non-communicable diseases: integrated care & health policy eliot sorel, m.d. senior scholar,...

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.

Non-communicable Diseases: Integrated Care & Health PolicyEliot 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


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

Non-communicable Diseases: Integrated Care & Health PolicyEliot 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


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


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


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


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



• India: 551 patients: 52.8% female; 47.2% male

F M

• Results: mild depression: 21.9%23.6%

moderate depression: 20.5% 21.3%

moderately severe: 6.8%5.0%

severe depression: 0.4% 0%


diabetes mellitus




• 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




• Romania: 1,710 patients: 61.3% female; 38.7% male

F M• 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%


diabetes mellitus


gastrointestinal


Percentage of Total Disease Burden – Depression

• Sub-Saharan Africa 28.62%• Latin America & the Caribbean 27.79%• Middle East & North Africa 24.39%• Europe & Central Asia 30.26%• South Asia

38.64%• East Asia & the Pacific 32.69%• High Income Countries 26.92%


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


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


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


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


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


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


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

non-communicable diseases: integrated care & health policy eliot sorel, m.d. senior scholar,...

Documents