Funded under contract #HHSA i by the Agency for Healthcare Research and Quality Pilot Survey of Approaches to Integrated Care in Solo & Small Primary Care Practices Collaborative Family Healthcare Association 16 th Annual Conference October 16-18, 2014 Washington, DC Session 3b October 17,

Vasudha Narayanan, MA, MBA, MS. Associate Director Westat Paul Weinfurter, MSPH Sr. Study Director Westat Benjamin F. Miller, PsyD Department of Family Medicine University of Colorado School of Medicine Garrett Moran, PhD Vice President Westat Co-Authors 2

National Integration Academy Council Agency for Healthcare Research and Quality Acknowledgements 3

Faculty Disclosure We have not had any relevant financial relationships during the past 12 months. 4

Learning Objectives At the conclusion of this session, the participant will be able to: Identify potential barriers to behavioral health integration due to lack of access to behavioral health providers Discuss what steps can be taken to overcome these barriers 5

Learning Assessment We will hold a question and answer/ discussion at the end of this presentation. 6

Integrated behavioral health care is the care a patient experiences as a result of a 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 and 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 What is Integrated Care 7

To understand how PCPs in solo and smaller practices manage behavioral health conditions Goal Of This Study 8

72 percent of all Americans make an average of 6 office visits to an ambulatory primary care setting each year (Bernstein et al 2003) Primary care is the logical basis of an effective health care system (IOM 1996) Ultimately good care is “whole person” care Why Is This Important 9

o Qualitative methods to design a pilot survey o Mixed method data collection Quantitative data from survey Qualitative data from in-depth follow-up interviews Study Methods 10

Sample frame o National Plan and Provider Enumeration System Providers with a National Provider Identifier (NPI) value o Subset to 10 states o Primary Care Practices Restricted to Internal Medicine and Family Medicine Practitioners o Solo and Small Defined a “small” practice as a practice with fewer than 10 total health care providers Who did we talk to? 11

33% response rate – 215 completed eligible surveys – 21 in-depth follow-up interviews Data have been weighted – Results should not be used to make inferences about physicians across the country. Response 12

Profile of Responding Physicians Size of practiceFamily medicineInternal medicineGeneral practiceAll One/solo practice11%18%2%32% 2-5 physicians41%8%0%49% %7%1%19% All64%33%3%100% Total population of PCPs in sampled states* 27,08213,9201,38742,389 Source: 2013 Survey of Behavioral Health Care in Solo and Smaller Primary Care Settings. 13 Colorado, California, Maine, North Carolina, Texas, Maryland, Virginia, Louisiana, Illinois, Kansas

87% of PCPs include other, non-physician health care providers 21% share practice with behavioral health providers Physicians’ Practice Staffing 14

o Nearly all PCPs treat with medication refer patient to a behavioral health provider o PCPs also treated patients by counseling them Treatment 15

79% systematically screen for behavioral health conditions 87% systematically screen for chronic physical conditions 74% have a systematic process to screen for both chronic physical and behavioral health conditions 8% have no systematic process for either conditions Screening 16

Treatment: Adoption of evidence-based standards Condition% of PCPs Diabetes62% Cardiovascular disease53% Asthma48% Depression28% Anxiety25% Substance abuse21% 17

Steps taken by PCPs during care of patients with behavioral health care needs Steps takenUsually or Always Screen patients periodically71% Adjust the treatment approach based on response to treatment88% Involve behavioral health specialists in challenging cases that do not quickly respond 76% Follow U.S.P.S Task Force guidelines for depression55% Follow U.S.P.S Task Force guidelines for alcohol misuse53% Follow U.S.P.S Task Force guidelines for tobacco use73% 18

Treatment: Referral 19 15% 79% refer to an offsite BHCP 6% refer to an onsite BHCP

o 69% of PCPs require their patients to be responsible for their own coordination and follow-up o 11% have a care manager or social worker in place to coordinate needed care for patients o 20% coordinate the follow-up directly with the behavioral health provider o 53% of practices with an onsite behavioral provider have a process for care coordination o 25% practices with no onsite behavioral provider have a process for care coordination Treatment: Care Coordination 20

o A quarter of PCPs do not work in care teams o Of those who do work in care teams: 88% agreed that collaboration within teams results in better decisions around patient care 68 % disagreed that involvement of multiple team members increases the likelihood of medical errors 66% disagreed that the team process creates a burden for the care team Almost all PCPs agreed they are responsible for behavioral care of patients Working in Care-Teams 21

o An onsite behavioral care provider improves o frequency of feedback 99% of the time vs. 70% of the time o frequency of verbal conversations 64% vs. 28% Feedback loop– Referral and Care Coordination 22

o An onsite behavioral provider does not appear to change how PCPs share decisions with patient and/or patient’s families 57 % vs. 54% Providing Behavioral Care – Shared Decision Making 23

o PCPs agreed they are responsible for behavioral care of patients o Co-location improves the ability of the PCP and behavioral care provider to communicate and collaborate However, co-location alone does not equal integrated care o This pilot study will be able to guide the development of a national survey of PCPs Conclusions 24

o The results are not generalizable to the entire United States o The small sample size prohibits analyzing subsets of the data and doing specific meaningful analyses Limitations 25

When you refer patients to behavioral health providers what is the system for care coordination and follow-up? How do you receive feedback from the psychiatrist or other behavioral health provider? How often do you and the behavioral health provider work together to make decisions about the patient’s treatment plan? There are a number of other standardized models for treating behavioral health conditions. Do you use any standardized model? Q&A 26

Vasudha Narayanan phone: Paul Weinfurter phone: Contact information 27

Thank you for participating. 28