Collaborative Care. APNA 28th Annual Conference Session 1012: October 22, Haverkamp 1. Bridging the Divide Between Mental Health & Medical Care

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Douglas Randall
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1 Collaborative Care with Rita Haverkamp, MSN, PMHCNS-BC, CNS The speaker has no conflicts of interest to disclose Learning Objectives Discuss the differences in integrated care programs and the evidence base for Collaborative Care. Describe the Collaborative Care tasks and how this differs from current care. Identify one way to change current clinical practices to incorporate Collaborative Care principles. Bridging the Divide Between Mental Health & Medical Care Mental health is part of overall health Treat mental health disorders where the patient is / feels most comfortable receiving care Established doctor-patient relationship is an important foundation of trust Less stigma Better coordination with medical care Language Matters Integrated Care not necessarily collaborative Collaborative Care goes beyond co-location true team-based care (team of four) shared care plan shared responsibility for care Focused on a population of patients A Few Distinctions Usual Care Co-located Care isn t enough Behavioral Consultation isn t evidence-based Collaborative Care has proven to be more effective than usual care in over 80 randomized controlled trials is based on a medical care model Haverkamp 1

2 Paradigm Shift Evidence-based integrated care Collaborative Care is Based on the Chronic Disease Model is NOT simply specialty BH services grafted onto a primary care setting is PRIMARY CARE behavioral health requires all providers to actively collaborate with a shared care plan, not simply practice in parallel Edward H. Wagner, MD, MPH What is IMPACT? The IMPACT study tested the Collaborative Care Model on depressed, older adults IMPACT Trial ,801 depressed adults 18 primary care clinics 8 health care organizations in 5 states Diverse health care systems Urban & semi-rural settings Capitated (HMO & VA) & fee-for-service 450 primary care providers IMPACT Treatment Protocol 1. Assessment, Engagement, Patient Education 2. Behavioral Activation / Pleasant Events Scheduling PLUS 3. a) Antidepressant Medication Usually an SSRI or other newer antidepressant AND / OR b) Problem-Solving Treatment in Primary Care (PST- PC) 6-8 individual sessions 4. Maintenance and Relapse Prevention Plan once better IMPACT Doubles Effectiveness of Treatment Percentage (%) 50% or greater improvement in depression at 12 months Usual Care IMPACT Participating Organizations Haverkamp 2

Co-Location is NOT Enough Improves Physical Function Percentage (%) 50% or greater improvement in depression at 12 months 70 Usual Care IMPACT 60 50 40 30 20 10 0 1 2 3 4 5 6 7 8 Participating

3 Co-Location is NOT Enough Improves Physical Function Percentage (%) 50% or greater improvement in depression at 12 months 70 Usual Care IMPACT Participating Organizations SF-12 Physical Function Component Summary Score (PCS-12) P=0.35 P<0.01 P<0.01 P<0.01 Baseline 3 mos 6 mos 12 mos Usual Care IMPACT Callahan et al., JAGS IMPACT: Summary Less depression IMPACT more than doubles effectiveness of usual care Less physical pain Better functioning Higher quality of life Greater patient and provider satisfaction More cost-effective I got my life back THE TRIPLE AIM What DOES Work? Collaborative Care Now over 80 Randomized Controlled Trials (RCTs) Meta-analysis of Collaborative Care for depression in primary care (US and Europe) Consistently more effective than usual care Since 2006, several additional RCTs in new populations and for other common mental disorders Including anxiety disorders, PTSD Evidence for Collaborative Care for Anxiety and PTSD Several studies show Collaborative Care more effective than usual care for: Panic Disorder Roy-Byrne, Katon, et al. Multiple Anxiety Disorders (CALM Study) Roy-Byrne, Craske, Sullivan, Stein, et al. PTSD Zatzick et al. Collaborative Care Differs from Most Co-located Care Models PCP involved in all aspects of care Combined treatment plan Combined medical record Other team members- consultant Patient involved in treatment decisions Evidenced-based care Treat to target Haverkamp 3

