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Slide 1-

Psychiatry Integrated Primary Care Trip Gardner, MD Chief of Psychiatry Clinical Director Summer Street Community Clinic Penobscot Community Health Care Bangor, Maine
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Outline Why we need psychiatry in primary care? Why we need primary care in psychiatry? Why we can not afford not to integrate? What is Psychiatry Integrated Primary Care What do patients think?
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Way Behind 1963 Community Mental Health Center Act President Kennedy “return mental health care to the mainstream of American medicine.” Idea was Community Mental Health Centers organized around hospitals, providing close collaboration between medical and community-based mental health Yet to be fulfilled Lebensohn ZM. General hospital psychiatry USA: retrospect and prospect. Compr Psychiatry 1980;21(6):500–9.
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http://www.hcp.med.harvard.edu/ncs/ftpdir/table_ncsr_LTprevgenderxage.pdf
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http://www.hcp.med.harvard.edu/ncs/ftpdir/table_ncsr_12monthprevgenderxage.pdf
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We Call it the NECK!!!!
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The Master of the Universe!
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It Is All In Your Head!
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PCPs Preferred 8 to 1 8 times as many undiagnosed, asymptomatic adults stated more likely to see PCP than a psychiatric professional for help with a mental health issue National Mental Health Association.America’s mental health survey, May 2000. Conducted by Roper Starch Worldwide, Inc. www.roper.com/Newsroom/content/news189.htm
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Most See PCPs anyway 54% of people with diagnosed psychiatric conditions are treated in primary care only Druss BG, Marcus SC, Olfson M Pincus HA. The most expensive medical conditions in America. Health Aff (Millwood). 2002 Jul-Aug;21(4):105-11.
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Most Prescriptions by PCPs Primary care providers write 75% of all psychotropic medication prescriptions. Pincus, Tanielian, Marcus, Olfson, Zarin, Thompson, Zito, (1998). Prescribing trends in psychotropic medications: Primary care, psychiatry, and other medical specialties. JAMA, 279, 526-531.
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Disease is a 3 Legged Monster
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Double the TroubleDepression and Diabetes Risk factor for type 2 diabetes mellitus Decreased adherence Worse control Increased costs Morbidity and Mortality Sooner Evans DL, Charney, DS http://www.nova-health.org/index.html
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Depression Causes Heartbreak Increased Depression risk with Ischemic Heart Disease Depression post MI > ↓ outcome Depression cardio-vascular risk = smoking risk Six-fold increase in mortality Charles Nemeroff, MD, PhD “Depression and Heart Disease: Link is Clear” JAMA 1993;270:1819-25
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10 Deadly Behaviors Tobacco use Poor diet Lack of physical activity Alcohol abuse Avoidable infectious exposure Exposure to toxins Gun use Unsafe sex Unsafe driving Illicit drug use. More than half - smoking, being inactive and eating badly. Actual causes of death in the United States.McGinnis JM - JAMA - 10-NOV-1993; 270(18): 2207-12 http://www.nhregister.com/articles/2008/09/22/news/b1-katzcolumn.txt
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Groundbreaking Report! Medicines Do Not Work If You Do Not Take Them 125,000 deaths per year 10% of hospital admissions 23% of nursing-home admissions 1/3 of prescriptions never filled 1/2 of prescriptions filled are taken incorrectly Meta-Analysis of Trials of Interventions to Improve Medication Adherence Andrew M. Peterson, Liza Takiya, Rebecca Finley Posted: 04/28/2003; American Journal of Health-System Pharmacy. 2003;60(7) © 2003 American Society of Health-System Pharmacists
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Lower IncomeHigher Psychiatric Problems Psych problems >2x more common Low-income frequently only have access to PCP Depression(23%), tobacco abuse(6.7%), anxiety(6.0%) - 3 of top 5 dx charted 50% ≥ 2 medical problems. 50% of these included depression, anxiety, or alcohol abuse. Mauksch LB, Tucker SM, Katon WJ, et al: Mental illness, functional impairment, and patient preferences for collaborative care in an uninsured primary care population. Journal of Family Practice 50:41-47, 2001
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Look Under the Rock Estimated 50 percent of mental health problems go un-identified Most do have contact with PCPs Meet and treat people where they are U.S. Dept. of Health and Human Services. (2001). Report of a Surgeon General’s working meeting on the integration of mental health services and primaryhealth care. Rockville, MD: Author. www.surgeongeneral.gov/library/mentalhealthservices/mentalhealthservices.PDF4.
