Advocating for Advocating for Collaboative CareCollaboative Care

Advocating for Advocating for Collaboative CareCollaboative Care

Collaborative Family Healthcare AssociationCollaborative Family Healthcare AssociationNational ConferenceNational Conference

November 6-8, 2008November 6-8, 2008

Alexander Blount, EdDAlexander Blount, EdD

What do we have to sell?What do we have to sell?

Primary care’s track record alreadyPrimary care’s track record already Data on behavioral health needs in Data on behavioral health needs in

primary careprimary care Data on evidence of care management Data on evidence of care management

programs for depression in primary careprograms for depression in primary care Data on improvement of productivity of Data on improvement of productivity of

people who get effective treatment for people who get effective treatment for depressiondepression

Primary care is our best Primary care is our best venue for improving venue for improving

population health and for population health and for controlling medical cost. controlling medical cost.

The Impending Collapse of Primary Care Medicine and Its The Impending Collapse of Primary Care Medicine and Its Implications for the State of the Nation’s Health Care:Implications for the State of the Nation’s Health Care:

A Report from the American College of PhysiciansA Report from the American College of PhysiciansJanuary 30, 2006January 30, 2006

Primary care is our best Primary care is our best venue for improving venue for improving

population health and for population health and for controlling medical cost. controlling medical cost.

The Impending Collapse of Primary Care Medicine and Its The Impending Collapse of Primary Care Medicine and Its Implications for the State of the Nation’s Health Care:Implications for the State of the Nation’s Health Care:

A Report from the American College of PhysiciansA Report from the American College of PhysiciansJanuary 30, 2006January 30, 2006

Why do we need the concept of Why do we need the concept of “Medical Home”“Medical Home”

We already know that primary care the way We already know that primary care the way we teach people to do it is hot stuff.we teach people to do it is hot stuff.

The Medical Home evidence is really The Medical Home evidence is really describing well-run primary care.describing well-run primary care.

This is the first model that has drawn large This is the first model that has drawn large physician groups, insurance companies physician groups, insurance companies and government agencies into agreement.and government agencies into agreement.

http://www.pcpcc.net/http://www.pcpcc.net/

Synthesis of best evidence research findings

Well-designed clinical trials

Observational analytical studies

Multiple time observational studies (“descriptive”)

Consensus of expert opinion

Anecdotal experience

Jenicek, 2006, Med Sci Monit 12: 241-251

Hierarchy of Evidence

Immediate benefit to the one influenced

or their loved ones

A powerful story that grabs the heart

or fits the values of the person

A logical argument or evidence that fits the person’s beliefs

Evidence that convinces a person’s the peer group

Indisputable evidence that contradicts the person’s beliefs

Level A, B and C of EBM that contradicts the person’s beliefs

Blount, unpublished musings

Hierarchy of Influence

What we need is a new What we need is a new familiar idea.familiar idea.

“Home is the place where when “Home is the place where when you have to go there they have to you have to go there they have to

take you in.”take you in.”

The Death of the Hired ManThe Death of the Hired Man by Robert Frost by Robert Frost

US News & World ReportUS News & World ReportJuly 14, 2008July 14, 2008

Six Pennsylvania insurers, including Independence Blue Six Pennsylvania insurers, including Independence Blue Cross and Aetna, in May said they would spend $13 Cross and Aetna, in May said they would spend $13 million over three years to pay doctors in 32 primary care million over three years to pay doctors in 32 primary care practices to help them set up medical homes.practices to help them set up medical homes.

Minnesota's governor in May signed a law that will use Minnesota's governor in May signed a law that will use state and private funds to pay primary care doctors who state and private funds to pay primary care doctors who create medical homes.create medical homes.

Nationwide, 27 of 39 Blue Cross Blue Shield insurers are Nationwide, 27 of 39 Blue Cross Blue Shield insurers are testing pilots of the model.testing pilots of the model.

Employers such as IBM, Dow Chemical and General Employers such as IBM, Dow Chemical and General Motors joined doctors, insurers and the AARP to Motors joined doctors, insurers and the AARP to advocate medical homes. advocate medical homes.

Evidence is accruingEvidence is accruing When adults have a medical home, their access to needed care, When adults have a medical home, their access to needed care,

receipt of routine preventive screenings, and management of receipt of routine preventive screenings, and management of chronic conditions improves substantially.chronic conditions improves substantially.

A medical home can reduce or even eliminate racial and ethnic A medical home can reduce or even eliminate racial and ethnic disparities in access and quality for insured persons.disparities in access and quality for insured persons.

