1. INTEGRATED PRIMARY CARE: BACK TO THE FUTURE (AND THE USH) Andrew Pomerantz, MD National Mental Health Director, Integrated Care VACO Associate Professor of Psychiatry Dartmouth Medical School

2. A Brief History of Psychiatric Care Hippocrates – The four humors: Blood, Phlegm, Black Bile, Yellow Bile. First description of depression. 400 B.C.: Romans remove civil rights of the mentally ill. 150 (or so) A.D.: “On Melancholia,” (Galen). –Depression caused by excess black bile –Many causes (Vapors, Wine, Age) 19 th /20 th Century America: Institutionalization

3. History of Psychiatric Care (cont’d) 1960s: Deinstitutionalization begins 1970s: Community Mental Health for SPMI 1980s/90s: Community Mental Health for all 2000: Moving back to integrated care

4. Models of MH Care in PC Referral Consultation/Liaison Co-location Collaborative Care Integrated Care

5. Depression in Primary Care 1970s: Biological underpinnings of MDD 1980s: PCPs criticized for underrecognition 1990s: PCPs criticized for undertreatment 2000s: PCPs criticized for overtreatment

6. Ongoing study of MDD in PC PROSPECT IMPACT PRISM-E RESPECT STAR-D To date, all consistently demonstrate improved outcomes with care management

7. The Problems “Voltage Drop” when moving from Research to Systems of Care Access to Mental Health Care can be difficult Limited # of Diagnoses in Evidence Base Increasing demands on PCP time

8. Organizational Ethics “…The intentional use of values to guide the decisions of a system.” “From Clinical Ethics to Organizational Ethics: The Second Stage of the Evolution of Bioethics.” Potter, Robert Lyman, in “Bioethics Forum.” Summer, 1996

9. 6 Dimensions of Integration Spatial Temporal Communication & Information Systems Availability of Psychiatric Expertise Financial Stigma

10. INTEGRATED CARE IN VA THE BLENDED MODEL CO-LOCATED COLLABORATIVE CARE –VERTICAL INTEGRATION –HORIZONTAL INTEGRATION CARE MANAGEMENT –BEHAVIORAL HEALTH LABORATORY –TIDES

11. A DECADE OF CALLS FOR INTEGRATED CARE Surgeon General report Institute of Medicine Quality Chasm Reports President’s New Freedom Commission VA Strategic Plan

12. Uniform Services Handbook September, 2008 Driven by VA strategic Plan Outlines basic “package” of MH benefits in all VA Medical Centers and Clinics All Medical Centers MUST have: –COLOCATED COLLABORATIVE CARE –CARE MANAGEMENT Varying requirements for CBOC based on size

13. USH requirements Medical Centers, Very Large CBOCs (10,000 +)must have full time CCC + Care Management Large CBOCs (5000-10,000) must have blended model – variable hours Mid sized CBOCs (1500-5000) must have onsite MH care Small CBOCs must have access to MH services “Adequate) MH staffing required for Polytrauma, SCI, blind rehab, Palliative Care, TBI

14. INTEGRATED CARE RFP FUNDING BEGAN 2007 –94 FACILITIES FUNDED IN INITIAL ROUND –131 OF 139 FACILITIES CURRENTLY HAVE PROGRAMS AT END OF FY 2009 –MANY FUNDED LOCALLY OR REGIONALLY

15. NATIONAL OFFICE OF PRIMARY CARE-MENTAL HEALTH INTEGRATION OFFICE OF PC-MH INTEGRATION OVERSEES IMPLEMENTATION –http://vaww4.va.gov/pcmhi/http://vaww4.va.gov/pcmhi/ –Monthly conference calls, Newsletters –Regional trainings –Site consultation/technical assistance –PCMHI dashboard GROWING WORKLOAD –Over 1,300,000 encounters

16. NEXT A single brand of PC-MHI Staffing guidelines Develop the Evidence Base for Brief Tx Rural Models Integration with the rest of MH Integration with PACT Integration with SAC

17. PACT? PATIENT ALIGNED CARE TEAM PC-MHI IS PART OF THE DISCIPLINE SPECIFIC TEAM (AKA EXPANDED TEAM) SPECIALITY MH IS SPECIALTY CARE SOME SPECIAL POPULATIONS, INCLUDING SMI MAY BECOME INDEPENDENT PACTS OR TEAMLETS

18. AND THEN… PCMHI? WHAT’S THAT?