The CAHPS Patient-Centered Medical Home (PCMH) Survey (Adult Version), is a new instrument used to evaluate patients’ experiences with a practice and indicates how well the practice meets patient expectations. A new composite measure for “Comprehensiveness – Adult Behavioral” is based on three questions from the survey:
- Q39: In the last 12 months, did anyone in this provider's office ask you if there was a period of time when you felt sad, empty or depressed?
- Q40: In the last 12 months, did you and anyone in this provider's office talk about things in your life that worry you or cause you stress?
- Q41: In the last 12 months, did you and anyone in this provider's office talk about a personal problem, family problem, alcohol use, drug use, or a mental or emotional illness?
Patient experience with health care is considered a critical component of quality of care by the National Committee for Quality Assurance (NCQA). The Committee believes that experience has an effect on care outcome, and that experience itself is an outcome measure.
The CAHPS PCMH Survey is used for decision-making by both the patient about health plans and by managers about resource allocation. Additionally, it is used for internal quality improvement of a practice and for public reporting. For patients to participate in this survey, they must be at least 18 years of age and speak English or Spanish (the two languages in which the survey is available). The number of “Yes” and “No” responses are collected and each weighted equally when scoring the survey. Questions that are unanswered or where the patient selected more than one response are not included in calculations.
The survey was created by the NCQA and the CAHPS Consortium and sponsored by the Federal Agency for Healthcare Research and Quality (AHRQ). The purpose was to develop a new version of the CAHPS Clinician and Group Survey to address questions of care “relevant to patient-centered medical homes.”
A summary of this measure is at: http://www.qualitymeasures.ahrq.gov/content.aspx?id=45109
In Building an Evidence Base for the Co-Occurrence of Chronic Disease and Psychiatric Distress and Impairment, published in the October 2014 issue of Preventing Chronic Disease, the comorbid nature of chronic disease and mental disorders is examined. In the United States, the number of people with multiple chronic conditions, including mental health disorders, is increasing. Almost half of the population lives with at least 1 chronic disease (e.g., cardiovascular disease, diabetes), and 7 out of 10 deaths occur because of these diseases. In addition, “1 in 4 Americans aged 18 years or older will experience a diagnosable mental disorder in any given year [and] nearly half will experience a mental health disorder in their lifetimes.”
Medical professionals want to understand how mental health disorders affect other health conditions and overall health. Recently, the wars in Iraq and Afghanistan of the past 10 years have spurred this interest since military populations experience mental health symptoms associated with chronic disease.
Since mental health conditions “are likely influenced by chronic disease diagnosis and maintenance,” the increasing burden of chronic disease must be understood in the context of mental disorders. Two previous Institute of Medicine (IOM) reports, Crossing the Quality Chasm: A New Health System for the 21st Century and Improving the Quality of Health Care for Mental and Substance-Use Conditions, call for integrating behavioral health and primary care services to better address mental health and comorbid conditions.
The U.S. Veterans Health Administration and many university health services have adopted integrated health care and demonstrated “both clinical improvements and financial benefits.” The Centers for Disease Control and Prevention’s (CDC’s) National Center for Chronic Disease Prevention and Health Promotion developed the Public Health Action Plan to Integrate Mental Health Promotion and Mental Illness Prevention with Chronic Disease Prevention, 2001-2015. This document proposed “increased surveillance of mental health and chronic and chronic disease measures” as well as epidemiology and prevention research, and more communication between health professionals and the general public.
Ultimately, “a continuum of care that integrates all aspects of health care” will be required to better comprehend disease comorbidities and risk factors. Integrated behavioral health and primary care will indeed help us“to understand the relationship between these health concerns which are often clinically disconnected.” Integration will result in better diagnosis, treatment, and prevention of mental disorders, leading to improved treatment and a reduction in treatment cost.
Read the related article: http://www.cdc.gov/pcd/issues/2014/pdf/14
Accountable Care Organizations (ACOs) are uniquely poised to provide integrated behavioral health and primary care. However, evidence from a recent Health Affairs article suggests that few ACOs are pursuing integrated efforts.
Researchers used data from the National Survey of Accountable Care Organizations, followed up with purposively sampled interviews of ACO leadership to examine the contextual factors influencing ACO decisions on whether or not to manage behavioral health services, and if so, how to go about it. Results point to three issues:
- ACOs with large patient populations experiencing behavioral health needs were more likely to provide primary care and behavioral health services. One interviewee noted that of their top five patient emergency department users, all five had a behavioral health diagnosis, four of the five had chemical dependency diagnoses, and three of the five had traumatic brain injury. This data played into the ACO’s decision to examine the services provided in their clinic.
- ACOs in regions with a low supply of behavioral health providers were more likely to provide such services in house.
- Payment mechanisms motivated ACO decisions to provide integrated behavioral health and primary care services. For example, Medicare includes a quality measure on depression that is linked to payment.
In summary, most ACOs are not currently providing universal integrated behavioral health and primary care services. Evidence suggests that contextual factors, such as patient population, regional supply of behavioral health providers, and payment mechanisms, influence ACO decisions on whether to integrate behavioral health and primary care.
