Why Behavioral Health Needs to be Integrated into the Patient-Centered Medical Home (PCMH) *Originally adapted from PCPCC’s Behavioral Health Task Force Slide Deck. Last updated September 2014.

Purpose of Slide Deck To allow users to adapt these slides for your own presentations. Please see the notes sections for more detailed information. This slide deck is focused on “why” behavioral health should be integrated in the patient-centered medical home (PCMH). You may also pull slides from a second deck to learn about the “where” and “how” behavioral health is being integrated into the PCMH. This slide deck is meant for use by organizations considering transformation to PCMH, those already practicing patient-centered care now moving on to integration of behavioral health, and those wanting to improve their integration model. Many of the slides include basic instruction to be bypassed by experienced clinics. The presenter should consider presenting the material in three sessions based on the audience. If they are already practicing PCMH and know about integration, but are not convinced, go to section two (“Reasons Why Behavioral Health Should be Part of the PCMH”). If the clinic is already convinced to integrate, start with the models (“PCMH Integrated Behavioral Health Models“).

Slide Deck Outline Definitions Behavioral Health Integrated Behavioral Health Reasons Why Behavioral Health Should be Part of the PCMH High prevalence of behavioral health problems in primary care High burden of behavioral health in primary care High cost of unmet behavioral health needs Lower cost when behavioral health needs are met Better health outcomes Improved satisfaction Collaborative care is a medical home Resources & Acknowledgements This slide deck is meant for use by organizations considering transformation to PCMH, those already practicing patient-centered care now moving on to integration of behavioral health, and those wanting to improve their integration model. Many of the slides include basic instruction to be bypassed by experienced clinics. Presenters should consider presenting the material in three sessions based on the audience. If they are already practicing PCMH and know about integration, but are not convinced, go to section two of this slide deck (“Reasons Why Behavioral Health Should be Part of the PCMH”). If the clinic is already convinced to integrate, start with the models on slide deck two (“PCMH Integrated Behavioral Health Models“).

Behavioral Health & Integration Defined 4

Defining Behavioral Health Behavioral Health is an umbrella term for care that addresses any behavioral problems impacting health, including mental health and substance abuse conditions, stress-linked physical symptoms, patient activation and health behaviors. The job of all kinds of care settings, and done by clinicians and health coaches of various disciplines or training. Source: Peek, C. J., National Integration Academy Council. (2013). Lexicon for Behavioral Health and Primary Care Integration: Concepts and Definitions Developed by Expert Consensus. In Agency for Healthcare Research and Quality (Ed.), AHRQ Publication No.13-IP001-EF.

Behavioral Health Integration Care resulting from a practice team of primary care and behavioral health clinicians, working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population. This care may address mental health, substance abuse conditions, health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stress-related physical symptoms, and ineffective patterns of health care utilization. Source: Peek, C. J., National Integration Academy Council. (2013). Lexicon for Behavioral Health and Primary Care Integration: Concepts and Definitions Developed by Expert Consensus. In Agency for Healthcare Research and Quality (Ed.), AHRQ Publication No.13-IP001-EF.

A Legacy of Separate and Parallel Systems Medical Care Mental Health Care A forced choice between: • 2 kinds of problems • 2 kinds of clinicians • 2 kinds of clinics • 2 kinds of treatments • 2 kinds of insurance Integrated behavioral health leads to a better match of clinical services to the realities that patients and their clinicians face daily. Original Source: CJ Peek 1996

Primary Care is the ‘De Facto’ Mental Health System Pie of all behavioral health needs Source: Wang P et al. Arch Gen Psychiatry, 2005: 62. Adapted from Katon, Rundell, Unützer, Academy of PSM Integrated Behavioral Health 2014

Mental Health Conditions Integrated Care for Medical Conditions Meeting Patients Where They Are: Deploy integrated behavioral health expertise to reduce stigma against seeking mental health care Integrated Care for Mental Health Conditions • Depression/Anxiety • Substance Abuse • ADHD • Other Integrated Care for Medical Conditions • Diabetes/BP/Obesity • Heart Disease • Childhood Chronic Illness • Stress-linked Physical Symptoms Integrated Care for Persons: Social and Care Complexity Functional impairments or diagnostic uncertainty Distress, distraction & readiness to engage in care Social safety, support & participation Organization of care / relationships in health system Shared language with providers / sufficient insurance Source: CJ Peek & Mac Baird, 2010

