayne Katon, MD and Jürgen Unützer, MD, MA, MPH, both University of Washington-based psychiatrists and leaders of integrated primary care efforts, discuss the many advantages of employing a successful integration program such as Washington State’s Mental Health Integration Program (MHIP).
Since 2008, MHIP has served more than 35,000 patients seen at Seattle-area health care clinics. The program has reduced overall costs and rates of police arrests and homelessness while improving mental health care for uninsured, high-risk populations. According to Drs. Katon and Unützer, there are several important elements of this program that contribute to its success. Notably, its design includes placing a mental health-care manager and a psychiatric consultant at the clinic who work together with other practitioners to detect and treat more common diagnoses such as depression and anxiety. Secondly, a pay-for-performance component incentivizes clinics for improving service quality. For example, this has included improving depression outcomes while adhering to reduced treatment duration.
Given Washington State’s continued integration research and integration accomplishments, other states are urged to adopt these efforts to meet the needs of the growing U.S. patient population.
Read the original article: http://seattletimes.com/html/opinion/2022642957_waynekatonjurgenunutzeropedmentalhealthparity12xml.html
To access additional articles on ACA and behavioral health integration see:
Take a look at the following funding opportunities:
National Institute on Drug Abuse (NIDA)
National Institutes of Health (NIH)
Agency for Healthcare Research and Quality (AHRQ)
The Research Demonstration and Dissemination Grant (R18) is an award made by AHRQ to an institution/organization to support a discrete, specified health services research project. The project will be performed by the named investigator and study team. The R18 research plan proposed by the applicant institution/organization must be related to the mission and portfolio priority research interests of AHRQ.
The Research Project Grant (R01) is an award made by AHRQ to an institution/organization to support a discrete, specified health services research project. The project will be performed by the named investigator and study team. The R01 research plan proposed by the applicant institution/organization must be related to the mission and portfolio priority research interests of AHRQ.
The Agency for Healthcare Research and Quality (AHRQ), announces its interest in supporting conferences through the AHRQ Conference Grant Program. AHRQ seeks to support conferences that help to further its mission to improve the quality, safety, efficiency, and effectiveness of health care for all Americans. The types of conferences eligible for support include: research development; research design and methodology; dissemination and implementation conferences; and research training, infrastructure, and career development. AHRQ is especially interested in supporting conferences that demonstrate strategies that include plans for disseminating complementary conference materials and products beyond the participants attending the event. Such strategies might include, but are not limited to, submitting articles for publication, posting information on a web site, and seeking formal opportunities to discuss conference information with others.
This Funding Opportunity Announcement (FOA) encourages Small Research Grant (R03) applications, and expresses AHRQ portfolio priority areas of interest for ongoing small research projects. The R03 grant mechanism supports different types of health services research projects including pilot and feasibility studies; secondary analysis of existing data; small, self-contained research projects; development of research methodology; and development of new research technology.
If interested in AHRQ funding opportunities listed here, please contact AHRQ after reviewing the full announcement(s):
Charlotte A. Mullican, B.S.W., M.P.H.
Phone: (301) 427-1495
Fax: (301) 427-1597
Community Care of North Carolina (CCNC) “a systemic care management intervention program” depends on the patient-centered medical home (PCMH) model to serve Medicaid recipients and their providers. A recently published study looked at the cost impact of their system of care “for nonelderly Medicaid recipients with disabilities” from 2007-2011. “In 2011, aged, and disabled Medicaid recipients represented 26% of Medicaid enrollees and accounted for 65% of expenditures nationally.” Additionally, from 2012-2021, Medicaid expenditures are expected to “remain substantially higher than for aged, or nondisabled adult and child beneficiaries.”
Fillmore and colleagues found that enrollment in the CCNC program produced “significant cost avoidance” in the first years of the study, which increased thereafter. Moreover, the cost impact for the program was “greater in persons with multiple chronic disease conditions.” CCNC’s cost-saving outcomes suggest that “carefully designed large-scale care management programs can have a significant impact and can increase program efficiency independent of financial risk sharing.” The study did present some limits in terms of unmeasured variables such as “differences in health system practices and socioeconomic factors that influence care utilization.” It also could not include “a direct measure of dose or test specific activities to parse the impact of particular CCNC program activities.” Additionally, the study did not take into account “Medicaid reimbursement differentials among providers and, to the extent enrollees systematically frequented higher or lower cost providers for the same service.” Including these variables would provide further insight, as noted in the article.