View an abstract of the article at: http://www.ncbi.nlm.nih.gov/pubmed/25288427
Coordinated patient-centered care is on the rise among medical providers aiming to improve health care quality while reducing overall costs. Last month, the U.S. Department of Health and Human Services announced an $840 million initiative to fund applicants who are transitioning to coordinated patient-centered care and are able to track progress toward measurable goals.
“The Transforming Clinical Practice Initiative is one of the largest federal investments uniquely designed to support clinician practices through nationwide, collaborative, and peer-based learning networks that facilitate large-scale practice transformation.”
The initiative will assist care providers in the following ways:
- Gaining access to patient information and medical history;
- Improving patient-provider relationships and communication;
- Enhancing coordinated team efforts; and
- Promoting the regular use of electronic health records.
The Centers for Medicare & Medicaid Services are seeking collaborative partnerships and will be awarding cooperative agreements to the following:
- Practice Transformation Networks: Successful practices that are joined to serve as trusted partners in providing expertise, coaching, best practices, and guidance. These networks will work with a diverse range of practices, including those providing care to the medically underserved and rural communities.
- Support and Alignment Networks: Networks of medical professional associations aligning memberships, communication, and continuing medical education credits to identify evidence-based practices and policies for dissemination. Their work will support the Practice Transformation Networks and practices.
Participation in the initiative ensures that practices will receive technical assistance and support, and will allow for overall success in the health care market due to increasing demand for efficient patient-centered care delivery by health care payers and purchasers.
Interested practices/clinicians should visit: http://innovation.cms.gov/initiatives/Transforming-Clinical-Practices/
View the official announcement: http://www.hhs.gov/news/press/2014pres/10/20141023a.html
The Third Edition of Clinical Integration: Accountable Care and Population Health, is a forthcoming book that will provide fresh insights and new information on the evolution of clinically integrated networks (CINs) across the U.S. health care system. Chapter 11 of this book, Non-Traditional Mental Health and Substance Use Disorder Services as a Core Part of Health in CINs and ACOs, was released in October 2014, and is co-authored by Roger Kathol, M.D., D.F.A.P.A., F.A.C.P., C.P.E.; Susan Sargent, M.B.A.; Steve Melek, F.A.A.A.; Lee Sacks, M.D.; and Kavita K. Patel, M.D., M.S.
This chapter describes how behavioral health (BH) services are delivered in the health system today, the influence of current payment practices have on how and where BH services are delivered, the impact of isolated BH care delivery on the quality and cost of care in national health plan, and the BH delivery system changes needed to improve both health and cost outcomes of untreated BH conditions, and the opportunities associated with BH service implementation within CINs and/or accountable care organizations (ACOs).
The authors conclude by saying:
“This Chapter recognizes that the inclusion of BH professionals and services in CINs/ACOs creates several challenges for those that are developing them. Therefore, it provides a roadmap that will allow those willing to maximize the effectiveness of their CIN/ACO to achieve the Triple Aim” (Berwick, Nolan, & Whittington, 2008)
Information on purchasing this book chapter is at: http://www.amazon.com/Clinical-Integration-Accountable-Population-Edition/dp/0991234529.
In September 2014, the Agency for Healthcare Research and Quality (AHRQ) published the National Strategy for Quality Improvement in Health Care2014 Annual Progress Report to Congress. As stated in this report’s Executive Summary,
“The National Quality Strategy [NQS] serves as a framework for aligning stakeholders across the private and public sectors at the Federal, State, and local levels….The initial National Quality Strategy, published in March 2011, established three aims and six priorities for quality improvement, with real implications for the person receiving the care, advocating for a loved one, or becoming healthier as part of a community-wide effort.”
The U.S. Department of Health and Human Services supports the implementation of the NQS. More about these plans can be found at http://www.ahrq.gov/workingforquality/index.html
Read the new AHRQ Report to Congress at http://www.ahrq.gov/workingforquality/reports/annual-reports/nqs2014annlrpt.pdf .
Additional information on public and private efforts to support the NQS are found at: http://www.ahrq.gov/workingforquality/index.html
Two slide decks have been created:
- Slide Deck 1: Why Behavioral Health Integration Is Critical to a Patient-Centered Medical Home (PCMH). This deck is appropriate for audiences with limited knowledge about the concept of integrated behavioral health, or for audiences that are already practicing PCMH but need to be convinced of the value of behavioral health integration.
- Slide Deck 2: Where and How Behavioral Health Can Be Integrated into the PCMH. This deck is appropriate for audiences that are already convinced on the need to integrate but want to learn more about the different models of integration.
These decks were prepared by the Patient-Centered Primary Care Collaborative (PCPCC) Special Interest Group on Behavioral Health. Several members of that group also serve on the National Integration Academy Council (NIAC) and are involved with the work of the Academy. They include Alexander Blount, Ed.D., Parinda Khatri, Ph.D., Benjamin Miller, Psy.D., and C.J. Peek, Ph.D.
