Reaching Out to Meet Behavioral Health Needs in Rural Communities An Innovative Approach. Faculty Disclosures. Objectives

Transcription

1 Reaching Out to Meet Behavioral Health Needs in Rural Communities An Innovative Approach Ashley Davidson MD Christy Endicott LICSW Caleb Holtzer MD, MPH Tanya Keeble, MD COLLABORATIVE CARE PRINCIPLES ASHLEY DAVIDSON, MD Objectives At the end of this presentation, participants will: Understand the core principles of Collaborative Care Understand the unique challenges faced by rural communities in accessing healthcare Know the standard collaborative care workflow and the role of the PCP in each phase of the workflow none Faculty Disclosures Behavioral Health Care in Washington State WHO GETS TREATMENT? Acute care psychiatric hospitals ~800 CMHC ~140,000 State Hospitals ~1000 No Treatment Primary Care Provider Population ~ 7 Million Primary Care ~300,000 Adults w/ MH Dx ~ 1 Million No Formal Treatment ~ 550,000 Mental Health Provider Wang et al., American Psychiatric Association. All rights reserved.

2 Percentage TWICE AS MANY PEOPLE IMPROVE Unützer et al., 2002, % or greater improvement in depression at 12 months 70 Usual Care IMPACT Participating Organizations 1) Improved Outcomes: Less depression Less physical pain Better functioning Higher quality of life 2) Greater patient and provider satisfaction 3) More cost-effective IMPACT: Summary THE TRIPLE AIM I got my life back It s good for other medical problems too Depressed diabetics are more likely to be more non-adherent, smoke, gain weight and have higher HgA1c scores Collaborative care decreased HgA1c, LDL, BP and Depression among diabetics in the TEAMCare study J Ambul Care Manage ; 34(2): COLLABORATIVE CARE PRINCIPLES: GOOD FOR ANY PRACTICE SUMMIT Trial: Collaborative Care in Opioid and Alcohol Use Disorders Collaborative care resulted in significantly more access to treatment and abstinence from alcohol and drugs at six months JAMA Intern Med Oct 1;177(10): Population-Based Care Measurement-Based Treatment to Target Patient-Centered Collaboration Evidence-Based Care Accountable Care Principles: University of Washington American Psychiatric Association. All rights reserved.

3 Principle 1: Patient Centered Collaboration Principle 2: Population Based Care PCP Patient BHP/ Care Manager New Roles Psychiatric Consultant University of Washington 13 Principle 3: Measurement Based Treatment To Target Treatment to Target Drives Early Improvement In a recent retrospective study ( ) of over 7,000 patients: Time to depression remission was 86 days for patients in collaborative care program Time to remission was 614 days in usual primary care 16 Time to Remission for Depression with Collaborative Care Management in Primary Care: JAM Board Fam Med, 2016 Jan-Feb Principle 4: Evidence-Based Treatment STAR-D Summary Level 1: Citalopram ~30% in remission Level 2: Switch or Augmentation ~50% in remission Level 3: Switch or Augmentation ~60% in remission Level 4: Stop meds and start new ~70% in remission Rush, 2007

4 Principle 5: Accountable Care Daniel s Story Stevens County: A Case Study in Collaborative Care in a Rural Setting Stevens County Overview Population 45, % below poverty line Per capita income $33,088, 37 th among Washington counties Unemployment rate 9% in % college educated (32% in the state)

5 Providence Resources in Stevens County Two critical access hospitals 5 outpatient clinics (PNEWMG) 21 primary care providers 6 specialty providers 2,681 unique Medicare patients at main clinic 790 visits per month are Medicare Why do collaborative care in Stevens County? Stevens County Faces Known Rural/Urban Health Disparities Driven by: Older, poorer population High patient to physician ratio Less employer provided health coverage Less education Distance to health care provider Stigma Rural Mental Health Disparities Higher Prevalence & Less Resources Past year any mental illness age 18 or older by urbanization level Past year serious mental illness age 18 or older by urbanization level

