# Presentation: 886927

## Delivering Integrated Primary Care

*Integrated Ambulatory Care Conference*
*June 24, 2003*
*Mary Schohn, Ph.D.*

## Characteristics of Integrated Primary Care*

- Goal is to have wide spread impact on the physical and mental health of the primary care population.
- Patient care viewed as continuous over time rather than as involving discrete treatment episodes
- Mental and physical health standards are viewed as equivalent in importance
- PCP and BH provider are co-located in the primary care setting.

## Characteristics of Integrated Primary Care*

- Care is coordinated across disciplines through the use of the primary care team
- PCP and BH providers have a consistent view of the mission of primary care
- PCP and BH providers deliver care within the same service delivery model.
- Delivery of care is minimally cost-neutral relative to traditional primary care.
- Adapted from Blount, 1998

## Principle Diagnoses Seen in VISN 2 Primary Care

- Hypertension
- Diabetes Mellitus, Type II
- Coronary Artherosclerosis
- Hypercholesterolemia
- Hyperlipidemia
- Chronic Obstructive Pulmonary Disease
- Depressive Disorder
- Prolonged PTSD
- Esophageal Reflux
- Atrial Fibrillation

- Acute Upper Respiratory Infection
- Osteoarthrosis
- Acute Bronchitis
- Back Disorder
- Hyperplasia of the Prostate
- Senile Cataract
- Dermatophytosis of the Nail
- Tobacco Use Disorder
- Obesity

## Traditional Mental Health Issues in Primary Care

- One-half of all patients with a diagnosable mental health disorder are never treated by a mental health professional
- 80% of these patients do make an annual visit to their primary care physician
- 70-80% of all visits to primary care result from problems related to psychological distress (Kroenke et al., 1989, 1990).

## PTSD

- 9-12% of primary care patients meet criteria for full or partial PTSD. (Taubman-Ben-Ari, O., etal., 2001; Stein, etal, 2000)
- Patients with PTSD report significantly greater functional impairment and greater healthcare utilization than patients without PTSD.(Stein, McQuaid, Pedrelli, Lenox, & McCahill, 2000)

## Traditional Mental Health Issues in Primary Care

- 35-40%  of veterans in a VA primary care setting have a diagnosis of depression, PTSD, or an alcohol-related disorder (Hankin, 1999)/VHA/DoD Clinical Practice Guideline for MDD
- An additional 30 % of patients in VA primary care complain of concerns related to pain, sleep, diet or sex (Dundon, 1998)
- PCPs fail to diagnose & treat effectively up to one-third to one-half of these mental health disorders.

## Behavioral Health Co-Morbidity in Primary Care

- Across a wide variety of medical conditions, untreated co-morbid psychiatric disorders are associated with a dramatic increase in medical complications and poorer patient outcomes.

## Diabetes

- Individuals with diabetes are twice as likely as non-diabetics to be clinically depressed. Among diabetics, co-morbid depression is associated with a five-fold increase in healthcare expenditures (Egede, Zheng & Simpson 2002).

## COPD

- Among veterans with COPD, the presence of co-morbid anxiety and depression contributed significantly to variances in functional status (Kim, Kunik, et al., 2000).
- Patients with severe COPD are 2.5 times more likely to be depressed than patients without COPD or mild COPD (van Manen, Bindels, et al., 2002).

## CAD

- The prevalence of panic disorder in cardiology outpatients and patients with CAD ranges from 10-50% (Fleet, Lavoie & Beitman, 2000).
- In CAD patients, co-morbid depression is the best single predictor of cardiac events during the 12 months following diagnosis (Sheps & Sheffield, 2001).

## Medical Cost Offset

- Literature demonstrates that behavioral interventions can substantially reduce medical utilization in primary care settings (Levant, 2002)...
- Lack of attention to psychological disorders sets up a pattern of misutilization of services as the provider attempts to resolve the problem biologically (Jenkins, 1996).
- Greater reduction of utilization occurs when specific disorders such as asthma or arthritis are targeted (Sobel, 1994)

## Benefits of Integrated Primary Care

- Patient outcomes improve due to improved recognition and treatment of psychosocial issues (Katon, 1995; Callahan et al., 1994)
- Patient compliance increases (Blount, 1998)
- Medical costs are reduced in the range of 20%-40% (Cummings, et al; 1991; Strosahl et al., 1996)
- Staff and patient satisfaction increases (Blount, 1998)

## VISN 2 Model of Integrated Primary Care

- Conceptualized as a biopsychosocial service provided by a team that includes all carelines
- Each careline contributes staff and services
- Patient treatment plans are comprehensive and coordinated across carelines

## Integrated Primary Care Team Members

- Primary Care Provider
- Triage Nurse
- Nursing personnel
- Behavioral Health Provider
- Medical Social Worker
- Dietician
- Clinical Pharmacist
- Clerical and Administrative Staff

## Role of Behavioral Health

- Assist primary care provider in the identification and treatment of behavioral health issues within primary care
- Initiating and co-lead prevention and  wellness groups
- Provide brief psychotherapy interventions
- Provide protocol driven mental health and behavioral medicine interventions within the primary care setting

## Role of Behavioral Health

- Consult with primary care team about treatment for patients with complex, comorbid conditions
- Educate/consult with primary care team members about issues such as lethality & compliance
- Serve as a gatekeeper for referral to more specialized behavioral health settings including non-VA care.

