Transcript Psychiatry in ACOs

Arthur E. Kelley, MD
Medical 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 System
National Comorbidity Survey Replication
Treated in
Primary Care
Untreated
59%
Wang et al, Arch. Gen. Psychiatry, 63, June ,2005
23%
Treated in
MH System
18%
Co-Morbidity Percentages 2001-2003
CANCER
10-20%
Chronic Pain
40-60%
NEUROLOGIC
DISORDERS
10-20 %
DEPRESSION
GERIATRIC
SYNDROMES
20-40 %
DIABETES
10-20 %
HEART
DISEASE
20-40%
University of Washington AIMS Center
No Health Without Mental Health
From: Center for Health Care Strategies, 2010
LACK
OF
ACCESS
Half 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
PCMH
The main vehicle
for the coming
change.
PCSP
The 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 Assessment
2.Patient Education/self
management support
3.Close follow-up to prevent
patients from “falling through
the cracks”
Caseload consultation
Stepped Care
Change treatment
according to evidence
based algorithm if patient
not improving
Support antidepressant
treatment by the PCP
Relapse prevention once
patient is improved
Diagnostic consultation on
difficult cases
Consultation is focused on
patients who are not improving
as expected
Brief Counseling
Facilitate treatment change
Recommendations for additional
treatment/referral according to
evidence-based guidelines
Triage to community
Relapse prevention
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.
2.
3.
4.
Clinical Symptoms
Mental Quality of Life
Physical Quality of Life
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): 1155-1159
Katon et al, Archives of General Psychiatry. December 2002: 59(12): 1098-1104
Druss et al, American J. of Psychiatry. November 2011: 168(11): 1171-1178
Cornerstone Care Outreach Clinic
Our Team
David Talbot, MD, Director
Eileen 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
PROTOCOL PATIENTS (N=33)
# ACHIEVING RESPONSE
7 (21%)
# ACHIEVING REMISSION
9 (27%)
# ACHIEVING NEITHER
17 (51%)
48% achieved response or remission
Non-Protocol Patients
 88 (73%) of patients with positive PHQ-9 did not enter
the depression protocol
 Reasons:
1. Depression comorbid with another disorder too
complicated for primary care
2. Already under psychiatric care
3. Refused
4. Lost to follow-up
Future Issues for CCOC
 Is 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?