Patients with chronic diseases like diabetes, congestive heart Patients with chronic diseases like diabetes, congestive heart failure, and adult asthma have fewer complications, leading to failure, and adult asthma have fewer complications, leading to fewer avoidable hospitalizations.fewer avoidable hospitalizations.

Medical Home = well run primary care officeMedical Home = well run primary care office

Commonwealth Fund Commonwealth Fund report (Beal, Doty, Hernandez, et al, June 2007)report (Beal, Doty, Hernandez, et al, June 2007)

Medical Home = well run primary Medical Home = well run primary care office in CF surveycare office in CF survey

Patients who reported all 4 were Patients who reported all 4 were considered to have a medical homeconsidered to have a medical home I have a regular doctor or source of care.I have a regular doctor or source of care. Not difficult to contact provider over the phoneNot difficult to contact provider over the phone Not difficult to get care or medical advice after Not difficult to get care or medical advice after

hourshours Doctor’s office visits are usually well Doctor’s office visits are usually well

organized and running on timeorganized and running on time

And PCMH looks like a fiscal And PCMH looks like a fiscal winner.winner.

The North Carolina Medicaid program enrolls recipients in a The North Carolina Medicaid program enrolls recipients in a

network of physician-directed medical homes. network of physician-directed medical homes.

A Mercer analysis showed that an upfront $10.2 million A Mercer analysis showed that an upfront $10.2 million

investment for North Carolina Community Care investment for North Carolina Community Care

operations in SFY04 operations in SFY04 saved $244 million in overall saved $244 million in overall

healthcare costs for the state.healthcare costs for the state. Similar results were Similar results were

found in 2005 and 2006. found in 2005 and 2006.

Care delivered by primary care physicians in a Patient-

Centered Medical Home is consistently associated with:

•better outcomes

•reduced mortality

•fewer preventable hospital admissions for patients with

chronic diseases

•lower utilization

•improved patient compliance with recommended care

•lower Medicare spending.

The (Public) Bottom LineThe (Public) Bottom Line

The (Private) Bottom LineThe (Private) Bottom Line The concept of the Medical Home gives us a The concept of the Medical Home gives us a

shot at re-branding primary care.shot at re-branding primary care. Maybe we can remake the image of primary care after Maybe we can remake the image of primary care after

the era of “gatekeeping”.the era of “gatekeeping”. We may have found a mechanism get payments We may have found a mechanism get payments

not tied to service by the physician.not tied to service by the physician. Unlike “capitation”, a PMPM that gives no incentive to Unlike “capitation”, a PMPM that gives no incentive to

restrict carerestrict care We have to get beyond “hamster care.”We have to get beyond “hamster care.”

Unless we fix access (urgent care, off hours Unless we fix access (urgent care, off hours phone, on time appointments), it isn’t a home phone, on time appointments), it isn’t a home anyone will want.anyone will want.

The Patient Centered Medical Home “Defined”The Patient Centered Medical Home “Defined”ACP, AAFP, AAP, AOAACP, AAFP, AAP, AOA

Personal physicianPersonal physician - - each patient has an each patient has an ongoing relationshipongoing relationship with a with a personal physician trained to provide first contact, continuous and personal physician trained to provide first contact, continuous and comprehensive care.comprehensive care.

Physician directed medical practicePhysician directed medical practice – – the personal physician leads a the personal physician leads a team of individualsteam of individuals at the practice level who collectively take at the practice level who collectively take responsibility for the ongoing care of patientsresponsibility for the ongoing care of patients..

Whole person orientationWhole person orientation – – the personal physician is responsible for the personal physician is responsible for providing for providing for all the patient’s health care needsall the patient’s health care needs or taking or taking responsibility for appropriately arranging care with other qualified responsibility for appropriately arranging care with other qualified professionals. This includes care for all stages of life; acute care; professionals. This includes care for all stages of life; acute care; chronic care; preventive services; and end of life care.chronic care; preventive services; and end of life care.

Care is coordinated and/or integratedCare is coordinated and/or integrated across all elements of the across all elements of the complex health care system (e.g., subspecialty care, hospitals, home complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (e.g., health agencies, nursing homes) and the patient’s community (e.g., family, public and private community-based services). Care is family, public and private community-based services). Care is facilitated by registries, information technology, health information facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated exchange and other means to assure that patients get the indicated care when and where they need and want it in a care when and where they need and want it in a culturally and culturally and linguistically appropriate mannerlinguistically appropriate manner

http://www.pcpcc.net/content/joint-principles-patient-centered-medical-homehttp://www.pcpcc.net/content/joint-principles-patient-centered-medical-home

Why Should Behavioral Health Be Why Should Behavioral Health Be a Core Service?a Core Service?

