Integrated Care The Inseparability of the Mental and the Medical CFHA Summit San Diego, California Frank deGruy October 22, 2009 I’m going to try for two things in this talk: 1) to outline what the medical home is 2) to make the case for the inclusion of mental healthcare. The PCMH is more of an aspiration than an actual entity. You can go visit places that have made some of the changes toward becoming a PCMH, but it remains to be seen whether this is even a good idea. Nevertheless, many people are working toward this ideal, and It would be great if, when we flip the switch, the lights actually come on. It would also be great if we had wired every room for light. To that point, I think there’s an elephant in one of these rooms, and I want to make sure that the light in that room goes on. This is behavioral healthcare.

A Medical Home is: “…responsible for providing for all the patient’s health care needs…” “Care is coordinated and/or integrated across all elements…” This is lifted straight from the definition of a medical home in the Joint Principles statement. I’m focusing on two elements of the medical home: It’s comprehensive, and it’s coordinated. It’s comprehensive: all means all. We don’t have the luxury of leaving an inconvenient or difficult problem out—we have to be comprehensive. And this also reminds us that we suffer from fragmentation as one of the fundamental problems with our health care system and with primary care, that the PCMH is designed to fix. Our success with the medical home turns on eliminating fragmentation. We can’t defragment by blindly referring away problems simply because we have not equipped ourselves to deal with them. Joint Principles of the Patient Centered Medical Home American Academy of Family Physicians (AAFP) American Academy of Pediatrics (AAP) American College of Physicians (ACP) American Osteopathic Association (AOA) February 2007

Without mental and behavioral healthcare, the PCMH fails. Fails! This is the elephant in the room.

Mental Disorders Symptoms, Stress, Concerns Substance Abuse Health Behavior Change Let’s not take on all of the psychosocial territory. Today, let’s just think about two of these: mental disorders and health behavior change. I don’t think I need to convince you that this stuff matters in primary care. I’m here to push you to a more radical conclusion: the Patient-Centered Medical Home cannot succeed as an answer—cannot exist—without fully integrating the psychosocial and the biomedical until they both become something else. We must create an alloy—this is adding to iron carbon, chromium, molybdenum, nickel, vanadium, manganese, titanium, cobalt, and other elements, to produce steel, that is harder, more flexible, stronger, better able to take and hold an edge, and less likely to break, than any of those elements taken alone.

Mental Disorders

Number of physical symptoms This is from the PRIME-MD validation study. 1000 primary care patients. There is a strong positive linear relationship between the number of physical symptoms and the likelihood of a mental diagnosis. The curve is identical for the number of physical symptoms and the number of psychological symptoms. So if you have one, you have both. They run together. They are inextricable—inseparable. Comorbidity is the only condition there is! What do we think we are doing? Number of physical symptoms

The Full Cost of Poor Health to Employers Personal Health Costs Medical Care Pharmaceutical costs Workers’ Compensation Costs 30% Iceberg of Full Costs to Employers from Poor Health Productivity Costs 70% Absenteeism Short-term Disability Long-term Disability Presenteeism This HPBS study showed the broader presenteeism and absenteeism costs of poor health to employers were $2.30 for every $1.00 spent on medical/pharmacy costs, and did not even include the additional costs of the following: Workers’ Compensation Costs Short-term Disability Long-term Disability Overtime Turnover Temporary Staffing Administrative Costs Replacement Training Off-Site Travel for Care Customer Dissatisfaction Variable Product Quality Overtime Turnover Temporary Staffing Administrative Costs Replacement Training Off-Site Travel for Care Customer Dissatisfaction Variable Product Quality Sources: Loeppke, R., et al., "Health and Productivity as a Business Strategy: A Multi-Employer Study", JOEM.2009; 51(4):411-428. and Edington DW, Burton WN. Health and Productivity. In McCunney RJ, Editor. A Practical Approach to Occupational and Environmental Medicine. 3rd edition. Philadelphia, PA. Lippincott, Williams and Wilkens; 2003: 40-152

Top 10 Health Conditions Driving Med + Rx Costs per 1000 FTEs Loeppke, R., et al., "Health and Productivity as a Business Strategy: A Multi-Employer Study“. JOEM. 2009;51(4):411-428.

Top 10 Health Conditions Driving Full Costs for Employers (Med + RX + Absenteeism + Presenteeism) Costs/1000 FTEs Loeppke, R., et al., "Health and Productivity as a Business Strategy: A Multi-Employer Study“. JOEM. 2009;51(4):411-428.

