Transcript Title of Presentation - Collaborative Family Healthcare Association

Session # D1b
Friday, October 11, 2013
Improving Behavioral Health Access
for At-Risk Patients in an Integrative
Healthcare Site
Cassidy Freitas, M.A.
Zephon Lister, Ph.D.
William Sieber, Ph.D.
Collaborative Family Healthcare Association 15th Annual Conference
October 10-12, 2013
Broomfield, Colorado U.S.A.
Faculty Disclosure
We have not had any relevant financial
relationships during the past 12 months.
Objectives
1) Describe rates of depression screening by social demographics
2) Describe the rates in which at-risk patients (lower SES,
geriatric, minority group patients) are being identified as
depressed, receiving behavioral health referrals, and followingthrough on behavioral health referrals
3) Describe a multi-level integrative healthcare model that may
bridge the disparity gap for these at-risk populations
4) Discuss the experience of physicians who are practicing under
the multi-level integrative care model that is suggested
Learning Assessment
Who are we?
Who are you?
What were your hopes in attending
this presentation?
• University of California, San Diego
• Department of Family and Preventive Medicine
• Three Family Medicine Clinics
•
•
Services 35,000+ patients
Each clinic:120-160 daily patient encounters
•
Population:
•
56% female
•
53% Caucasian, 28% Hispanic, 12% Asian/Pac Isl, 7% African Am.
•
Payors from low SES and Medi-Cal to PPO
• Integrated Primary Care
• Patient-Centered Medical Home
• Stepped-Care Behavioral Health
Program
•
•
Co-Located & Shared Care
T-CARE
Targeted,
Collaborative,
Assessment,
Response, and
Empowerment
C.J. Peek’s Lexicon:
Parameters of Integration
UCSD Department of Family and Preventive
Medicine
1. Range of care team function and expertise that can be
mobilized to address needs of particular patients and
target populations
Foundational plus others for population
•Triage/identification with registry and
tracking/coordination functions
•Complex or specialized mental health therapies
•Complex or more specialized pharmacologic intervention
2. Type of spatial arrangement employed
Co-located space
•BH and PC clinicians in different parts of the same
building
Fully shared space
•BH and PC clinicians share the same provider rooms,
spending all or most of their time seeing patients in that
shared space
•Typically, the clinicians see the patient in the same exam
room
3. Type of collaboration employed
Full collaboration/integration
•Fully shared treatment plans and documentation, regular
communication facilitated and/or clinical workflows that
ensure effective communication and coordination
4. Method for identifying individuals
Universal screening or identification process
•All or most patients or members of clinic panel are
screened or otherwise identified for being part of a target
population
Health disparities can be defined as the unequal
spread of disease across different
groups, psychiatric disorders included.
Why the Focus on Depression?
Depression is commonly found at the center of many medical illnesses
Heart
Disease
Irritable
Bowel
Syndrome
Diabetes
Depression
Cancer
Pain
Thyroid
Disorders
At-Risk Populations, Primary Care, and Depression
• Major Depressive Disorder affects
approximately 15 million American
adults a year1, and remains a costly
and significant public health
concern2.
• The United States Preventive
Services Task Force suggests that
depression screening should occur
within primary care when support is
in place to assure accurate
diagnosis, treatment, and followthrough3.
1.
2.
3.
Kessler et al., 2005; SAMHSA, 2007; U.S. Census Bureau, 2004
World Health Organization, 2004
US Preventive Services Task Force, 2002
At-Risk Populations, Depression, and Primary Care
• At-risk populations (such as the elderly,
minority groups and low income) are at higher
risk for depression and are likely to present
within primary care1.
• These populations are also less likely to
follow-through on behavioral health referrals
and recommendations due to stigma and
challenges in accessing care2.
1.
2.
Kessler et al., 2005
Kessler et al., 2001
The Elderly, Depression, and Primary Care
• Depressed elderly primary care patients
• In the month prior to their
have increased
suicide, a majority of elderly
• Frequency of appointments (on average
patients had visited their
2 more appointments a year)
primary care physician1.
• Number of lab tests, x-rays and scans
• Nonspecific medical complaints1
• One study found that 20% of
older adults who committed
suicide saw a primary care
provider on the same day2.
1.
2.
3.
Luber et al., 2001
Luoma, Martin, & Pearson, 2002
Conwell, Duberstein, & Caine , 2002
Minorities, Depression, and Primary Care
•
PC providers recommend depression
treatments for Latino and AfricanAmerican patients as frequently as
they do for white patients, however…
– Latino and African-American
patients are less likely to take
anti-depressant medications
– Latinos are less likely to obtain
specialty mental health care
– Both groups are more likely to
present themselves within
primary care rather than a
specialty mental health clinic.1
• While sometimes considered the
‘model minority,’ Asian Americans are
also at risk for depression and suicidal
ideations, particularly when they are
U.S. born.3,4
• Ethnic minority patients have less
collaborative relationships with
their white providers than do
white patients.5
• African Americans, Asian
Americans, and Latinos had
differing beliefs regarding the
causes of mental illness when
compared with whites.6
• Race/ethnicity associated with
– Who makes healthcare decisions
– Treatment preferences.6
1.
2.
3.
4.
5.
Miranda & Cooper, 2004
Lee, Lei, & Sue, 2001
Duldulao, Takeuchi, & Hong, 2009
Cooper-Patrick et al., 1999
Jimenez et al., 2012
Low Income, Depression, and Primary Care
• Expected challenges for low-income patients
– Less resources
– Poor access to care
– Poor health behaviors
• 29% of Low income (<24k a year) Americans report they have
been diagnosed with Depression, with an 18.7% gap
difference between Low and High income (>90k a year)
Americans.1
– Depression being one of the largest health disparity gaps
experienced by Low Income Americans
1. Gallup-Healthways Well-Being Index, 2010
•
An IPC model can create more
– efficient coordination of services
– can allow for scheduling of
several services in one
appointment
– thus reducing the cost and
ensuring greater follow-through
for at-risk groups such as lowincome minorities*1
* This is important since ethnic minority groups are
more likely to delay treatment and receive less
follow-up appointments.2, 3
•
Simply having co-located mental health and
primary care is not always the answer.
–
One clinic serving predominately MediCaid
patients found that co-located mental
health care and primary care was
providing only minimally adequate care for
depressive patients, and that minority
patients were less likely to receive any
care.4
–
Yet, there is a demand for specialty mental
health services within primary care for
those patients whose needs go beyond the
several brief visits and interventions they
would receive within other IPC models.
1. Peterson, 2011
2. Edelman, Gao, & Mosca, 2008
3. Mosca et al., 2010
4. Uebelacker et al., 2009
Methods
• Our data set
• Sample
• The variables that were used and how they
were defined
UCSD Stepped-Care Model
Targeted
• Universal Screening
• At-Risk Patients Identified Using EMR
• Trained BHCs discuss patient risk factors with PC provider before PC visit
Collaborative
• PC provider assesses for need during visit
Assessment
Response
Empowerment
• Targeted, systemic, and evidence-based responses based on presenting need
• Multi-disciplinary treatment plan
• Follow-up T-CARE visits, referrals to Mental Health sector, Psychotropic medications, follow-up phone
calls
Physician Interviews
• Sample
– 6 Physicians, 2 from each clinic
– 2 Males, 4 Females
– DO’s, MD’s
– 4 Caucasian, 2 Asian American
– All Physicians were either chosen to participate in T-CARE’s pilot year
or were identified as high T-CARE utilizers
•
•
Physicians were interviewed who had been utilizing our complete stepped-care
behavioral health model
Our aim was program quality improvement, but we also uncovered that PC
providers believed our new behavioral health structure was bridging gaps for our
at-risk populations
Physician Interviews
– How do the doctors see the availability of BHC’s
during patient visits in addition to having colocated traditional behavioral health options
benefiting their at-risk patients?
– Themes:
•
•
•
•
Warm hand-off
Reducing stigma
Easier access
Resources
Patient
trusts PC
Provider
Doctor
trusts
BHC
Patient
trusts
BHC
Physician Interviews
– “They [Depressed Geriatrics] are so hard to get
into therapy, but there’s so much need. Their
health is poor, their friends are dying so their
social circle is getting smaller, their sphere of the
world is getting smaller as they no longer feel safe
driving on the freeway, their health is poor. I have
one guy that I see every 2 weeks, I think just
because he is lonely…having T-CARE put a face to
this ‘voodoo thing called Therapy’ and when he
got to see [BHC] we were then finally able to get
him connected to one-on-one therapy.”
Physician Interviews
• “It [the stepped-care model] has been really useful for the
patients who, if they don’t have a face that they’ve connected
to in the office, would probably never follow-up.”
• “A specific example would be when I had a patient [Medi-Cal
Latina Patient] whose daughter had recently committed
suicide. She needed to talk to someone right then and there,
and she was able to. I think she was comforted in knowing
that somebody cares, somebody’s going to help me, and I
don’t feel so desperate because I know help is coming. I think
she was comforted in knowing that she had a follow-up
appointment [with BHC] and a face to connect with to that
appointment.”
Physician Interviews
• Other patient-types that PC Provider’s
identified as finding our structure useful in
behavioral health follow-through
– Young families that are just overwhelmed and
have busy schedules
– Depressed males
– Military spouses and families
– Postpartum mothers and fathers
Clinical Implications
• How is it impacting us programatically
• Broader implications- how our findings might
be important to others who are working in
similar environments or working with similar
populations
Conclusions
• What can we say about our findings, what
can’t we say
• Lessons learned
• Future studies/directions
References
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Conwell, Y., Duberstein, P. R., & Caine E. D. (2002). Risk factors for suicide in later life. Biological Psychiatry, 52(3), 193-204.
Cooper-Patrick, L., Gallo, J.J., Conzales, J. J., et al. Race, gender and partnership in the patient-physician relationship, JAMA, 1999, 282583.
Duldalao, A. A., Takeuchi, D. T., & Hong, S. (2009). Correlates of suicidal behaviors among asian americans. Archives of Suicide Research,
13(3), 277-290.
Jimenez, D. E., Bartels, S. J., Cardenas, V., Dhaliwal, S. S., & Alegría, M. (2012). Cultural beliefs and mental health treatment preferences
of ethnically diverse older adult consumers in primary care. The American Journal Of Geriatric Psychiatry, 20(6), 533-542.
Kessler, R. C., Berglund, P. A., Bruce, M. I., Koch, J. R., Laska, E. M., Leaf, P. J., Manderscheid, R. W., Rosenheck, R. A., Walters, E. E., &
Wang P. S. (2001). The prevalence and correlates of untreated serious mental illness. Health Services Research Journal, 36, 987-1007.
Kessler, R. C., Chiu, W. T., Demler, O., Walters, E. E. (2005). Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in
the National Comorbidity Survey Replication (NCS-R). Archies of General Psychiatry, 62(6), 617-627.
Lee, J., Lei, A., & Sue, S. (2001). The current state of mental health research on asian americans. Journal of Human Behavior in the Social
Encironment, 3, 159-178.
Luoma, J. B., Martin, C. E., & Pearson J. L. (2002). Contact with mental health and primary care providers before suicide: A review of the
evidence. American Journal of Psychiatry, 159(6), 909-916.
Luber, M., Meyers, B. S., Williams-Russo, P. G., Hollenberg, J. P., DiDomenico, T. N., Charlson, M. E., & Alexopoulos, G. S. (2001).
Depression and service utilization in elderly primary care patients. The American Journal Of Geriatric Psychiatry, 9(2), 169-176.
Miranda, J., & Cooper, L. A. (2004). Disparities in Care for Depression Among Primary Care Patients. Journal Of General Internal
Medicine, 19(2), 120-126.
Petersen, S., Hutchings, P., Shrader, G., & Brake, K. (2011). Integrating health care: The clear advantage for underserved diverse
populations. Psychological Services, 8, 69-81.
Substance Abuse and Mental Health Services Administration (SAMHSA). (2007). Results from the 2006 National Survey on Drug Use and
Health: National Findings (Office of Applied Studies, NSDUH Series H-32, DHHS Publication No. SMA 07-4293). Rockville, MD.
Uebelacker, L., Smith, M., Lewis, A., Sasaki, R., Miller, I. (2009). Treatment of depression in a low-income primary care setting with
colocated mental health care. Families, Systems & Health, 27(2), 161-171.
US Preventive Services Task Force. (2002). Screening for depression: recommendations and rationale. Annals of Internal Medicine, 136,
760-764.
World Health Organization. (2008). The global burden of disease: 2004 update. Geneva, Switzerland: WHO Press.
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