American Health Quality Association Sept Baltimore Maryland Managing Behavioral Health Problems and Solutions

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1 American Health Quality Association Sept Baltimore Maryland Managing Behavioral Health Problems and Solutions Meeting the Challenges of Behavioral Health Integration

2 IBHI IS: 501C3 Organization Dedicated to helping improve the outcome of behavioral health care Now nearly ten years old Eager to hear your ideas on ways to achieve the goal Available to lead integration efforts Visit

3 Task Order Emphasis Behavioral health in all health Reducing readmissions by addressing behavioral health Reducing readmissions of admissions for behavioral health issues

4 Primary Topics Today Improving Identification and diagnosis of depression and alcohol abuse in primary care Reducing high readmissions of people who have a behavioral health diagnosis as a part of their diagnosis Reducing psychiatric discharges and post discharge follow-up

5 Some General Comments CMS has recognize Descartes was wrong. Our message today is: to reduce costs, improve health and meet the difficult targets CMS established is going to require unprecedented integration of care. The idea of integration is frightening. Despite a lot of discussion it has been slow to develop. Effective utilization of behavioral health skills and services will yield major improvements A Breakthrough Collaborative approach is a very good way to achieve improvement, but it requires expertise and dedication to achieve

6 Behavioral Health Problems Increase Costs At 5-year follow-up: Somatization at baseline predicted an increase of inpatient (+39.9%) and outpatient costs (+11.9%). Depression predicted an increase of inpatient (+24.1%) and outpatient costs (+8.9%). Comorbidity of somatization and depression and somatization and anxiety predicted an increase in overall health care costs of 50%.

7 The Hidden Menace Up to 50 percent of primary care patients present with physical symptoms that cannot be explained by a general medical condition Unexplained symptoms of somatoform disorders often lead to: general health anxiety; frequent or recurrent and excessive preoccupation with unexplained physical symptoms; inaccurate or exaggerated beliefs about somatic symptoms; difficult encounters with the health care system; disproportionate disability; displays of strong, often negative emotions toward the physician or office staff; unrealistic expectations; and, occasionally, resistance to or noncompliance with diagnostic or treatment efforts.

8 Higher cost evidence Behavioral health patients are more likely to be readmitted. ( 21% vs 16%) Four mh/su disorders among the conditions resulting in the most all-cause, 30-day readmissions for Medicaid patients: mood disorders, schizophrenia and other psychotic disorders, alcohol-related disorders, and substance-related disorders.

9 Improving Identification and diagnosis of depression and alcohol abuse in primary care PHQ-9 From Primary Care Evaluation of Mental Disorders (PRIME-MD) The PHQ-9 looks at 9 symptoms for dx of depression from DSM-IV Validated in multiple studies Other (GAD-7, PHQ-15) Adrencorticothalamic dysfunction

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11 Scoring Score Severity Action 0-4 None None 5-9 Mild Counsel, repeat at follow up Moderate Tx plan, counseling, f/u, meds Mod/Severe Active tx, meds and/or therapy Severe Immediate pharmacotherapy, likely referral to MH specialist

12 Response If BH care is available on site connect with provider If off site - know the delay in care - how soon the appointment For Refer to Collaborative Care For >15 Immediate Initiation of Treatment

13 Other Screening for Anxiety and Depression PRIME-MD SADPERSON scale Generalized Anxiety Disorder Scale No scale is an adequate substitute for professional clinical evaluation

14 Screening for Alcohol Abuse Addiction is a brain disease. People do it to: Feel good Feel Normal Most common evaluation tool SBIRT

15 Questions for Alcohol Screen How many times in the past three months have you had five or more drinks in a day? On Average how many days a week do you have an alcoholic drink? On a typical day how many drinks do you have? Scored by number of one time person drinks or multiplying days by average.