The Comorbidity Story First, comorbidity is common—more than half of these patients with so-called chronic medical diseases meet criteria for a coexisting mental disorder. Second, as this graph shows, costs, even adjusted costs, are much higher in these patients. Third, if you treat them together, it is less expensive. Wayne Katon has nailed this one. Especially treat the depression in depressed diabetics. Fourth, if you treat them together, the health outcomes are better. Treat a depressed diabetic’s depression, and the diabetes gets better. Conclusion: wherever you’re treating chronic illnesses, you’d better be treating mental health problems. Robert Graham Center, “Why there must be room for mental health in the medical home; NBGH: An Employers’ Guide to Behavioral Health Services

Health Behavior Change

Look at this! Health behavior kills more people than anything! Changing health behavior is more important to health than anything. Whether we’re talking about prevention or chronic disease management, it takes health behavior change. Sometimes it’s easy, and sometimes it’s hard. Myopia doesn’t take a lot of skill—the amount of change is low, the motivation is high, and it generally takes only a nudge. Obesity, Type II DM, Bipolar disorder, are a different matter. They require heavy artillery. Motivational interviewing and other patient activation, self management plans with close monitoring, community support, and so on. Here you need either a very special care manager or health behavior change expertise—this is beyond the time and skill set of the usual PCP. Other problems, like GERD, or CAD, may or may not fall within the skill set of a PCP and care manager. McGinnis JM, Foege WH. Actual Causes of Death in the United States. JAMA 1993;270:2207-12. Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual Causes of Death in the United States, 2000. JAMA 2004;291:1230-1245.

Myopia Psoriasis Hypothyroidism Allergies Depression Multiple Sclerosis Epilepsy Chronic Back Pain Infertility Crohn’s Disease GERD Ulcerative Colitis Sickle Cell Disease Type I Diabetes Parkinson’s Cystic Fibrosis CAD Chronic Hep B Osteoporosis Cerebrovascular Dz Hypertension Hyperlipidemia Asthma CHF Schizophrenia Type II DM Alzheimer’s Obesity Bipolar Disorder Addictions Motivation to change Requirement for behavior change

So What Does A Comprehensive Medical Home Look Like? And where do we get the behavioral horsepower we need for it?

The Shape Of Practices Today: A solo doc in a micropractice A doc and a nurse Three partners, four staff …joined by a care coordinator …joined by a psychologist Eight partners, three care coordinators, a clinical pharmacist, two psychologists, and a partridge in a pear tree Staff HMO office with a full complement of resources FQHC with a different full complement of resources The Patient-Centered Medical Home is an ideal—a formulation of how care should be rendered. This ideal will be lived out, or embodied, in a number of forms. We have a lot of different kinds of practices right now, and my hypothesis is that all of them can undergo transformation into PCMHs. We can give examples of how that might work under certain conditions, such as practice size, proximity of resources, financing, etc., but the actual solutions are local and worked out on the ground.

Possible Structures for Integrated, Comprehensive Care A psychologist who does CBT both in her office and in the PCMH A psychiatrist who is in the medical home one afternoon a week A CMHC staff who are available any time by phone An MFT who works part time in the practice A Depression Center that consults by teleconferencing hookup A psychiatrist who spends one long breakfast a week with the PCPs and the Care manager reviewing charts A psychologist who works with the care coordinator .25 FTE on motivational interviewing and other health behavior change modalities I can keep going. The problem is not finding the people to do this—the problem is making it worthwhile to do it. The real problem is that right now it is impossibly difficult to do this—there are so many barriers. Tillman Farley worked as a solo PCP in Van Horn Texas, in the middle of nowhere, and he had a psychologist in his practice, and it was sustainable. All of these are options, and things we haven’t even thought of yet. The reason we aren’t doing this now is because we have built such bulletproof systems to insure fragmentation.

Principles Specify the job to be done Pay for outcomes Offer ideas and options about means Encourage local solutions Support the cost of change Closely evaluated case studies and demos Don’t force integration, and don’t overprescribe by discipline, FTE, or physical structure. Specify the job to be done, give some ideas about how some people have put this together, and incent working together. Offer help with personal transformation. Help with the wrenching transformation of practices. Be patient and persistent. Stay on it. So we need ACT trials. Remember the principles of self-management: learning collaboratives are very useful here.