Nevertheless, through the use of “targeted care management interventions, aligned with person-centered medical homes, and with a focus on systems to enable change, the CCNC program demonstrates an important part of the solution for creating lasting health care improvement”.
Fillmore H, DuBard CA, Ritter GA et al. Health care savings with the patient-centered medical home: Community Care of North Carolina’s experience. Popul Health Manag 2013.
“One of the most rewarding benefits for psychiatrists who practice collaborative care is the opportunity to work with patients who have a wide range of backgrounds and conditions.” Jürgen Unützer, MD, MA, MPH, National Integration Academy Council (NIAC) member, made this statement in a recent article in Psychiatric News. Dr. Amy Bauer, MD, MS similarly explains that practicing psychiatry in primary care allows her to see a wider range of patients than in specialty care because those working solely in specialty care “see only the 10 percent of patients who are able to overcome the substantial barriers that exist to getting specialty mental health care.”
Through her residency experiences in the Rural and Remote Mental Health Service in South Australia, she gained insight into the “importance of working with our primary care colleagues to help address the burden of mental disorders at large,” as well as “the value of leveraging psychiatric expertise through consultative models such as collaborative care.” Dr. Bauer provides an example through the case of a patient who had been untreated for over a decade, but who was now receiving the care she needed through integration and case management.
Dr. Bauer, who now works in the Washington Mental Health Integration Program (MHIP) and the University of Washington’s Behavioral Health Integration Program (BHIP) sums up her experiences:
“Working in primary care offers a wonderful opportunity for a psychiatrist to shape the care of a variety of patients, and I’ve found that collaborative care is a particularly efficient, effective, and rewarding way to do so”.
View the original article here: http://psychnews.psychiatryonline.org/newsarticle.aspx?articleID=1812234
An accountable care organization (ACO) is a multidisciplinary system built on collaborative care principles, performance measured against quality measures, and financial rewards based on cost savings. As such the emergence of ACOs provides an excellent opportunity to incorporate behavioral health integration into primary care practices.
“Our friends in Primary Care and specialty medicine are…very aware of the need for behavioral health and are actively seeking partnerships” says Henry Chung, MD, psychiatrist with Montefiore Medical Center in New York.* Montefiore has a long history of collaborative care and financial-risk management that is key to success. In 2013, Montefiore was the top financial performer of the 32 organizations participating in the Centers for Medicare and Medicaid Innovation (CMMI) Pioneer ACO model. Initial CMMI data indicate “the savings represent a 7 percent reduction in the cost of care, as compared to the benchmark CMMI established for more than 23,000 patients attributed to Montefiore ACO physicians.”
Dr. Chung explains that one of the main focuses at Montefiore is on patient and physician engagement to achieve their results. “We really want physicians to know that they have the support they need to care for patients with complex needs.” He added “We have really worked hard to let doctors know that when they see such patients, we can support them with care-management programs. And we can use claims data to stratify patients and reach out to the highest utilizers and most complex cases.”
Many health systems and practices entering the world of integrated care find that those patients with comorbid medical and psychiatric disorders are the highest users of health care services. At Montefiore, one third of the patients seen over the last 3 years have some form of diagnosed behavioral disorder and also 50-60 percent higher costs in utilization than patients without behavioral disorders. Thanks to the “bundled payment” arrangements in the ACO model, Montefiore can focus on providing good collaborative care that includes psychiatric services for a procedure and up to 90 days after the procedure to achieve the best possible patient outcomes.
Dr. Chung encourages members of the American Psychiatric Association to collaborate with and develop relationships with the medical community to provide good care to patients and achieve optimal patient results.
*Dr. Chung is also Chief Medical Officer at Montefiore Medical Center’s Managed Care Organization, and ACO Medical Director.