4 Collaborative Team Approach Patient PCP Care Manager New Roles Core Program Psychiatric Consultant Other Behavioral Health Clinicians Additional Clinic Resources Substance Treatment, Vocational Rehabilitation, CMHC, Other Community Resources Outside Resources Consultation Caseload-focused psychiatric consultation supported by a behavioral health specialist Psychiatric consultant has regular (weekly) meetings with a BHS Reviews all patients who are not improving and makes treatment recommendations Focuses in-person visits on the most challenging patients Better access PCPs get input on their patients behavioral health problems: same day or within a week versus months More patients covered by one psychiatric consultant Provides input on multiple patients as opposed to small numbers of patients How Can a Registry Help? Keep track of all clients so no one falls through the cracks Up to date client contact information Referral for services Tells us who needs additional attention Clients who are not following up Clients who are not improving Reminders for clinicians & managers Customized caseload reports Facilitates communication, mental health specialty consultation, and care coordination Haverkamp 4

Creates common language Focuses on function Avoids potential stigma of diagnostic terms Helps identify patterns of improvement or worsening Flexibility of administration Additional Assessment?

5 Behavioral Health Measures as Vital Signs Behavioral health screeners are like monitoring blood pressure! Identify that there is a problem Need further assessment to understand the cause of the abnormality Help with ongoing monitoring to measure response to treatment Advantages Objective assessment Creates common language Focuses on function Avoids potential stigma of diagnostic terms Helps identify patterns of improvement or worsening Flexibility of administration Additional Assessment? PHQ9 Depression Bipolar CIDI- MDQ Measurement-based Treatment To Target Anxiety Psychosis Problematic Substance Use Organic and Cognitive Generalized anxiety disorder Panic Disorder PTSD OCD GAD7 Symptom review PCL_C Y-BOCS Primary Psychotic Disorders Substance-Induced Psychosis Mood Disorders with Psychosis CAGE- AUDIT-C Acute: Delirium Chronic: Dementia, Psychotic Disorders Systematic Clinical Approach Process to identify members to treat Engaging patients and families in care Using unified care plans Shared electronic medical record Systematic follow-up and adjustment of treatment plans if patients are not improving Haverkamp 5

Evidence-based Treatments Follow an evidence-based model Brief treatment 4-8 sessions shorter time

tolerance/ stress management techniques CBT First line depression treatment Behavioral Activation set

thoughts increase flexibility and decrease depressed way the thoughts function Good evidence for C, B,

evidence-based treatment for depression by the National Institute for Health and Clinical Excellence

g., we wait to feel motivated before completing tasks) In BA, we ask people to act according to a plan

Assign increasingly more difficult tasks to move toward full participation in activities Help break

completing other tasks Have them tell you what and how they ll do the task (Details! Details!

If it seems too challenging, it is! Break it down further.

a structured process to come up with an action plan to address the problem Seven Steps of PST-PC

6 Evidence-based Treatments Follow an evidence-based model Brief treatment 4-8 sessions shorter time frames Ones that we used: Medications Behavioral activation Problem solving treatment Distress tolerance/ stress management techniques CBT First line depression treatment Behavioral Activation set of strategies at the beginning of CBT treatment Cognitive dysfunctional cognitions or automatic thoughts increase flexibility and decrease depressed way the thoughts function Good evidence for C, B, and C+B BA: Cuijpers et al 2007, Ekers et al 2008, Mazzucchelli et al 2009; listed as an evidence-based treatment for depression by the National Institute for Health and Clinical Excellence (2009) Maximizing Activation Approach: Outside In Typically we think of acting from the inside out (e.g., we wait to feel motivated before completing tasks) In BA, we ask people to act according to a plan or goal rather than a feeling or internal state Avoiding Mount Everest: Selecting the BA Targets Assign increasingly more difficult tasks to move toward full participation in activities Help break tasks down into manageable tasks Mastery and success of one small task will increase likelihood of completing other tasks Have them tell you what and how they ll do the task (Details! Details! Details! Have them walk you through it) Help problem solve and ask how likely it is they will do it. If it seems too challenging, it is! Break it down further. Complex tasks Simple tasks PST Process Overview Take a patient s identified problem and assist them in a structured process to come up with an action plan to address the problem Seven Steps of PST-PC Orient, Clarify and Define the Problem Set Realistic Goal Generate Multiple Solutions Evaluate and Compare Solutions Select a Feasible Solution Implement the Solution Evaluate the Outcome Haverkamp 6

Problem Solving Worksheet Name: Date: Visit #: Review of progress during previous week: Rate how Satisfied you feel with your effort (0 10) (0 = Not at all; 10 = Super): 9 Mood (0-10): 6 1.