Scope of Integrated Behavioral Health: A Range of Goals Patients with mental health/ substance abuse conditions / risks Depression/Anxiety/PTSD/ADHD, other Substance Abuse/Dependence Patients with stress-linked or unexplained physical symptoms. Headache, insomnia, pain, fatigue, dizziness, numbness, “don’t feel well”, frequent visits for no apparent medical cause Patients with unmanaged behavioral risk factors in chronic illnesses Diabetes / High BP /Obesity / Heart Disease Asthma / Childhood Chronic Illness Other Persons with any complex social/ medical situation that interferes with standard care Functional impairment, diagnostic uncertainty Multiple interacting conditions Distress, distraction, difficulty engaging care Lack of social safety & support Disorganized care or patient-clinician relationships Language / Culture / Insurance barriers Clients with mental health/ substance abuse conditions receiving care in intensive mental health / substance abuse settings Basic primary care / chronic illness management Timely preventive care Health behaviors Source: CJ Peek 2010

Why Behavioral Health Should be Part of the PCMH

Six Reasons Why Behavioral Health Should be Part of the PCMH High prevalence of behavioral health problems in primary care (needing long-term follow-up) High burden of behavioral health in primary care High cost of unmet behavioral health needs Lower cost when behavioral health needs are met Better health outcomes Improved satisfaction Triple Aim the map to PCMH success… Behavioral health integration achieves the triple aim.

Prevalence Sources: 1McGinnis JM et al. JAMA 1993; 270:2207-12. 2Mokdad AH, et al. JAMA 2004; 291:1230-1245.

Prevalence Behavioral Health is Highly Prevalent in Primary Care 84% of the time, the 14 most common physical complaints have no identifiable organic etiology1 80% of individuals with a behavioral health disorder will visit primary care at least 1 time in a calendar year2 50% of all behavioral health disorders are treated in primary care3 20-40% of primary care patients have behavioral health needs4 48% of the appointments for all psychotropic agents are with a non-psychiatric primary care provider5 Sources: 1Kroenke & Mangelsdorf, Am J Med. 1989;86:262-266. 2Narrow et al., Arch Gen Psychiatry. 1993;50:5-107. 3Kessler et al., NEJM. 2006;353:2515-23. 4Martin et al., Lancet. 2007; 370:859-877. 5Pincus et al., JAMA. 1998;279:526-531. Sources: 1Kroenke & Mangelsdorf, Am J Med. 1989;86:262-266. 2Narrow et al., Arch Gen Psychiatry. 1993;50:5-107. 3Kessler et al., NEJM. 2006;353:2515-23. 4Martin et al., Lancet. 2007; 370:859-877. 5Pincus et al., JAMA. 1998;279:526-531.

Source: Barnett et al, Lancet 2012 Prevalence As physical health worsens, the odds of having mental illness increase. Source: Barnett et al, Lancet 2012

Unmet Behavioral Health Needs 67% of individuals with a behavioral health disorder do not get behavioral health treatment1 30-50% of referrals to behavioral health from primary care don’t make first appt2,3 Two-thirds of primary care physicians reported not being able to access outpatient behavioral health for their patients4 due to: Shortages of mental health care providers Health plan barriers Lack of coverage or inadequate coverage Depression goes undetected in >50% of primary care patients5 Only 20-40% of patients improve substantially in 6 months without specialty assistance6 Why do they go “unmet? STIGMA! Sources: 1Kessler et al., NEJM. 2005;352:515-23. 2Fisher & Ransom, Arch Intern Med. 1997;6:324-333. 3Hoge et al., JAMA. 2006;95:1023-1032. 4Cunningham, Health Affairs. 2009; 3:w490-w501. 5Mitchell et al. Lancet, 2009; 374:609-619. 6Schulberg et al. Arch Gen Psych. 1996; 53:913-919 Sources: 1Kessler et al., NEJM. 2005;352:515-23. 2Fisher & Ransom, Arch Intern Med. 1997;6:324-333. 3Hoge et al., JAMA. 2006;95:1023-1032. 4Cunningham, Health Affairs. 2009; 3:w490-w501. 5Mitchell et al. Lancet, 2009; 374:609-619. 6Schulberg et al. Arch Gen Psych. 1996; 53:913-919

Source: Martin et al., Lancet. 2007; 370:859-877 Unmet Behavioral Health Needs (21%) Behavioral health conditions account for the largest proportion of years of productive life lost (YPLL). Source: Martin et al., Lancet. 2007; 370:859-877

High Cost of Unmet Behavioral Health Needs Individuals with behavioral health and substance abuse conditions cost 2-3 times as much as those without1 Behavioral health disorders account for half as many disability days as “all” physical conditions2 Annual medical expenses--chronic medical & behavioral health conditions combined cost 46% more than those with only a chronic medical condition3 Top five conditions driving overall health cost4 Depression Obesity Arthritis Back/Neck Pain Anxiety Sources: 1Milliman report to the APA, August 2013 available here. 2Merikangas et al., Arch Gen Psychiatry. 2007;64:1180-1188. 3Original source data is the U.S. Dept of HHS the 2002 and 2003 MEPS. 4Loeppke et al., J Occup Environ Med. 2009;51:411-428.

