1. 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

2. 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

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

4. 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

5. 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

6. 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

7. 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!)

8. 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

9. 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?

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