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Treat Mild Illness Prevent Severe Illness If there was increased detection of early stage psychiatric illness in primary care, there would be prevention of individuals going on to more severe episodes of major psychiatric illnesses Outcome = Morbidity, Mortality and Money
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Treatment in Primary Care Works IMPACT (Evidenced Based PCP Care) intervention - 50% or greater improvement in depression at 12 months, compared to 19% in usual care Costs over 4y - IMPACT patients had $3300 lower average costs for all their medical care vs usual care http://impact-uw.org/about/research.html http://www.impact.ucla.edu/index.html
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Substance Abuse Treatment in Primary Care Works Screening and Brief Intervention and Referral to Treatment (SBIRT) 536,000 people across all settings in 17 states 14.8% were positive Protocol-driven brief intervention in primary care. 30 positive trials Gentilello L, Villaveces A, Ries RR et al. Detection of acute alcohol intoxication and chronic alcohol dependence by trauma center staff. J Trauma; 47:1131-9.
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Why we need primary care in psychiatry?
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The Seriously Mentally Ill (SMI) Need more whole body care SMI → ↑diabetes, dyslipidemia, lung disease,liver disease, hypertension, obesity cardiovascular disease, infectious disease, dental disease Die 25 years too early 70% - 1; 45% - 2; 30% - ≥ 3 Freeman, E, Yoe, J. The Poor health status of consumers of mental healthcare: Behavioral disorders and chronic disease, Presentation to NASMHPD Medical Directors Work Group,May 2006
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Desegregate Mental Health Outcome of Segregating Mental Health “dead at 55” COD = heart attack
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Stigma Kills In schizophrenia – no treatment for: 30.2% with diabetes 62.4% with hypertension 88.0% with dyslipidemia Nasrallah HA, Meyer JM, Goff DC, et al. Low rates of treatment for hypertension, dyslipidemia and diabetes in schizophrenia: data from the CATIE schizophrenia trial sample at baseline. Schizophr Res. 2006; 86: 15-22.
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Why we can not afford not to integrate?
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$653,000,000,000 Non-adherence = $100 billion Depression = $83 Billion Nicotine = $193 Billion Alcohol = $185 Billion Obesity = $92 Billion Meta-Analysis of Trials of Interventions to Improve Medication Adherence Peterson, Liza Takiya, Rebecca Finley Posted: 04/28/2003; American Journal of Health-System Pharmacy. 2003;60(7) © 2003 American Society of Health-System Pharmacists http://www J Clin Psychiatry 2003; 64: 1465-1475 http://www.cdc.gov/tobacco/data_statistics/fact-sheets/economics/econ_facts/index.htm http://pubs.niaaa.nih.gov/publications/economic-2000/alcoholcost.PDF cdc.gov/obesity/causes/economics.html
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Behaviors Kill 50% Tobacco (435 000 deaths; 18.1% of total US deaths) Poor diet and inactivity (400 000 deaths; 16.6%) Alcohol (85 000 deaths; 3.5%) Microbial agents (75 000) Toxins(55 000) MVA (43 000) Firearms (29 000) Sexual (20 000) Drugs (17 000). Actual Causes of Death in the United States, 2000 Ali H. Mokdad, PhD; James S. Marks, MD, MPH; Donna F. Stroup, PhD, MSc; Julie L. Gerberding, MD, MPH JAMA. 2004;291:1238-1245.