16 If the Number of Drinks Exceeds 14 for Men and 7 For women Per Week Ask Questions to SCREEN for Alcohol Dependence: a. In the past year, have you sometimes been under the influence of alcohol in situations where you could have caused an accident or gotten hurt? b. Have there often been times when you had a lot more to drink than you intended to have? If patient responds negatively to both questions: provide brief advice to cut back, counseling. If patient responds positively to either question, or if unsuccessful at cutting back, recommend to patient a referral to Chemical Dependency services

17 On The Spot Counseling 1. I m concerned that you are drinking more than is medically safe. 2. This could affect your [hypertension, depression, sleep disorders, weight gain, diabetes, acid-related peptic disorders, erectile dysfunction, injury, health], and 3. I recommend you cut back to no more than 4(3) drinks per day and no more than 14 (7) per week.

18 Some Basic Facts About Alcohol Abuse 20% of Primary Care Patients Are At-Risk for Alcohol Use Problems. 80% of At-Risk, Problem or Dependent Drinkers are seen only by Primary Care

19 DAST -10 Drug Abuse Screen YES NO These questions refer to the past 12 months only. 1. Have you used drugs other than those required for medicalreasons? Do you abuse more than one drug at a time? Are you always able to stop using drugs when you want to? Have you had blackouts or flashbacks as a result of drug use? Do you ever feel bad or guilty about your drug use? Does your spouse (or parent) ever complain about your involvement with drugs? Have you neglected your family because of your use of drugs? Have you engaged in illegal activities in order to obtain drugs? Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs? Have you had medical problems as a result of your drug use (e.g., memory loss, hepatitis, convulsions, bleeding Etc.)?... * DAST Score * See scoring instructions for correct scoring procedure

20 DAST-10 Questions These questions refer to the past 12 months only. YES NO 1. Have you used drugs other than as required for medical reasons? 2. Do you abuse more than one drug at a time? 3. Are you always able to stop using drugs when you want to? 4. Have you had blackouts or flashbacks as a result of drug use? 5. Do you ever feel bad or guilty about your drug use? 6. Does your spouse (or parent) ever complain about your involvement w/drugs 7. Have you neglected your family because of your use of drugs? 8. Have you engaged in illegal activities in order to obtain drugs? 9. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs? 10. Have you had medical problems as a result of your drug use (e.g., memory loss, hepatitis, convulsions, bleeding etc.)? * DAST Score One for each yes

21 DAST-10 Score Degree of Problem Related to Drug Abuse Suggested Action 0 No problems None at this time. reported 1 2 Low Level Monitor, reassess at a later date. 3 5 Moderate Level Further investigation is required. 6 8 Substantial Level Assessment required Severe Level Assessment required.

22 Using the tools PHQ-9 or other plus DAST-10: screens should be used with some training Most concerns about application are covered in training Objective is to identify and get to treatment Treatment is dependent on connection to care Achieving connection is possible and we will cover that in a few minutes

23 Reducing high readmissions of people having behavioral health diagnosis as part of diagnosis People deny behavioral health diagnoses but recognize confounding problems Best improvements in practice come from collaborative efforts Collaboratives need to extend to other organizations There is no single solution

24 Care Integration to Prevent Re-hospitalization Leadership Requirements Culture change: looking at our own resistance System specific issues Working between systems Technology issues Activating support systems Different perspectives on same issues: let s not be rigid 24

25 Leadership Transformative change requires top-to-bottom and bottom-to-top leadership Empowering all staff to contribute Creating a safe environment for change Plan for dealing with resistance Change in perspective, change in operations Turf issues 25

26 Identification and Screening Ideas for developing processes for screening/identification. Who gets screened? How are they identified? Who does the screening? What happens to the results? What are the tools for screening? PHQ SBIRT/SUD screens Others

27 Focus on Patient Close attention to what the patient goes through, emotionally, cognitively and chronologically Attention to compromises between patient needs and system continuity Legitimate concerns about provider time Activation of family and peers Partnering with the patient 27

28 Care on the Unit Hospitalists, Behavioral Health/SA clinicians, Consultation/Liaison MD Secret therapists (usually nurses and Peers) Seeing behavioral health problems as medical problems Clear plan on amount of BH support on unit Role of family, helpful and not Security Relationships matter 28