7 Problem Solving Worksheet Name: Date: Visit #: Review of progress during previous week: Rate how Satisfied you feel with your effort (0 10) (0 = Not at all; 10 = Super): 9 Mood (0-10): 6 1. Problem: Head ache - will be visiting Mother soon, visits lead to doing what her Mother wants to do- especially cooking and pt doesn t get much time with her own children and grandchildren 2. Goal: Have time alone with children/grandchildren and cook less for her Mother 3. Options/Solutions 4. Pros versus Cons (Effort, Time, Money, Emotional Impact, Involving Others Problem Solving Worksheet Continued 5. Choice of solution: stay a few days with son, go out to eat 6. Action Plan (Steps to achieve solution): Write down the tasks you completed. a) Talk to son about the plan tomorrow- practice wording talked to son of how to tell mother with son so he can support the plan b) take these days in middle of trip took the middle days c) tell mother a few days before going rather than prior did this to trip d) go out to eat a number of times on the trip went out a few times Pleasant Daily Activities Rate how Satisfied it made you feel (0 10) (0 = Not at all; 10 = Super) Date Activity Daily work on puzzle, read Sat walk with friend Next appointment: If it s Problem Solving, why does the structured process matter? It s a cognitive training technique (plasticity intervention) Personalized action plans The patients need to know the process first before incorporating it into their way of being Follow-Up Contacts Weekly or every other week during acute treatment phase In person or by telephone to evaluate depression severity (PHQ- 9) / treatment response Initial focus on: Adherence to medications Discuss side effects Follow-up on activation and PST plans Later focus on: Complete resolution of symptoms and restoration of functioning Long term treatment adherence Discussion How does Collaborative Care differ from how you were trained or from current practice? In what ways does it incorporate aspects of your training? Haverkamp 7

8 Nursing Role in Integrated Care General practice RNs General practice RNs Psychiatric specialist RNs Psychiatric Nurse Practitioners Adding treatment of depression/anxiety to existing care management functions for other chronic conditions i.e. diabetes, pain, CHF Psychiatric Specialist RNs Care management functions Management/support of medication treatment through existing protocols Providing evidenced-based therapy/treatments as needed for more complex patients Psychiatric Nurse Practitioners Psychiatric consultation to care managers Weekly case consultation to other care managers regarding medications, diagnostic and therapy issues Achieves the Triple Aim Patient Satisfaction Clinical Outcomes Healthcare Costs Common Problems in Developing Integrated Care Setting up only co-located care Not using evidenced-based treatments Not tracking patient progress with a tool No registry Staying with care plan when it isn t working Keeping records separate Haverkamp 8

9 Critical Process Factors for Consulting Psychiatric NP 2-3 hours dedicated time per week for consultation and caseload review Regular and effective communication and collaboration with care manager and PCP Treatment suggestions based on evidence and stepped care approach In-person consultation preferred, by phone if relationship established and distance is a challenge Menu of Inspiration Options Use patient centered goals. Communication with other providers. Use screeners regularly. Track patient goals regularly. Track patient outcomes. Set a practice improvement goal. Patient Centered Team Population Based Care Measurement-Based Treatment Care Use a registry. Lead efforts for implementation. Participate in continuing ed. Form a learning collaborative. Plan for Clinical Practice Change Identify all Collaborative Care team members and organize them for training Identify a population-based tracking system Develop a clinical flowchart and detailed action plan Develop a plan for funding, space, human resources Develop a plan to merge Collaborative Care monitoring and reporting outcomes into existing quality improvement efforts What Will You Do to Change Your Practice? Take one of the two pages Form a small group discussion Report what changes you plan to make in your practice or system For more information: Web based training Forms and step by step plans for setting up collaborative care programs Haverkamp 9

Integrated Mental Health Care. Questions

Integrated Mental Health Care. Questions Integrated Mental Health Care Closing the gap between what we know and what we do. Jürgen Unützer, MD, MPH, MA Questions Due to the large number of participants, it is not practical to take questions over