Behavioral Health Services for Injured or Ill workers – Collaborative Care Analysis and Recommendations January 22, 2015

Collaborative Care Review  Informal IIMAC meetings to review data and discuss psychiatric care issues (July – October 2013)  IIMAC recommended Focus on Collaborative Care (January 2014).  Requested Review to –update L&I data on claims with psychiatric treatment –identify current Washington state implementation –summarize currently well done literature reviews  Use Review and IIMAC feedback as a base for executive recommendations and next steps 2

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Local Collaborative Care Implementation 1.Identified Models currently implemented in WA state –Group Health –Medicaid’s Community Health Plan of Washington (CHPW) 2.Conducted Semi-Structured interviews 3.Defined Core Components/Key Elements 4.Identified Key Contacts 5.Obtained and Summarized Detailed information Outcome: Documented and understand local implementation status, potential for collaboration or coordination and key informant assistance (learnings), if move forward. 6

Key Collaborative Care Components Identified key elements from the Medicaid/Group Health comparison for further investigation via a review of collaborative care studies  Conditions treated (mild, moderate or severe)  Screening protocols and validated instruments  Role of the care coordinator  Typical providers participating  Best practices for communication (e.g., systematic protocols, timing, tools, technology)  Reported outcomes (e.g., clinical improvement, process measures) 7

Key Studies Identified Five key studies related to collaborative care models for behavioral health in primary care were identified: 3 systematic reviews including a Cochrane review, 1 randomized controlled trial and 1 prospective study.  Archer, et.al. 2012, Cochrane Review, Collaborative care for depression and anxiety problems. A meta-analysis/systematic review.  Gilbody, et.al. 2006, Arch Intern Med, Collaborative care for depression, A cumulative meta-analysis and review of longer-term outcomes.  Williams, Jr., et.al. 2007, General Hospital Psychiatry, Systematic review of multifacted interventions to improve depression care.  Unutzer, et.al. 2002, JAMA, Collaborative Care Management of Late-Life Depression in the Primary Care Setting. A randomized controlled trial  Katon, et.al. 2002, J Gen Intern Med, Long-term effects of a collaborative care intervention in persistently depressed primary care patients. A prospective cohort study. 8

Strong and consistent evidence For example, the Williams review included 28 studies with over 1,800 clinicians and 11,000 patients where the majority of studies had low risk of bias; randomized by either patient, providers or practices; outcomes were assessed blind to treatment assignment; an intent to treat assignment was used; and interventions were generally well defined and compared to usual care where the clinician or patient was educated about the assessment of depression. More rapid and sustained improvement in both short and longer term: mental health outcomes employment rates, functioning, quality of life Example: Unutzer 2002 found that at 12 months follow up, 45% of the intervention (collaborative care) patients had a 50% or greater reduction in symptoms from baseline as compared to 19% of patients in the usual care group (OR 3.45, p<0.001). 9

Review includes excellent analysis to organize further considerations. Example: Williams provided a useful framework that groups the intervention into four categories 1.Delivery system redesign (care management and enhanced mental health access) – structured assessment and regular monitoring Decision support (PCP and patient education) – educational materials; treatment algorithms; and/or patient specific feedback 2.Information systems –electronic systems to track and monitor patient assessment and progress 3.Self-management – educational materials, and half of the studies built self-management support into care manager functions 10

Review includes excellent analysis to develop focus group questions regarding program design, measures, outcomes, leading to better outcomes for example: Sample of correlation found 1.Structured (proactive) care management 2.support of medication management by primary care providers 3.Supervision (regular/planned) of care managers (usually by psychiatrist) 4.Case managers with a mental health background 5.Strong clinical champion 6.Resources to support infrastructure, training, and care manager Sample of lack of correlation 1.Number of sessions with a case manager 2.Addition of specific types of psychotherapy to medication management, or where antidepressants were prescribed at start. 11

COHE: Innovation in Collaborative, Accountable Care Primary Occupational Health Best Practices Surgical & Specialty Best Practices HSCs OHMS Burns Prosthetics Chronic Pain Best Practices Behavioral Health Next Steps 12