Access – At least 50% better access to MH care if offered in Access – At least 50% better access to MH care if offered in primary care. (different from managing care across medical primary care. (different from managing care across medical specialties) (Bartels, Coakley, Zubritsky, et al. Am J Psych, specialties) (Bartels, Coakley, Zubritsky, et al. Am J Psych, 2004)2004)

Complex patients with chronic illnesses needing behavioral Complex patients with chronic illnesses needing behavioral health care are more likely to be designated for Medical Home health care are more likely to be designated for Medical Home level of care.level of care.

Care in medical setting is a better cultural fit for many patients.Care in medical setting is a better cultural fit for many patients. Behavioral Health Clinicians free up time for PCPs to spend Behavioral Health Clinicians free up time for PCPs to spend

with other patients, while enhancing patient satisfaction and with other patients, while enhancing patient satisfaction and self-efficacy.self-efficacy.

Care management is more effective when done by Care management is more effective when done by professionals with behavioral health skills. (Pincus, Pechura, professionals with behavioral health skills. (Pincus, Pechura, Keyser, et al. Administration & Policy in Mental Health. Keyser, et al. Administration & Policy in Mental Health. 33(1):2-15, 2006 33(1):2-15, 2006

What are we missingWhat are we missing

Evidence of impact of integrated practices rather Evidence of impact of integrated practices rather than targeted integrated programsthan targeted integrated programs

A name/concept/description of integrated care A name/concept/description of integrated care that would make patients demand itthat would make patients demand it

Implementation instructions that solves Implementation instructions that solves administrative and financial barriers (Everyone administrative and financial barriers (Everyone re-invents the same wheel).re-invents the same wheel).

Understanding of primary care behavioral health Understanding of primary care behavioral health by most payers and administratorsby most payers and administrators

An agreed upon list of necessary changes to An agreed upon list of necessary changes to remove barriers. (Somewhat different in different remove barriers. (Somewhat different in different states)states)

It Will Take AdvocacyIt Will Take Advocacy

With the exception of Medicare, healthcare With the exception of Medicare, healthcare is done state by state.is done state by state.

Tell us a story.Tell us a story. I have a story.I have a story. Make some friends. Make some friends.

AAFPAAFP APAAPA NAMINAMI Who else?Who else?

It May Take StruggleIt May Take Struggle

John’s story of threatening litigationJohn’s story of threatening litigation Anyone else have a story?Anyone else have a story?

It Will Surely Take It Will Surely Take Information SharingInformation Sharing

ResourcesResources What should we have?What should we have?

Peer exchangePeer exchange Web chat thread or backchannel Web chat Web chat thread or backchannel Web chat

thread or backchannelthread or backchannel Can we get an Editor?Can we get an Editor?

Who are our natural allies?Who are our natural allies? Disease focused groups that want best Disease focused groups that want best

care.care. Advocates for mental health access and Advocates for mental health access and

parityparity Mental health guilds who want opportunitiesMental health guilds who want opportunities Enlightened physicians and physician Enlightened physicians and physician

groups who want to improve primary caregroups who want to improve primary care Enlightened health administrators (HRSA, Enlightened health administrators (HRSA,

VA)VA) Employers who want a better deal for their Employers who want a better deal for their

health dollar.health dollar.

What are we asking for?What are we asking for? That people would learn how important That people would learn how important

collaborative care can be in healthcare.collaborative care can be in healthcare. Adding in-practice behavioral health care to the Adding in-practice behavioral health care to the

definition of the medical home servicesdefinition of the medical home services This may be more a task of exegesis than getting new This may be more a task of exegesis than getting new

text.text. That they help us construct/target our messageThat they help us construct/target our message That they would connect us to other interested That they would connect us to other interested

folksfolks That they would do what they can to eliminate That they would do what they can to eliminate

barriers (regulatory, financial, personnel, lack of barriers (regulatory, financial, personnel, lack of information)information)

Let’s get to work!Let’s get to work!

Get in a group and identify whom you think Get in a group and identify whom you think you might approach, and how.you might approach, and how.

Assemble the categoriesAssemble the categories Re-group by category and make a plan to Re-group by category and make a plan to

keep in touch and report back.keep in touch and report back. Give the lists and the minutes to us.Give the lists and the minutes to us. Agree on information exchange formatAgree on information exchange format

For further information:For further information:

www.CFHA.netwww.CFHA.net

www.IntegratedPrimaryCare.comwww.IntegratedPrimaryCare.com

Blounta@ummhc.orgBlounta@ummhc.org