Affordable Care Act & Best Practices for Hispanics

Enhancing Quality and Improving Outcomes for Latinos through

Integrated Health and Behavioral Health Care

March 29, 2014

Learning Objectives Participants will:

◦Learn the basics of integrated primary care and behavioral health care, and how the approach benefits Latinos.

◦ Review innovative practice-based examples in the delivery of integrated care to reduce & eliminate health disparities.

◦ Discuss the concrete recommendations related to the delivery of integrated health care services to racial and ethnic minority communities as outlined in the Hogg Foundation - Office of Minority Health Consensus Report that can be implemented in your setting.

2

Eliminating Racial and Ethnic Disparities through Integrated Health

Care

Literature review Consensus Meeting Consensus Statements Recommendations Innovations from the

field http://www.hogg.utexas.

edu/

3

Health Disparities Exist!

Factors affecting quality of health care for Latinos including:Primary care does not have expertise in

providing behavioral health services and Behavioral Health clinics do not have expertise in providing primary care.

Provider shortages/Network insufficiency Lack of provider Spanish language capacity; Few culturally competent servicesPoor doctor patient communication (DPC) Behavioral health conditions are among the

most expensive to treat.

4

Primary Care Serves as the De Facto

Behavioral Health Care System

…are often the gateway to health care for Latinos and other racial and ethnic minority populations, including individuals with limited English proficiency (LEP) and, as such, have become the portal for identifying undiagnosed or untreated mental health and substance use disorders.

Persons with serious mental illness (SMI) are now dying 25 years earlier than the

general population

6

Increased morbidity and mortality are largely due to treatable medical conditions that are caused by modifiable risk factors such as smoking, obesity, substance abuse, depression and inadequate access to medical care (60% of premature deaths in persons w/SMI are due to natural causes).

1. Overall health is essential to mental health. 2. Recovery includes wellness.3. Recovery is possible!

What is Integrated Care?

The care that results from a practice 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.

Addresses 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.

Principles and Components of Integrated Health Care

Informed and activate patient Team-based approach Measurement/Evidence-based,

stepped treatment Shared record/EMR PCP supported by care

manager Patient registry to track

progress Psychiatric consultation and

caseload review Training Referral to specialty

providers/more intensive services 9

Stages of Integrated Care

Why Integrate?

11

Silos of Care

Community Based

Services

SocialServices

ClinicalSocial Work

&Psychology

PsychiatryPrimary

Care

Unutzer, 2009

Patient-Centered Medical Home and Integrated Care

Pressure for transformation in health care has intensified in response to unsustainable costs and escalating concerns with quality and patient experience. Thanks in large part to these pressures, interest in successfully implementing the patient-centered medical home (PCMH) has been exploding.

In turn, this has led to widespread interest in integration of behavioral health and primary care, widely viewed as a critical component or function of PCMH and required if primary care is to do its part in achieving “The Triple Aim” of health, affordability, and enhanced patient experience (IHI, 2010).

Role of Integrated Care in the ACAPromote Integrated Behavioral Health &

Health Care through the Patient-Centered Medical Home:

Coordination of care for patients' total healthcare needs in a timely, personal manner that achieves measurable high-quality outcomes

Improvement the quality of careAddress the social determinants of healthEstablish functioning financial arrangementsRecruitment and training of culturally and

linguistically competent workforceUtilization of information technology for optimal

communication among health professionals and patients

Physical Health and Substance Abuse

Alcohol and drug abuse as a causal or contributing factor to illness, injury, or the transmission of infectious disease (e.g., cocaine-induced myocardial infarction, substance-related cardio- and skeletal myopathy, alcohol induced bone loss, intentional and unintentional injury, poor fetal outcomes, tobacco-related cancers, hepatitis and HIV transmission among drug injectors).

Alcohol and drug abuse as an exacerbating factor to a non-substance-related illness (e.g., abdominal pain, diabetes, epilepsy, essential hypertension).

Alcohol and drug abuse as a complicating factor in treatment or patient compliance (e.g., asthma, diabetes, depression, tuberculosis).