6 Past year major depressive episode 18 or older by urbanization level Suicide rates among persons 15 years of age and older Unmet need for mental health professionals among counties with an overall shortage Available Psychiatrist Time Per Consult Darker shading equals highest quartile of need Represents both prescribers and non prescribing mental health professionals Thomas KC et al, 2009 Ideal Urban Rural 50 Min 6 Min 1.5 Min Population Served Population / FTE Psychiatrist Urban US 7,000 6 min Rural US 30, min * Assuming psychiatrist sees patients for 30 hours / week and 3 % of population need mental health services Psychiatrist time available per week for each patient in need Overview of Colville Collaborative Care Program: Timeline Spring 2017: PNEWMG approached by UW collaborative care fellowship for expansion to rural site July: Business case approved, UW Fellow Ashley Davidson starts August: Collaborative care manager, Christy Endicott hired September: Site visit from UW team. Goals, outcome measures, roll out plan developed October: Initial patient referral from one of the four pods in main clinic November-March: Expansion Overview of Colville Collaborative Care Program: Implementation Program rolled out to three of five clinics Total Number of Referring Providers: 21 Total Referrals: 81 Current Case load: 28 Patients in relapse prevention: 4 New patients not yet seen: 10 96% of enrolled patients have had psychiatric consultation 13 inactive cases (improved (4) economic (3), moved away (1), changed mind (2), too busy (1), medical (2)) Remainder (~30) not enrolled due to complexity of the case, curbsides with Christy, curbsides with Dr. Davidson, waiting to begin treatment or declined to participate after interview with Christy

7 Overview of Colville Collaborative Care Program: Patient Stories Patient JK, 63 y.o. female: Depression X 10 years complicated by grief. Medication change and grief counseling. PHQ 14 6 Patient MF, 70 y.o. female: Recently psych hospitalization bi-polar. Consultant made medication recommendations. Patient and Social Worker created robust relapse prevention plan. PHQ 16 2 Patient CT, 65 y.o. female: Bipolar, PCP concerned for anorexia. After brief counseling patient now eating. PHQ Patient KB, 68 y.o. male: Trauma and anxiety related to implantable defibrillator going off. GAD 11 3 PHQ 9 3 Patient WA, 79 y.o. male: Depression and grief. MOCA administered revealed cognitive decline. Plan put in place for further neurological assessment and home support. Overview of Colville Collaborative Care Program: Results Screening test Active Patients Score Mean Initial PHQ Mean Last Follow up PHQ Mean Initial GAD Mean Last Follow up GAD7 9.1 Screening test Inactive Patients Score Mean Initial PHQ Most Recent 12.4 Mean Initial GAD Mean Last Follow up GAD Overview of Collaborative Care Program: Challenges Rural health clinic designation, collaborative care coding not approved until Jan 2018 Physical Location of Care Manager Scheduling Unintended Consequences Standardizing Screening protocol Work flow Known barriers to rural mental health care Overview of Collaborative Care Program: Future Financial stability Psychiatric collaboration transition Consultation taken over by psychiatric residency program July 1, 2018 Expanded Access in Stevens County Other insurance populations (non Medicare population and veterans) Chewelah clinic More personnel Single care manager case load of patients in treatment Projection to need additional care managers if expanding geographically or to other populations Other Illness Substance use disorder What s next for rural mental health? Telepsychiatry services Partnering with Psychiatry Residency Spokane Working group to design pilot project Goals and objectives and measureable outcomes Billing Documentation Prescribing Workflow Technology Timeline: Start date July 2018 Capacity ½ day per week initially with plans for expansion ~20 patients seen in continuing care Generalizing psychiatric consultation to inform future patient care Let s get to work