29 These programs: Transitional Care: Components Engage patients with chronic illnesses while hospitalized Follow patients intensively post-discharge Teach/coach patients about medications, self-care, and symptom recognition and management Remind and encourage patients to keep follow-up physician appointments Approaches to achieving these goals differ across programs

30 Transitional Care: Three Promising Models None Tested for Dual Diagnosis Care Transitions Intervention (Coleman) Patient-centered intervention designed to improve quality and contain costs for patients with complex care needs as they transition across care settings Transitional Care Intervention (Naylor) Patient-centered intervention designed to improve quality of life, patient satisfaction, and reduce hospital readmissions and cost for elderly patients hospitalized with CHF Enhanced Discharge Planning Program (RUSH) Telephone-delivered social work-based transitional care model (hospital to home) designed to promote patient safety and satisfaction, improve quality of life, and reduce preventable re-hospitalizations and ED visits.

31 Transitional Care: Target Populations Care Transitions Intervention (Coleman) Included: Patients dc d from hospital with certain diagnoses; 30-day Medicare readmissions for HF, MI, PNE; additional risk algorithm for readmission drawn from administrative data Excluded: Dementia with no caregiver, primary psychiatric diagnosis, with psychotic elements, active drug or alcohol use Transitional Care Intervention (Naylor) Included: 65+ CHF patient admitted to certain hospitals and residing within 60 miles of designated hospital Excluded: ESRD, non-english speaking Enhanced Discharge Planning Program (RUSH) Included: 65+ returning home after discharge with 7+ prescriptions and 1 additional risk factor including living alone, past admission, no/unstable support system, other psychosocial issue Excluded: Transplant

32 Transitional Care: Staffing Care Transitions Intervention (Coleman) APN, RN, social worker, or occupational therapist 1 care coordinator per 40 patients Duration: 30 days following hospitalization Transitional Care Intervention (Naylor) Advanced Practice Nurses (3) 1 care coordinator per 39 patients Duration: 3 months following index hospitalization Enhanced Discharge Planning Program (RUSH) Master s prepared social worker with experience in health and aging 1 care coordinator per 48 patients Duration: Up to 30 days, average 8 days

33 Transitional Care: Intervention Care Transitions Intervention (Coleman) Home visit post discharge, three follow-up calls Based on 4 pillars: medication management, patient-centered record, primary care and specialist follow-up, knowledge of red flags Transitional Care Intervention (Naylor) Hospital visit and home visits of varying frequency Comprehensive assessment in hospital, defining priority needs and services Ongoing advocacy, education, and communication to ensure plan of care Enhanced Discharge Planning Program (RUSH) Pre-assessment through medical chart review to determine potential needs Telephonic biopsychosocial assessment and care coordination to stabilize situation, ensure medical and home health follow-up, and engage community-based service providers

34 Stages In Reducing General Health Readmissions I Identification and Screening II Communication between all stakeholders III Key Steps in Care a. Patient Engagement i. Using the patient-consumer perspective ii. Patient needs assessment iii. Medication management/compliance b. Community Partnerships and establishing connections with other providers c. Referrals for care and support i. Addressing social and basic needs ii. Peer Support iii. Support Groups d. Ensuring follow-up care a. Feedback loops between providers b. PCMH model of care

35 Communication Between All Stakeholders Between doctors, nurses, patient, family members, peer support, social services Education about the behavioral healthcare problem Explaining the disease process Symptom Identification Managing behavioral and physical health conditions cohesively Addressing denial, hostility, health literacy and cognitive impairment (barriers) Communication techniques Patient self-management

36 Key Steps Patient Engagement Using the patient-consumer perspective Patient needs assessment Medication management/compliance Community Partnerships and establishing connections with other providers Referrals for care and support Addressing social and basic needs Peer Support Support Groups Ensuring follow-up care Feedback loops between providers PCMH model of care

