Integrated Care The Inseparability of the Mental and the Medical CFHA Summit San Diego, California Frank deGruy October 22, 2009

“…responsible for providing for all the patient’s health care needs…” “Care is coordinated and/or integrated across all elements…” 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 A Medical Home is: 2

Without mental and behavioral healthcare, the PCMH fails. Fails! 3

Mental Disorders Symptoms, Stress, Concerns Substance Abuse Health Behavior Change 4

Mental Disorders 5

6 Number of physical symptoms

Personal Health Costs Medical Care Pharmaceutical costs Workers’ Compensation Costs Productivity Costs Presenteeism Overtime Turnover Temporary Staffing Administrative Costs Replacement Training Off-Site Travel for Care Customer Dissatisfaction Variable Product Quality Absenteeism Short-term Disability Long-term Disability The Full Cost of Poor Health to Employers Iceberg of Full Costs to Employers from Poor Health Sources: Loeppke, R., et al., "Health and Productivity as a Business Strategy: A Multi-Employer Study", JOEM.2009; 51(4): 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: % 30% 7

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):

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):

10 The Comorbidity Story 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 11

12 McGinnis JM, Foege WH. Actual Causes of Death in the United States. JAMA 1993;270: Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual Causes of Death in the United States, JAMA 2004;291:

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 Requirement for behavior change Motivation to change

So What Does A Comprehensive Medical Home Look Like? 14 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 15

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 16

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 17