The slides can be customized for presentations about the value of behavioral health integration into primary care and the PCMH. The slides are designed for organizations and practices interested in the following tasks:
- Transforming into a PCMH;
- Already practicing patient-centered care and planning on integrating behavioral health care; and
- Interested in improving their integration models.
These slide decks reference the work of the Academy, including:
- The Academy Portal;
- Lexicon for Behavioral Health and Primary Care Integration; and
- The Academy Integration Map.
You may access the slide decks at: http://www.pcpcc.org/resource/behavioral-health-integration-pcmh
Aligning Payers and Practices to Transform Primary Care: A Report from the Multi-State Collaborative
The Milbank Memorial Fund has recently released a new report, Aligning Payers and Practices to Transform Primary Care: A Report from the Multi-State Collaborative. This report describes the efforts of several states that have developed and implemented initiatives to transform their primary care delivery systems in order to improve the health of their populations and reduce costs.
There is a great deal to learn about restructuring health care in the United States in the post-Affordable Care Act (ACA) era. Primary care transformation is essential to a well-performing health care delivery system, and payment reform works best when it is consistent across payers. Though transforming primary care and achieving payment reform are daunting tasks, evidence and experience show they are possible.
According to the Milbank Memorial Fund,
“this report details the experiences of the Multi-State Collaborative (MC), a voluntary group composed of representatives of state-based, multi-payer primary care transformation initiatives that are themselves collaborations between payers, providers, employers and state officials. With support from the Milbank Memorial Fund since 2009, the MC has provided a forum for member states to share data, participate in collaborative learning, and advocate for improved collaboration between the states and the federal government on primary care transformation. The report, which is based on a 2013 observational survey of the MC states and interviews with their leaders, looks at the similarities and differences in the activities of each state.
The implementation of the ACA may have focused much attention on insurance provisions, but the real challenges and opportunities for health reform lie in improving the performance of the medical care delivery system. The lessons learned here have implications not only for primary care transformation, but also for state-convened provider payment reform initiatives and any effort at health care transformation requiring alignment across multiple payers.”
The Executive Summary of the report is at: http://www.milbank.org/uploads/documents/papers/Milbank%20-%20Aligning%20Payers%20and%20Practices%20-%20Exec%20Summary.pdf
Several payment reform initiatives are shaping the world of behavioral health and primary care integration. A recent blog post by the National Academy for State Health Policy (NASHP) provided an overview of state strategies being developed and implemented for integrating behavioral health and primary care. Notably, a number of Medicaid programs now allow Federally Qualified Health Centers (FQHCs) to bill for behavioral health and primary care services that are provided on the same business day. The SAMHSA-HRSA Center for Integrated Health Solutions website provides information on policies, billing codes, and procedures regarding these changes in all 50 states. Universal changes to state-level Medicaid payment policies are encouraged to remove barriers related to the provision of integrated behavioral health and primary care.
The Medicare program has also examined payment reform initiatives as related to FQHCs. As of October 2014, Medicare’s new Prospective Payment System for FQHCs allows for reimbursement for same-day behavioral health and primary care services.
For information on NASHP and their work on policy and payment issues see NASHP.
More information about government-sponsored insurance and payment reform initiatives surrounding behavioral health and primary care can be found at SAMHSA.
Major depression affects women twice as often as men over the lifetime. Women’s highest rates of depression occur during reproductive and menopausal transitions. Additionally, more than one-third of obstetrics-gynecology (OB/GYN) patients use their OB/GYN physician as their primary care provider, particularly those with limited income and limited or no health insurance. However, OB/GYN physicians often have less training in depression than other primary care physicians.
In addition, markers of social disadvantage (lack of health insurance, low income, unemployment, lower educational attainment, and single parenthood) are related to higher rates of depression and anxiety, as well as more persistent depression. The Depression Among Women Now (DAWN) study was conducted to determine whether collaborative depression care in an OB/GYN setting was as effective in treating socially disadvantaged women with no health insurance or public coverage as it was in treating women with commercial insurance.
The DAWN intervention included hiring a social worker at two different OB/GYN clinics to assist in overcoming barriers to care, such as lack of transportation and housing issues. Social workers provided an initial engagement session that has been shown to improve rates of mental health follow-up care, as well as follow-ups by phone or in person every 1 to 2 weeks for 12 months. During weekly meetings, a social worker, a psychiatrist, and an OB/GYN physician recommended medication and behavioral treatment plans.. One of the clinics was a county-hospital-based clinic that mostly treated a socially disadvantaged population, and the other was a university-based OB/GYN clinic that treated a mixed socioeconomic population.
The DAWN intervention was found to be more effective than usual care for patients with no health insurance or public coverage. Intervention patients had improvements in depression treatment, as well as improvements in depressive symptoms and functioning during the 18 months following the 12-month-long intervention. Additionally, results were similar for both clinics, despite differences in the socioeconomic status of their patients.
Follow The Academy Portal in November for additional information on the use of integrated behavioral health care in the OB/GYN setting.
For more information, refer to: