No Health Without Mental Health: Using Collaborative Care to Deliver Value Anna Ratzliff, MD, PhD TCPI National Faculty APA-SAN University of Washington This presentation is provided free-of-charge and is supported by Grant Number 1L1CMS-331480-01-00 from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services. The contents provided in this webinar are solely the responsibility of the presenters and do not necessarily represent the official views of HHS or any of its agencies.

TCPI National Faculty Anna Ratzliff, MD, PhD Dr. Anna Ratzliff is an Associate Professor in the Department of Psychiatry & Behavioral Sciences at the University of Washington. Dr. Ratzliff currently serves as the Director of the UW Integrated Care Training Program, Associate Director for Education for the AIMS Center and trains psychiatrists in Collaborative Care at the University of Washington and as part of the American Psychiatric Association Support and Alignment Network. Her clinical expertise includes primary care consultation and providing mental health care to underserved populations. Dr. Ratzliff’s academic pursuits include developing strategies to provide mental health education to members of integrated care teams. Please visit the AIMS Center Website (aims.uw.edu) for Collaborative Care information.  

Why Mental Health? TCPI COMMON MEASURES NQF 0018: Controlling High Blood Pressure in Patients with Hypertension              NQF 0052: Use of Imaging Studies for Low Back Pain        NQF 418: Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan                    PQRS 402: Tobacco Use and Help with Quitting Among Adolescents                          NQF 2597: Substance Use Screening and Intervention Composite  NQF 2152: Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling NQF 0028: Preventive Care & Screening: Tobacco Use: Screening and Cessation Intervention        TCPI 01:  Comprehensive Health and Life Plan      TCPI 02:  Referral of At-Risk Patients TCPI 03:  Medication Management

Who Gets Mental Health Treatment? Wang et al., 2005

No Treatment Primary Care Provider Mental Health Provider

Mental Health in Primary Care Settings Hospital CMHC Specialty Care Collaborative Care Brief Behavioral Interventions Primary Care Patient Self-Management COORDINATION

Patient-Centered Collaborative Care Team New Roles Primary Care Provider Psychiatric Consultant Care Manager ( MSW, RN, PhD) Patient © University of Washington Part 2

Behavioral Health Services Available Assessment and treatment planning by team Indirect case-reviews by psychiatric consultant Tele-video assessment as needed by psychiatric consultant Care Planning Patient tracking of all active patients by care manager Relapse prevention planning by care manager Facilitated referral to specialty mental health by care manager Care Management Primary care provider prescribes medications Medication Prescribing Psychosocial support delivered by care manager Brief behavioral interventions delivered by care manager Psychotherapy Intervention

Doubles Effectiveness of Care for Depression 2. Key Components of Integrated Care_Unutzer Doubles Effectiveness of Care for Depression 50 % or greater improvement in depression at 12 months % Participating Organizations Unützer et al., JAMA 2002; Psych Clin North America 2004

IMPACT Care Benefits Diverse Populations 50 % or greater improvement in depression at 12 months Arean et al. Medical Care, 2005

Collaborative Care Effective for Asian-American Populations Three groups compared: Asians at Community health center that focuses on Asians (culturally sensitive clinic) General community health centers Matched population of whites treated at the same general community clinics Implementation study of collaborative care for 345 participants primary care visits with depression care managers, PCP prescribing, psychiatric consultation depression severity (PHQ9) tracked at baseline and 16 weeks RESULT: After adjustment for differences in baseline demographic characteristics, all three groups had similar treatment process and depression outcomes  Asian patients served at the culturally sensitive clinic (N=129) were less likely than Asians (N=72) and whites (N=144) treated in general community health clinics to be prescribed psychotropic medications CONCLUSION: Collaborative care effective way to treat depression in Asian American populations More Asian American served when collaborative care delivered in culturally sensitive clinics Ratzliff et al. Psychiatr Serv. 2013

State-wide Collaborative Care program Safety-net practices/FQHCs Mental Health Improvement Program (MHIP) Behavioral Health Improvement Program (BHIP) Our Practice State-wide Collaborative Care program Safety-net practices/FQHCs Started in 2008 >50,000 patients served to date UW primary care clinics- now 19 Mixed payer population Started in 2011 4660 indirect/ 8717 direct patient assessments to date Part 2

Variable number of PCPs ~3-20 0.2 FTE psychiatric consultant Mental Health Improvement Program (MHIP) Team Behavioral Health Improvement Program (BHIP) Team Our Practice 1.0 - 3.0 FTE care manager Variable number of PCPs ~3-20 0.2 FTE psychiatric consultant 1.0 FTE care manager ~ 5.0 FTE PCPs 0.2 FTE psychiatric consultant Part 2

What is performance? Process Outcomes Close follow-up (Minimum 2 contacts/month) Regular use of behavioral health measures (PHQ-9) Psychiatric consultation if patient not improved Clinical Outcomes PHQ-9 (depression measure for screening and tracking) GAD-7 (anxiety measure for screening and tracking)

PHQ-9: Scale 0 to 27 (increasing severity) Over the last 2 weeks, how many days have you been bothered by any of the following problems? Not at All Several Days More than Half the Days Nearly Every Day 1. Little interest or pleasure in doing things 1 2 3 2. Feeling down, depressed or hopeless 3. Trouble falling asleep, staying asleep or sleeping too much 4. Feeling tired or having little energy 5. Poor appetite or overeating 6. Feeling bad about yourself – or that you are a failure or have let yourself or your family down. 7. Trouble concentrating on things, such as reading the newspaper or watching television 8. Moving or speaking so slowly that other people could have noticed. Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual. 9. Thoughts that you would be better off dead or of hurting yourself in some way. If you checked off any problem on this questionnaire so far, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? Not difficult at all Somewhat difficult Very Difficult Extremely difficult

High Performance Areas: MHIP Initial results from pilot showing taking a long time for patients to show improvement in depression Pay for performance on process measures Complete initial assessment Meet with psychiatric consultant weekly and obtain indirect assessments on all patients not improving Half of caseload had to receive 2 contacts per month Population management target = 50% of patients show improvement on PHQ-9 Part 3 and 4

MHIP: Pay-for-performance cut in half the median time to achieve improvement in 50% of patients. © University of Washington AFTER P4P: ~ 26 week s to 50% of patients to improve BEFORE P4P: ~68 week s to 50% of patients to improve Unützer et al., 2012

BHIP: High Performance Areas Population management target >50% of patients show improvement on PHQ-9 Estimated costs savings: defined as medical care cost savings per patient enrolled

BHIP: High Performance over 4 years 2012 2013 2014 2015 Number of Clinics 10 12 15 Number of Patients Enrolled 262 771 763 705 Average PHQ-9 at First Assessment 14.5 13.5 12.9 Indirect Psychiatric Consultations 231 1505 1087 1417 Face-to-Face 320 2346 2394 3044 Percent of Patients Improved 81% 68% 64% 63% Estimated Cost Savings $340,000 $1,002,000 $991,900 $916,500

BHIP: High Performance Spread Early success helped with implementation Started with 5 clinics  now at 19 clinics PCP satisfaction helped with spread “I practiced for 16 years without it and I will never go back” primary care physician, UW Neighborhood Clinic Part 3 and 4

Using Data to Manage Performance Registry tool allows practice to track patient data and response to treatment Visits Indirect assessments Graphs of measures Clinic level data Caseload number Processes ( ex. Completed clinical assessment) Outcomes (ex current number of patient with clincial improvement)

Behavioral Health Measurement-Based Treatment to Target Part 5 Regular use of behavioral health measures to track response to treatment Use of psychiatrists to help intensify treatment Stepped care makes efficient use of behavioral health resources

Continuous Quality Improvement Care Manager 1 Manager 2 © University of Washington Part 5 This example shows is summary data from a web-based registry which shows aggregate data from two different care manager caseloads, Care Manager 1 and Care Manager 2. In this particular situation, the team was regularly reviewing the data and making observations. If you call your attention to the red box, both of these care managers were having a positive impact on their patient populations with respective improvement rates of 49% and 68%. Although both of these are good numbers, it is notable that Care Manager 2 was able to obtain higher improvement rates than Care Manager 1. So the clinic manager sat down with these two care managers and looked at the data with them. One of the things that the clinic manager noticed was that Care Manager 2 was having almost twice as many follow-up contacts as Care Manager 1. This was a really important observation. In digging a little bit deeper, the clinic manager found that Care Manager 2 conducted a lot more phone contacts than Care Manager 1. One hypothesis was that the increased availability and frequency of engagement with the patients might be driving some of those higher outcomes. When the team reviewed this information and spoke to Care Manager 2, what they found was that every time Care Manager 2 had a cancellation or a no-show patient, she would pick up the phone and make 2-3 phone calls to patients that hadn’t come in. By doing this, she was getting in a lot more phone contacts with those patients that were falling through the cracks: she was able to deliver PHQ-9 screeners, and she was also able to engage patients in both coming back in and assessing how their treatment was going. So a typical quality improvement effort that you might be able to implement when you see data like this is to train up Care Manager 1 to follow the same protocol, and then you could observe over time: is Care Manager 1 able to have more phone visits, and does that in fact drive better patient outcomes? This example illustrates the commitment to regularly using data to look at the care delivered and commit to continuously looking for opportunities to improve it. This idea can be useful no matter what type of practice you are currently working in.

Data Workflow Individual Patient Records Care Manger Caseload Registries Clinic Level Summaries Data Workflow

Critical to communicate a clear vision the ‘Why’ to everyone involved Lessons Learned Critical to communicate a clear vision the ‘Why’ to everyone involved IT infrastructure important tools to support the registry, tracking of patients and metrics Effective recruitment and training of care managers was essential Operationally, it helped to have strong pilot sites Part 6

Need and Demand 1500 patients 1 PCP with 10% of the population with mental health needs Insured Population  ~2% enrolled = 30 patients 0.05FTE psychiatric consultant 0.5FTE care manager Safety-Net Population  ~5% enrolled = 75 patients 0.1FTE psychiatric consultant 1.0FTE care manager

Gather stakeholders and develop a vision How to Get Started Gather stakeholders and develop a vision What are behavioral health needs? What resources are available? Establish clear goals to determine value Define value broadly: patient and provider experience, PCP efficiency, etc… How will you measure? Map on to other organizational change NCQA, PCMH, TCPI Part 7

Questions?

Presenter Info Anna Ratzliff, MD, PhD Email: annar22@uw.edu Telephone: 206-543-4292 Websites: APA-SAN - https://www.psychiatry.org/psychiatrists/practice/professional-interests/integrated-care UW AIMS - http://aims.uw.edu/ UW ICTP - http://ictp.uw.edu/