Advantages of Integrating Substance Use & Abuse Treatment into Primary

CareTreatment goal is to end addiction and avoid

relapsePsychiatric co-morbidities such as anxiety and

depression are common in the substance abuse patient; must aggressively managed by the team. If not, leads to increased rates of addiction relapse.

Attention to health maintenance issues such as hypertension, diabetes, obesity, tobacco use and lipids essential.

Acute an chronic pain most safely managed in the SA patient non-pharmacologically, and modalities such as Physical Therapy, Chiropractic, Acupuncture and massage can be safe and effective.

Treatment engagement and compliance.

SBIRT: Screening, Brief Intervention, and Referral to Treatment

An evidence-based practice used to identify, reduce, and prevent problematic use, abuse, and dependence on alcohol and illicit drugs. Consists of 3 major components:

Screening: a healthcare professional assesses a patient for risky substance use behaviors using standardized screening tools. Screening can occur in any healthcare setting.

Brief Intervention: a healthcare professional engages a patient showing risky substance use behaviors in a short conversation, providing feedback and advice.

Referral to Treatment: a healthcare professional provides a referral to brief therapy or additional treatment to patients who screen in need of additional services

Chronic Disease May Lead to Depression

Increased depression and anxiety

Poor adherence

Increased perception of symptoms

Additional impairment

in functioning

Increased risk of complications, higher medical

costs

Chronic disease

What is the PHQ-9?

Is a nine item depression scale of the Patient Health Questionnaire.

Is a powerful tool to assist clinicians with diagnosing depression and monitoring treatment response.

The nine items of the PHQ-9 are based directly on the nine diagnostic criteria for major depressive disorder in the DSM IV.

Advantages to the PHQ 9This tool :

• Is shorter than other depression rating scales,

• Can be administered in person, by telephone, or self-administered,

• Facilitates diagnosis of major depression,

• Provides assessment of symptom severity,

• Has proven effective in a geriatric population, (Löewe B,et al, 2004 Medical Care)

• Is well validated and documented in a variety of populations

FREE/PUBLIC DOMAIN: http://www.integration.samhsa.gov/images/res/PHQ%20-%20Questions.pdf

Challenges to BH Treatment in Primary Care

Primary care providers may lack necessary training and confidence, and even well-trained providers are limited in what they can address in a 15 minute office visit.

The time constraints of primary care physicians have begun to force them to redesign their practices and rely upon ancillary providers in the management of chronic disease.

20

A Paradigm Shift-1Imbed Cultural Competence

Administrative policies, job descriptions, performance reviews, confidentiality agreements, and care coordination practices should all reflect a culturally competent integrated care practice.

◦Establish a “change team” to influence culturally competent integration.

◦Consider a team composed of senior leaders, program directors, and consumers from all of your organization’s service areas.

◦Develop organizational expectations, workflows, job descriptions, performance review language, and quality improvement benchmarks.

21

A Paradigm Shift-2Strategy: organization's strategic and business plans must reflect culturally competent integrated health care goals as a priority.Technology: sharing information between primary care and behavioral health providers is a core component to providing culturally competent integrated health care services.

22Source: SAMHSA-HRSA Center for Integrated Health Solutions; Hogg Foundation for Mental Health-OMH Consensus Report (2012)

A Paradigm Shift-3Clinical Workflows: must be clear and consistent. Example: Are you monitoring to ensure that your primary care and behavioral health staff create person-centered culturally competent integrated health care plans for each person served that includes all of the person’s behavioral health and primary health goals?

Quality Improvement: CQI is a valuable way to make sure one is meeting culturally competent integrated health care goals which improve the overall health status of your clients.