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Working is Healthy Psychiatric conditions are the leading cause of disability in the US and Canada for ages 15-44 http://www.nimh.nih.gov/health/topics/statistics/index.shtml
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Not Working is Costly Mood disorders are the: 7th most costly 2nd most disabling Druss BG, Marcus SC, Olfson M Pincus HA. The most expensive medical conditions in America. Health Aff (Millwood). 2002 Jul-Aug;21(4):105-11. http://www.nimh.nih.gov/health/topics/statistics/index.shtml
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Depression Plus DM or CHF 1y costs with $22,960, $11,956 without. Depressed spent significantly more in nearly every health care cost category except specialty mental health care. Mental health care costs - less than 1 % Unützer J, Schoenbaum M, Katon W, Fan M, Pincus H, Hogan D, Taylor J. Health care costs associated with depression in medically ill fee-for-service Medicare participants. Journal of the American Geriatric Society. Published online ahead of print Jan. 16, 2009.
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What is Psychiatry Integrated Primary Care?
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Family Doctor’s Perspective “To provide holistic care, we must always strive to meet patients where they are physically, emotionally and spiritually. The integration of primary medical and psychiatry services is a constant reminder to be conscious of all areas since no one area can be fully addressed in isolation of the others.”
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Different Levels of Integration Doherty WJ, McDaniel SH, Baird MA. Five levels of primary care/behavioral healthcare collaboration. Behav Healthc Tomorrow. 1996 Oct;5(5):25-7
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PCHC PIPC History Began Integration over 10 years ago by placing a PCHC employed counselor in the primary care clinic with partially integrated care using a shared site but different medical record
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Level 3 Failed In 2003 added an on-site, part-time psychiatric nurse practitioner through contract with an area community mental health agency with separate systems 2 separate systems (level 3) proved too expensive for survival
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Level 5 Success In 2004 PCHC decided to start level 5 psychiatry integrated primary care PCHC hired a psychiatrist as the first step and added multi-disciplinary providers to keep up with the demand at a financially responsible pace
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Goals Meet the primary care needs De-fragment and De-stigmatize care Allow collaboration in the moment Reduce psychological and social barriers Cut costs of chronic disease care Promote cross-education Be financially viable
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What we do? 30 minute medication (illness) management 90 minute psychiatric evaluation Groups 60 – 90 minutes 30 – 90 minute consultations 30-60 minute Biofeedback for pain 30 – 60 minute counseling sessions 60 minute psychosocial evaluations 30 minute health and behavior assessments 30 minute focused behavioral consultations
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Group Synergism Med/Psych Chronic Disease – Obesity, DM, Fibromyalgia, Pain Educational Substance Abuse including“SmokeLess” Dialectical Behavioral Motivational Enhancement Change Parenting – Incredible Years Children - Dinosaur Group Cognitive Behavioral
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How many? 29705 Encounters in 2009 19 % of all PCHC Primary Care Encounters
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Where Do I start? Start with psychiatrist, psychiatric nurse practitioner or psychotherapist as dictated by the primary care practice’s own evaluation of their needs based on their population and strengths Most choose Psychiatric NP - can prescribe and do counseling.
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Next Pattern has been to then add a Psychologist, LCSW or LCPC within 1 year after the Psychiatric NP starts Psychiatric professionals in integrated settings should be comfortable with treatments for all psychiatric conditions including substance abuse Works as well if start with Psychologist, LCSW or LCPC and then add a psychiatric prescriber as needed. Takes 1-2 years to mature and “feel the same”
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Qualities needed Experienced Independent Thinker Flexible Confident Experience on a health team Non-judgmental Good Communicator Motivated to build something more than individual practice. Not hyper-sensitive Not expecting everyone else to change for them
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One system, One Site, One Vision, One Mission, One Budget Psychiatric providers are part of the primary care team Evaluation feedback is gotten from all No separate designations, no separate signs Chief of Psychiatry and the Primary Care Medical Director report to the Executive Medical Director.