8 Using a Patient Registry to Prioritize Patients for Case Review Population Based Care Measurement-Based Treatment to Target Accountable Care Which principles could you practice now? Where could you implement it? Could you track outcomes with your medical disorders? Why Track Outcomes? Proactive treatment adjustment Avoid Patients staying on ineffective treatments for too long Treatment plan shelf life = weeks max Full, partial, no response Know when to refer for consultation/get help Flags Key Activity: Prioritize Patients for Caseload Review Patient ID First Score PHQ-9 Last Score Date of Initial Visit Date of Last Follow-up Contacts Relapse Psychiatric Prevention Case Review Plan # Sessions # Weeks in Treatment * 6/3/2017 9/13/2017 9/21/ /16/ /1/2017 5/11/ /15/ /8/ /1/ /8/ /29/ /9/ /5/ /14/ /30/2017 7/13/2017 9/29/ /29/ /11/2017 7/27/ /20/ /8/2017 9/21/ /8/ /15/ /12/ * 9/17/ /29/ /29/ /13/ /15/2017 9/21/ * 9/9/ /4/ /30/ /2/ /13/ /14/ /12/ /1/2017 9/21/2017 7/29/ /30/ /20/2017 4/21/ /1/ /31/ /13/ Indicates patient has been flagged for discussion during next psychiatric consultation Score in the Last column will have an asterisk (*) if it is older than the specifications for that clinical measure (e.g., if the * PHQ-9 is older than 30 days) How Does a Registry Help? Keep track so no one falls through the cracks All patients being treated What s happening for each Shows who needs additional attention Not in contact Not improving Outcome of referrals Facilitates communication with PCP, Consulting Psychiatrist, other providers Using the Registry to Facilitate Case Reviews Brief check-in Changes in the clinic Systems questions BOTH looking at registry during consultation hour Identify patients and conduct reviews Requested by BHP/CM Not improved w/o note Severity of presentation Disengaged from care Ready for relapse prevention or referral Wrap up Celebrate successes Confirm next consultation hour Send any educational resources discussed Practice: Prioritize Patients for Caseload Review Materials Handouts Practice Caseload Considerations Before Caseload Review Instructions Work in small groups Review the practice caseload & Considerations Before Caseload Review Identify 6-8 patients that you would prioritize for caseload review with the psychiatric consultant Be prepared to explain your reasoning

9 Activity: Prioritize Patients for Caseload Review PHQ-9 Contacts Relapse Flags Patient ID Date of Initial Date of Last Psychiatric # Weeks in First Score Last Score Prevention # Sessions Visit Follow-up Case Review Treatment Plan * 6/3/2017 9/13/2017 9/21/ /16/ /1/2017 5/11/ /15/ /8/ /1/ /8/ /29/ /9/ /5/ /14/ /30/2017 7/13/2017 9/29/ /29/ /11/2017 7/27/ /20/ /8/2017 9/21/ /8/ /15/ /12/ * 9/17/ /29/ /29/ /13/ /15/2017 9/21/ * 9/9/ /4/ /30/ /2/ /13/ /14/ /12/ /1/2017 9/21/2017 7/29/ /30/ /20/2017 4/21/ /1/ /31/ /13/ Key Indicates patient has been flagged for discussion during next psychiatric consultation Score in the Last column will have an asterisk (*) if it is older than the specifications for that clinical measure (e.g., if the * PHQ-9 is older than 30 days) Using a Patient Registry to Prioritize Patients for Case Review Population Based Care Measurement-Based Treatment to Target Accountable Care Which principles could you practice now? Where could you implement it? Could you track outcomes with your medical disorders? 49 Collaborative Care Financing Medicare 2018 CoCm CPT codes 2017 CMS final rules for Medicare payments for patients enrolled in integrated behavioral health services Jan 2018 implementation: FQHC and RHC CMS billing codes for behavioral health integration and chronic care management services Aetna in WA State: first commercial insurance plan to adopt integrated care reimbursement - fee for service plus enhanced reimbursement Collaborative care codes reimburse better than psychotherapy codes 99492: First 70 minutes in the first calendar month for collaborative care services Must be seen and referred by PCP. PCP must obtain and document patient consent. Must have an initial assessment by care manager with validated scales and tx plan Must be reviewed by psychiatric consultant Patients must be tracked on registry Weekly caseload review with a psychiatrist Provision of brief interventions, evidence based

10 99493: First 60 min in a subsequent month Ditto requirements Can be billed after 30 min This is for each month after the (can t use during same month as the 99493) 99494: each additional 30 in a calendar month Can be billed after 15 min Ditto requirements This is an add on code to the or 99493(would use both codes) UW PACC: Psychiatry and Addictions Case Consultation FREE to in WA State Started July 2016 Available through tele-video Weekly sessions Mental health and addictions lectures Case consultation Training opportunity UW TelePain ain/telepain/ Objectives At the end of this presentation, participants will: Understand the core principles of Collaborative Care Understand the unique challenges faced by rural communities in accessing healthcare Know the standard collaborative care workflow and the role of the PCP in each phase of the workflow