1. Non-communicable Diseases: Integrated Care & Health Policy Eliot Sorel, M.D. Senior Scholar, Clinical Practice Innovations Professor, Global Health, Health Policy and Management Psychiatry and Behavioral Health Sciences The George Washington University Washington, D.C.

2. Non-communicable Diseases: Integrated Care & Health Policy Eliot Sorel, M.D. Outline Overview Epidemiology, Behavioral Health, in Primary Care China, India, Iran, Romania Research Project Evidence-Based Collaborative/Integrated Care Wagner Model of Measurement-Based Care Clinical Outcomes & Economic Consequences Care Implementation & Management Conclusions

3. Non-communicable Diseases: Integrated Care & Health Policy Eliot Sorel, M.D. Overview Depression & anxiety & alcohol abuse – prevalence: In primary care – 20% In secondary care – 30-60% 25% of all these patients receive effective care 20% of the adult patients seen by specialists Severely & persistently mentally ill seen by specialists Their co-morbid medical conditions not well attended to

4. Non-communicable Diseases: Integrated Care & Health Policy Eliot Sorel, M.D.D. Overview, continued Regular, systematic psychiatric case load reviews For patients who do not show clinical improvement Substantially improve health care outcomes Patients’ functioning Reduced health care costs

5. Non-communicable Diseases: Integrated Care & Health Policy Eliot Sorel, M.D. Overview, continued Collaborative/Integrated care is evidence-based 70 randomized controlled trials show effectiveness & cost effectiveness Care coordination & management Regular/proactive monitoring and treatment Using validated clinical rating scales

6. Non-communicable Diseases: Integrated Care & Health Policy Eliot Sorel, M.D. Epidemiology, Behavioral Health in Primary Care Non-communicable diseases (NCDs) lead global burden of disease Cardiovascular disorders & depression lead among NCDs Mental disorders = 30-45% of global burden of disability 50% of mental disorders exist by age 14 75% of mental disorders exist by age 24 40% of Americans with mental disorders Receive minimally adequate care

7. Non-communicable Diseases: Integrated Care & Health Policy Eliot Sorel, M.D. China, India, Iran, Romania Research Project Method: multi-centric cross-sectional study Site: primary care health centers Population: all informed/consenting adult patients Instrument: Patient Health Questionnaire – 9 (PHQ-9) Aggregate: 4090 patients

8. Non-communicable Diseases: Integrated Care & Health Policy Eliot Sorel, M.D. China, India, Iran, Romania Research Project, continued China:2 regions – north, south; 823 patients:51% female; 49% male Results:mild depression: 34.3% moderate depression:16.4% moderately severe: 5.7% sever depression: 2.4% Co-Morbid conditions: diabetes mellitus cardiovascular disorders gastrointestinal

9. Non-communicable Diseases: Integrated Care & Health Policy Eliot Sorel, M.D. China, India, Iran, Romania Research Project, continued India:551 patients: 52.8% female; 47.2% male FM Results:mild depression:21.9%23.6% moderate depression:20.5%21.3% moderately severe: 6.8%5.0% severe depression: 0.4% 0% Co-Morbid conditions: diabetes mellitus cardiovascular disorders

10. Non-communicable Diseases: Integrated Care & Health Policy Eliot Sorel, M.D. China, India, Iran, Romania Research Project, continued Iran:1,006 patients: 80.5% female; 19.5% male Results:minimal, mild, or moderate depression:63.3% moderately severe & severe: 7.0% Co-Morbid conditions: diabetes mellitus cardiovascular disorders

11. Non-communicable Diseases: Integrated Care & Health Policy Eliot Sorel, M.D. China, India, Iran, Romania Research Project, continued Romania:1,710 patients: 61.3% female; 38.7% male FM Results:minimal depression:55.8%71.2% mild depression:26.8% 9.2% moderate depression:10.5% 5.0% moderately severe: 5.1% 3.3% severe depression: 1.6% 1.2% Co-Morbid conditions: diabetes mellitus cardiovascular disorders gastrointestinal

12. Non-communicable Diseases: Integrated Care & Health Policy Eliot Sorel, M.D. Percentage of Total Disease Burden – Depression Sub-Saharan Africa28.62% Latin America & the Caribbean27.79% Middle East & North Africa24.39% Europe & Central Asia30.26% South Asia38.64% East Asia & the Pacific32.69% High Income Countries26.92%

13. Non-communicable Diseases: Integrated Care & Health Policy Eliot Sorel, M.D. Evidence-Based Collaborative/Integrated Care Primary care provider Family physician, nurse practitioner, physician assistant Care management staff Nurse, clinical social worker, psychologist Evidence-based cognitive behavioral therapy Monitoring adherence to treatment plan Psychiatric consultant Advises/consults with primary care treatment team Diagnostic, treatment progress challenges

14. Non-communicable Diseases: Integrated Care & Health Policy Eliot Sorel, M.D. Wagner Model of Measurement-Based Care Progress is closely tracked Using validated clinical rating scales PHQ-9 for depression screening Analogous to patients with diabetes Monitored via HbA1c lab tests Treatment systematically adjusted if no improvement Lack of progress&/or acute crises referred to specialists

15. Non-communicable Diseases: Integrated Care & Health Policy Eliot Sorel, M.D. Wagner Model, continued The IMPACT Program (Clinical Outcomes) 1801 adults age 60+ with depression 18 primary care clinics in 5 states Sites with fee for service & capitated Medicare & Medicaid Patients averaged 3.5 chronic medical disorders Randomly assigned to collaborative care program Or to usual care

16. Non-communicable Diseases: Integrated Care & Health Policy Eliot Sorel, M.D. Economic Consequences Depression increases health care costs by 50-100% Depression reduces productivity & diminishes return to work Collaborative & integrated care enhances productivity Augments return to work Diminishes absenteeism & presenteeism US $1 collaborative care saves US $6.50 in total health care costs

17. Non-communicable Diseases: Integrated Care & Health Policy Eliot Sorel, M.D. Care Implementation & Management US Affordable Care Act health home provision (§2703) Vehicle to incorporate principles of collaborative care Comprehensive care management Care coordination & health promotion Comprehensive transitional care from inpatient out Individual & family support Referral to community & social services Health IT to link services

18. Non-communicable Diseases: Integrated Care & Health Policy Eliot Sorel, M.D. Conclusions NCDs lead in the global burden of disease & disability Cardiovascular disorders & depression lead among NCDs NCDs frequently are comorbid with each other Collaborative & integrated care teams effective response Clinically most effective & economically beneficial New challenges & opportunities Education, training, research, services, systems, & policy

19. Non-communicable Diseases: Integrated Care & Health Policy Eliot Sorel, M.D. References Wagner, E.H., et al., “Organizing Care for Patients with Chronic Illness,” The Milbank Quarterly 1996; 74 (4): 511-544 Sorel, E. & Lopez-Ibor, Jr., J. J., “Reconnecting Mind & body in Contemporary Health Systems,” European Congress of Psychiatry, Munich (March 2014) Hyman, S., et al., “ Mental Disorders, ” in Disease Control Priorites in Developing Countries, Jamison, D.T., editor, Oxford University Press (2006) pp 605-625. Unützer, J., et al., “The Collaborative Care Model: An Approach for Integrating Physical & Mental Health Care in Medicaid Health Homes,” Centers for Medicare & Medicaid Services (May 2013) U.S. Affordable Care Act, §2703