37 Reducing Psychiatric Readmissions John Peter Smith Hospital Year long project to reduce readmissions Created breakthrough collaborative process Hospital developed assessment of risk for readmission Developed many interventions Created Discharge Management Program

38 Discharge Management Program Project created a Comprehensive Behavioral Health Discharge Management Program Transition Managers responsible for proactive pre- and postdischarge interaction, intervention, and coordination with patients discharged from Trinity Springs Pavilion as they return to the community. The engagement activities are stratified based on the assessed level of risk for readmission. Activities range from simple followup calls to home visits and transportation assistance. We also utilize Peer Support Specialists throughout our continuum as well as a Patient & Family Advisory Council to better inform our discharge/transition practices.

39 The Predictive Model analysis process: 1. Identified the independent demographic and clinical variables that were present on admission of each Index visit: 2. Identified the dependent variable: Index with 1 or more Readmits 3. Segmented values in each independent variable into meaningful groups that had sufficient volumes to make a statistically significant impact on the dependent variable 4. Identified the Reference Group for each independent variable as the group with the lowest Observed over Expected (O/E ratio) Age Range: Gender: Female Zip Code: Race: Caucasian Ethnicity: Hispanic Diagnostic Class: Other

40 The Predictive Model analysis process cont d: 5. Created odds ratio (Exp(B)) of each of the independent variable groups on the dependent variable 6. Assign a weighted risk score to each independent variable group with a contribution coefficient > 1 Exp(B) 1.0 to 1.49 = 1 point Exp(B) 1.5 to 1.99 = 2 points Exp(B) 2.0 to 2.49 = 3 points Exp(B) 2.5 or greater = 4 points Reference Table 1: Readmission Risk Values by Variable 7.Determine the Risk classification scale based on total Risk Score per visit 8.Calculate the Percentage and Readmit Rates for each Risk Classification

41 Readmission Risk Values by Variable COLUMN CRITERIA POINT VALUE DiagClass Bipolar Disorder 2 DiagClass Psychosis 2 DiagClass Schizophrenia 2 DiagClass Substance Abuse 2 AgeRange Race_Name BLACK OR AFRICAN 1 AMERICAN Race_Name ASIAN 4 Ethnic_Name NOT HISPANIC OR LATINO 2 patientzip patientzip

42 Appointment with an Embedded Behavioral Health Specialist (EBHS) Group Therapy with an EBHS Appointment for counseling Appointment with psychologist Group Therapy Session with Transition Coordinator (TC) Telephonic Supportive/Mentoring minutes phone appointment Telephonic Supportive/Mentoring minutes phone appointment Interventions Developed Attend appointment with patient at their 1st visit with psychiatrist Assist w/navigation of DC meds Family Education/Consultation Support Interventions Disease Management Education Recovery Messages sent by mail or Setup appointment for home visit Consultation w/pharm D regarding meds Assistance with establishing a Primary Care Appointment Assistance with establishing JPS Connection Programs Facilitate process with aftercare at Substance Abuse Treatment Center Facilitate process with other community support groups Referral to Partial Hospitalization Program

43 Appointment with an Embedded Behavioral Health Specialist (EBHS) Group Therapy with an EBHS Appointment for counseling Appointment with psychologist Group Therapy Session with Transition Coordinator (TC) Telephonic Supportive/Mentoring minutes phone appointment Telephonic Supportive/Mentoring minutes phone appointment Interventions Developed Attend appointment with patient at their 1st visit with psychiatrist Assist w/navigation of DC meds Family Education/Consultation Support Interventions Disease Management Education Recovery Messages sent by mail or Setup appointment for home visit Consultation w/pharm D regarding meds Assistance with establishing a Primary Care Appointment Assistance with establishing JPS Connection Programs Facilitate process with aftercare at Substance Abuse Treatment Center Facilitate process with other community support groups Referral to Partial Hospitalization Program

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45 Thanks For Coming Questions? Observations? Issues? For further information contact P Peter C Brown Executive Director Institute for Behavioral Healthcare Improvement pbrown34@nycap.rr.com