Top 10 Costliest Conditions for Employers ($/1,000 FTE) High Cost of Unmet Behavioral Health Needs Top 10 Costliest Conditions for Employers ($/1,000 FTE) Source: Loeppke, et al., JOEM. 2009;51(4):411-428.

High Cost of Unmet Behavioral Health Needs Annual healthcare costs are much greater for diabetes and heart disease patients with depression1 Untreated mental disorders in chronic illness are projected to cost commercial and Medicare purchasers between $130 and $350 billion annually2 Approximately 217 million days of work are lost annually to related mental illness and substance use disorders (costing employers $17 billion/year)2 Sources: 1Original source data is the U.S. Dept of HHS the 2002 and 2003 MEPS. 2Hertz RP, et al. Pfizer Outcomes Research. Publication No P0002981. Pfizer; 2002.

Lower Cost when Behavioral Health Treated Medical use decreased 15.7% for those receiving behavioral health treatment while medical use increased 12.3%1 for controls who did not receive behavioral health treatment Depression treatment in primary care for those with diabetes resulted in $896 lower total health care cost over 24 months2 Depression treatment in primary care resulted in $3,300 lower total health care cost over 48 months3 This resulted in a return of $6.50 for every $1 spent Multi-condition collaborative care for depression and diabetes saved $594 per patient over 24 months.4 Sources: 1Chiles et al., Clinical Psychology. 1999;6:204–220. 2Katon et al., Diabetes Care. 2006;29:265-270. 3Unützer et al., American Journal of Managed Care 2008;14:95-100. 4Katon et al. Arch Gen Psych, 2012:69:506-514

Lower Cost when Behavioral Health Treated IMPACT: Collaborative Care for Depression Reduces Costs Cost Category 4-year costs in $ Intervention group cost in $ Usual care group cost in $ Difference in $ IMPACT program cost 522 Outpatient mental health costs 661 558 767 -210 Pharmacy costs 7,284 6,942 7,636 -694 Other outpatient costs 14,306 14,160 14,456 -296 Inpatient medical costs 8,452 7,179 9,757 -2578 Inpatient mental health / substance abuse costs 114 61 169 -108 Total health care cost 31,082 29,422 32,785 -$3363 $avings Source: Unützer et al., American Journal of Managed Care 2008;14:95-100

Improved adherence to evidence-based treatment3 Improved Mental Health Outcomes Over 75 trials in collaborative care in nearly 2 decades have proven significant benefit for depression and anxiety disorders1 Interventions work in a wide variety of settings in a wide variety of mental health conditions2 Improved Outcomes2 Sources: 1Archer et al, Cochrane Syst Data Rev, 2012: 10. 2Woltman et al, AJP, 2012: 169:790-784. 3Gilbody et al, Arch Int Med, 2006:166:2314-2321 Improved adherence to evidence-based treatment3 Sources: 1Archer et al, Cochrane Syst Data Rev, 2012: 10. 2Woltman et al, AJP, 2012: 169:790-784. 3Gilbody et al, Arch Int Med, 2006:166:2314-2321

Overall quality of life and physical health improve consistently2 Leading to Improved Physical Health Outcomes When treated in harmony with mental health, chronic physical health improves significantly1 Improved Diabetes1 Improved BP1 Improved Cholesterol1 Sources: 1Katon et al, NEJM, 2010:363:2611-2620. 2Woltman et al, AJP, 2012: 169:790-784. Overall quality of life and physical health improve consistently2 Physical health Quality of life Sources: 1Katon et al, NEJM, 2010:363:2611-2620. 2Woltman et al, AJP, 2012: 169:790-784.