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I Can Not Tell the PCPs Apart From the Shrinks! Co – located with offices in the primary care mix Part of the primary care team, helped by same staff, go to same meetings, have the same practice manager, under the same budget, chart in the same record, follow same policies and procedures
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We are Family Attends clinical meetings with family practice practitioners as a member of the “family” Same practice manager, and clinical coordinator All providers on same email list
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Curbsides Helps patients in the moment Cross-educates Multiplies the exchange across matching cases Assimilates the psychiatric professional Develops the “I have your back” team attitude Interruptions are OK
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Greasing the Wheel Pop-ins used to reduce fear of “shrinks” Non-same day referrals made via EMR Complicated referrals followed up with a provider to provider communication Same-day consults Same-day urgent referrals
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Have Same Support Needs 0.45 FTE medical secretary per psychiatric medication prescriber 0.30 FTE medical secretary per counselor 0.25 FTE medical assistant per psychiatric medication provider for vital signs, narcotics contract, pill counts, labs, triage all clinical calls, call in med refills
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Same Language EMR Templates for all notes Psychiatric medical record is kept sequentially with the rest of the medical record Special electronic key offers extra protection as only providers have access Looks like other health records
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Record EMR Print scripts Print instruction for patients Print education for patients Medication reconciliation Hand out for medication side effects Allows for multiple members of the team to easily collaborate in the service of the patient
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Population Risk Stratification and Management Health Behavior and Screening Assessments Untreated chronic psychiatric disorders have a significant negative effect on other chronic disease management, health risk, and social risk Psychosocial roadblocks like transportation, lost job, few natural supports and no insurance which also have a significant negative effect on chronic disease management, health risk, and social risk 30 minute visit before initial PCP Billable provider – LCSW/LCPC
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Making It in the Real World Financially viable on its own in a FQHC
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Roadblocks Small barriers being made into huge roadblocks; Assumptions winning over facts Compensation plans that lead to people thinking consciously or unconsciously that they do not have time to screen, treat and collaborate about messy psychiatric conditions Separate Locations – even one door Separate Records FQHC Medicare – will not pay for group psychotherapy, does not have parity yet for mental health,will not pay for LCPCs
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Roadblocks Mental health professionals unwilling to assimilate into the primary care culture Mental health professionals that think the current mental health system works well Mental Health professionals that fail to understand that the medical model is taught to be a biopsychosocial model Mental Health professionals that believe that office furnishings are an important part of their therapeutic skills
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Roadblocks Primary care practitioners that prefer to keep the psychiatric medical care separate from all the other medical care Primary Care practitioners that follow the BIOpsychosocial Medical Model not the Integrated BioPsychoSocial Model of Healthcare Primary care practitioners that “don’t believe in psychiatry” Primary care practitioners that are hesitant to consult with non-physicians
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Family Doctor’s Perspective “The interface between providers in our office encourages a free flow of information and feedback which allows us to be more immediately responsive to patients’ needs, provides a supportive environment for patients which reinforces treatment, and promotes true health and wellness”
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What do patients think?
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Patient Outcomes SF 12 – health survey measuring 8 domains Found patients improved from baseline in 7 out of 8 domains including Physical Functioning, Role – Physical, General Health, Vitality, Social Functioning, Role – Emotional, Mental Health Bodily Pain did not show improvement
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Most Importantly – What do Patients Think? “It’s easier to get care when I need it” “I know folks understand me and care about me”
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Most Importantly – What do Patients Think? “Because they all get to know all aspects of your life. They all know what meds you are on and can ask and tell what is wrong, even when you don’t know what you might forget to ask”
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Most Importantly – What do Patients Think? “ For me, the best part of this is that we rarely need just psych or just medical services. Often – as in my case – we have interconnected medical issues. ‘Physical’ health issues that effect psychiatric health or vice versa”
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Most Importantly – What Do Patients Think? “ By having both services together and connected, it is far easier on the patient to get coordinated services which helps to get to the root of the problems, and more quickly!”
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Most Importantly – What Do Patients Think? “I knew that my PCOS/hormone issues were affecting my depression, but in the past I was forced to be the point person between two doctors who had absolutely nothing to do with each other. Very difficult. This process has become a breeze now and takes the burden off of me, which lets me concentrate on getting better.”
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