23Source: SAMHSA-HRSA Center for Integrated Health Solutions; Hogg Foundation for Mental Health-OMH Consensus Report (2012)

Chronic Illness and Depression Care Management Model: TEAMcare Variant

PCMH Primary Care Team12 PCP, Nursing Staff

•Educate about benefits of treatment• Initiate appropriate medication treatment based on depression severity (PHQ-9 score) and patient choice

•Screen for depression, confirm clinical diagnosis

•Receive active feedback from Synergy Team via EMR and/or telephone

Behavioral Health Manager (LCSW)1 FTE

• Initiates screening, eligibility, assessment

•Conducts face-to-face behavioral health treatment assessment and reviews treatment plan with consulting psychiatrist

•Provides onsite and telephonic brief psychotherapy tailored to patient’s needs

•Collaborates with nurse care manager, Monitors PHQ-9, and medication effects, including side effects

Nurse Care Managers3 experienced RNs, totaling 1 FTE

effort•Conducts comprehensive biopsychosocial assessment

•Monitors PHQ-9 and medical indicators•Chronic disease education•Assists with appointments and concrete services

•Uses patient-centered motivational strategies to promote self management and wellness

Consulting Psychiatrist0.4 FTE

•Reviews cases with Synergy Team with focus on patients not at target goals

•Reviews EMR and confirms/recommends psychotropic medication adjustments or additional workup to PCP

•Limited face-to-face treatment for complex patients

•Available for telephone or email collaboration

Care ManagerEssential to Integrated Care

TeamProvides patient-centered care Understands the person in their

environment Coordinates care delivery systemsUnderstands barriers and full and

equal access to careCommunicates with the entire

provider team and family system Advocates for the patient’s rights

25

For Depression:Tracks outcomes (with quantitative

instruments)Educates patients about depressionMay offer a brief course of evidence

based counseling (billable service)Monitors antidepressant therapy prescribed

by the patient's primary care provider Monitors depression symptoms for treatment

response Completes a relapse prevention plan patients

who have improved 26

Care Manager Role: Improving engagement, treatment and follow-

up

Care Manager Role: Improving engagement, treatment and follow-

up

Enhancing the Delivery of Health Care: Eliminating Health Disparities through a Culturally & Linguistically Centered

Integrated Health Care Approach

Integrated Health Care: National Movements

The Affordable Care Act Academy for Integrating Behavioral

Health and Primary Care, Agency for Healthcare Research and Quality (AHRQ): Lexicon & Atlas

Primary and Behavioral Health Care Integration (PBHCI), Program, Substance Abuse and Mental Health Administration.

CMS Health Care Innovation AwardsBehavioral Health and Integrated Care

Initiative: HHS Office of Minority Health30

Integrated Health CareOrganizational Level Example

The Connecticut Latino Behavioral Health System: a collaborative of over a dozen organizations who have joined with the Yale University School of Medicine/Department of Psychiatry and the Connecticut Mental Health Center to build a comprehensive system of care that integrates components of behavioral health and primary care for the Latino population.

Provides qualitative and quantitative evaluation process designed to assess the program at three levels: organizational, staff and patient/consumer.

The Cultural Competency Index: designed to evaluate culturally responsive clinical services and is being measured at three time points. Evaluation at the staff level includes pre- and post-training evaluations, satisfaction with trainings, and random tape ratings to assess for language fluency and the integration of Latino cultural values in treatment. 31

If Not Now---------When? The train is leaving has left the station!

Health disparities persists. Affordable Care Act driving system change Increased demand for cost effectiveness &

outcomes. TRIPLE AIM! Improve outcomes, enhance

the patient experience of care, and decrease cost.

What does this mean for you?Is your organization on the train?

What are you doing to strengthen/expand cultural and linguistic competent integrated health care services?

Opportunity to be a part of a “new” system of care to address the “whole health” needs of patients/consumers.

32

Panel Contact InformationKatherine Sanchez, LCSW, PhD

Assistant Professor

University of Texas, Arlington ksanchez@uta.edu

Pierluigi Mancini, Ph.D.

Chief Executive Officer

CETPA, Inc.

www.cetpa.org

Octavio N. Martinez, Jr., MD, MPH

Hogg Foundation for Mental Health

Hogg-ED@austin.utexas.edu

Teresa Chapa, Ph.D., MPA

Senior Policy Advisor, Mental Health

US DHHS, Office of Minority Health

http://minorityhealth.hhs.gov/