Improved Patient Satisfaction After 12 months of care, multi-condition collaborative care improved patient satisfaction in depression AND diabetes care1 Diabetes care Depression care synergy Patient testimonial on integrated care: "...the staff at Marillac Clinic actually cared about what I had to say- they were there to help when I needed it - not just medical help, but counseling - and the medications I needed to get well. They helped me learn how to care for myself - I understood how to accept myself from the kindness in their eyes.” - Past patient of Marillac Clinic, Grand Junction, Colorado Source: 1Katon et al, NEJM, 2010:363:2611-2620

photo courtesy: http://www.teamcarehealth.org/ Improved Provider Satisfaction Primary care physicians like integrated care for a variety of reasons1 Behavioral health specialists are also satisfied with working in integrated settings2 Sources: 1Gallo et al, Ann Fam Med, 2004:2: 305-309. 2Levine et al., Gen Hosp Psych. 2005; 27:383-391 photo courtesy: http://www.teamcarehealth.org/ Sources: 1Gallo et al, Ann Fam Med, 2004:2: 305-309. 2Levine et al., Gen Hosp Psych. 2005; 27:383-391

Review: Six Reasons Why Behavioral Health Should be Part of the PCMH High prevalence of behavioral health problems in primary care High burden of behavioral health in primary care High cost of unmet behavioral health needs Lower cost when behavioral health needs are met Better health outcomes Improved satisfaction BONUS! Collaborative care IS a medical home! Behavioral Health is an integral component of the PCMH. the map to PCMH success…

Core Principles of Effective Collaborative Care Patient-Centered Medical Home A PCMH is not a PCMH without Behavioral Health Core Principles of Effective Collaborative Care Patient-Centered Care Teams Team-based care: effective collaboration between PCPs and Behavioral Health Providers. Nurses, social workers, psychologists, psychiatrists, licensed counselors, pharmacists, and medical assistants can all play an important role. Population-Based Care Behavioral health patients tracked in a registry: no one ‘falls through the cracks’. Measurement-Based “Treat to Target” Measurable treatment goals clearly defined and tracked for each patient. Treatments are actively changed until the clinical goals are achieved – “treat to target”. Evidence-Based Care Treatments used are ‘evidence-based’. Pharmacology, brief psychotherapeutic interventions, models. Source: http://uwaims.org

Core Principles of the Medical Home Patient-Centered Medical Home A PCMH is not a PCMH without Behavioral Health Core Principles of the Medical Home Whole Person Orientation Integrated mind AND body health care. Coordinated Integrated Care Personalized care across acute and chronic problems, including prevention with focus on the physical, social, environmental, emotional, behavioral and cognitive aspects of health care. Enhanced Access Improved access to the range of physical and mental health needs for systems implementing collaborative care for mental health and physical health. Payment for Added Value Enhanced evidence-based screening, assessment and intervention for mental/behavioral health, substance use and health behavior change resulting in achieving the triple aim for mental and physical health Source: https://www.ncqa.org/

Patient-Centered Medical Home Collaborative care is a medical home New NCQA PCMH Standards released in 2014 – out of 6 must-pass elements, Behavioral Health meets 5! Patient-Centered Appointment Access Practice Team (Team-Based Care) Use Data for Population Management Care Planning and Self-Care Support Referral Tracking and Follow-up Implement Continuous Quality Improvement https://www.ncqa.org/

Resources & Acknowledgements

Selected Resources AHRQ Academy for Integrating Behavioral Health and Primary Care: http://integrationacademy.ahrq.gov/ AIMS CENTER: http://aims.uw.edu/ Center for Integrated Primary Care: http://www.umassmed.edu/cipc/ Collaborative Family Healthcare Association: www.cfha.net Evolving Models of Behavioral Health Integration in primary Care. Milbank Memorial Fund 2010. http://www.milbank.org Lexicon for Behavioral Health and Primary Care Integration. AHRQ 2013: http://integrationacademy.ahrq.gov/sites/ default/files/Lexicon.pdf National Alliance on Mental Illness. Integrating Mental Health & Pediatric Primary Care Resource Center: http://www.nami.org SAMHSA/HRSA Center for Integrated Health Solutions: http://www.integration.samhsa.gov

Acknowledgements Special thanks to: PCPCC’s Behavioral Health Group PCPCC’s Behavioral Health Advisory Team Alexander Blount, EdD, University of Massachusetts Parinda Khatri, PhD, Cherokee Health Systems Benjamin Miller, PsyD, University of Colorado George Patrin, MD, Serendipity Alliance CJ Peek, PhD, University of Minnesota David Pollack, MD, Oregon Health & Science University Erik Vanderlip, MD, University of Oklahoma *Originally adapted from PCPCC’s Behavioral Health Task Force Slide Deck. Last updated September 2014.