Integrated Care: Where’s this going? Why? IBHP Grantee Convocation Sacramento, CA September 12, 2008 Frank deGruy What are my assumptions about you? You are already believers—you don’t need convincing that integration is a good thing You are informed—you don’t need a comprehensive, detailed review of the collaborative care literature I’ll be very selective here You are researchers—you are testing something out Your questions will be more how than why—you really are interested in methods Who am I? Family Doc Mental Health Services Researcher Program developer An old guy who’s been around for thirty years of this Impatient activist

Definitions Integrated Behavioral Health Combining dissimilar things into a coherent whole that has meaning and value Behavioral Health Mental disorders Substance use problems Health behavior change

Where Did This Come From? Mental Health Services Research NIMH AHRQ RWJ MacArthur Substance Use and Criminality Quality Improvement Clinical Decisionmaking and EBM PBRNs

Progress In Methods, 1 Basic Design Issues Efficacy to effectiveness Heterogeneous study samples Usual Care control groups Multilevel interventions Multilevel and mixed methods evaluations Stepped Care Multistep interventions QI “Research” PBRN methods

Progress In Methods, 2 Economic analyses Chronic Disease Management Direct and Indirect Costs Cost Offset Cost Effectiveness Cost Benefit Chronic Disease Management Registry Self management Care manager Care protocol Objective outcome measurement

What Have We Learned? 1 Prevalence and nature of the problems Depression & impairment, then the others Comorbidity Adequacy of treatment Health behavior change Nature of primary care practices Patients are reluctant to fragment care Practices are overwhelmed: competing demands Systemic nature of practice Easier to change than to sustain Depression occurs in 20% of patients w/ MI. In 60-70%, it lasts 1-4 months It’s associated with a 3X increased mortality. Associated with inflammatory markers Associated with poor compliance with rehab regimen SSRIs improve outcomes DM w/ depression more out of control BS Blood pressure actually better Lipids lower LDL Treatment w/ antidepressants helped glucose, helped BP, not lipids. Mental dxs assoc with increased utilization esp anxiety disorders. Rx lowers utilization Depression is a risk factor for medical rehospitalization

What Have We Learned? 2 Nature of the partners Strange environment, different assumptions Different work styles Not used well Teamwork: new layer of overhead Nature of supporting systems Commodification of clinicians and practices Carveouts More difficult to change Different priorities, incentives (incentives!)

The Medical Home What is it? Probable defining context Behavioral/mental health integration at risk for marginalization Mandate for MH resources to serve multiple purposes Learn DM, Asthma, CAD literature Comorbidity

Today’s Problems System Issues How to deal with carveouts Reimbursement rules & productivity incentives Benefits design How to deal with carveouts Who pays for care managers? Specialty consultants? Who “owns” them? Where do they live?

Design Issues Pilot Mentality Running assessment Midcourse corrections Emphasis on teamwork Vertical Integration