## Staffing

- BH staff assigned to all primary care teams and CBOCs in VISN 2
- BH staff includes psychiatric nurse practitioners, psychologists and social workers
- Psychiatry staff allocated as needed to consult about medication issues

## Staffing

- On site staff supplemented with telepsychiatry services (Currently present in 13/28 CBOCs)
- Standarized staffing levels determined:
- 		1:4400 in Medical Centers
- 		1:1200 in CBOCs
- Immediate access to Behavioral Health services as determined by patient/provider need

## Screening in Primary Care

- Selected General Health Questionnaire (GHQ) to screen for psychiatric “caseness”
- Selection of GHQ obviates need to add additional screens as CPG measures are added
- Primary care team members developed an algorithm for intervening with for patients who screened positive
- Dialogue developed between PCP & BH Providers in this process encouraged cross-care line education and ongoing consultation

## GHQ Screening Algorithm for Primary Care

- GHQ
- self-administered

- Call PC- based
- Behavioral
- Health Provider

- Valid elevated
- GHQ score

- Actively followed by
- BVAHCL Services

- No

- Yes

- No referral

- GHQ scored

- Continue
- with primary care

- No

- Serious
- psychopathology

- Refer to BVAHCL
- Services

- PC- based
- intervention

- Yes

- No

- Yes

- PCP reviews
- GHQ >=4

- No

- Yes

## GHQ Screening results

- 20% of patients screened show evidence of psychological distress  (conservative estimate)
- 50% of these patients have no prior behavioral health treatment
- 44% of these patients accepted behavioral health treatment in the primary care setting.
- High-risk patients screened for lethality in primary care

**Notes:**
Primary care/provider profiling can target over/under utilization of BH services for system interventions

## MST Screening

- BH providers worked with Women Veteran Coordinators and Primary Care staff to roll-out MST screening initiative
- BH staff in primary care able to provide immediate assessment and linkage in response to positive screens.
- Access to behavioral health in primary care increases receptivity to services among veterans.

## Treatment Protocols

- Primary Care emphasizes screening and brief interventions to improve primary and secondary prevention.
- Quit Smart and other lifestyle interventions
- Disease management programs in hypertension, COPD, diabetes, chronic pain, pulmonary rehab, headaches, irritable bowel syndrome and CAD.
- Disease Management programs in PTSD, and substance abuse

## Quit Smart

- VISN-wide smoking cessation program
- Primary Care providers provide medical clearance/referral as part of the annual tobacco counseling process.
- Through this process, patients can readily access the program and the psychopharmacological aids without obstacles.
- 34% one-year success rate and the ease of referral, provided PCPs with an example of the benefits of BH interventions beyond traditional psychiatric problems

## Pain Management Initiative

- VISN needed to develop a cost-effective, multidisciplinary chronic pain team
- Collaboration between the integrated primary care teams and the pain task force led to recognition of many potential  resources already in place.
- Algorithm adopted used existing resources and emphasized role of primary care in managing pain treatments.

## Coordinated Care Program for Dementia

- GEC pilot study to improve care of dementia patients in VISN 2
- Emphasis on education of PCP to recognize early signs of dementia
- GEC using case managers for improving patient care management.
- Case managers collaborate with integrated primary care teams to improve access to neurocognitive assessments.

## Other Behavioral Health Group Interventions in Primary Care

- Weight Management
- Stress Management
- Sleep Hygiene Clinic
- Drinkers Check-up
- Adapting to Chronic Illness

## Quality Outcomes

## Mental Health Disease 2nd Qtr FY 03

## Cancer Disease 2nd Qtr FY 03

## Cardiovascular Disease 2nd Qtr FY 03

## Endocrinology Disease 2nd Qtr FY 03

## Infectious Disease Group 2nd Qtr FY 03

## Tobacco Disease 2nd Qtr FY 03

## Cost/Utilization Outcomes

## Service Delivery

- Developed standardized scheduling grid
- Majority of visits to behavioral health provider are 30 minutes or less
- Average number of visits/patient was 3.
- Cost/visit was 28% lower than cost/visit than in mental health clinic.

## Utilization Changes FY01-FY02

- 13% decrease in number of patients seen in mental health clinics.
- Overall increase in patients seen in lifestyle groups such as smoking cessation (100% increase since 2000), and living with chronic illness.

## Satisfaction 

## Patient Satisfaction*

- First in VHA for:
**Access**
**Visit coordination**
**Pharmacy Pick-up**
**Provider wait times**
- * Shep 2nd/4th quarter FY02

## Patient Satisfaction*

-  Top three in VHA for:
**Courtesy**
**Education/Information**
**Emotional Support**
**Overall Coordination**
**Preferences**
**Specialist Care**
**Overall Quality**
- * Shep 2nd/4th quarter FY02

## Access

## Access

- Leader in use of ACA principles in scheduling all primary care patients
- Leader in assigning BH staff to CBOCs

## Slide 44

## Additional Outcomes

- Development of a Primary Care Council that provides VISN-wide guidance for primary care.
- Development of Integrated Primary Care Administrative Manual and Behavioral Health Education Manual
- Development of Primary Care Comparison Tool
- Development of disease management databases

## Lessons Learned

- BH staff assigned must have both excellent clinical skills and good social skills
- BH interventions must be shorter than those delivered in a more traditional setting and build on psychoeducation
- Model of service delivery needs to be agreed upon by all levels of the organization prior to beginning service delivery

## Lessons learned

- Quality measures should be built into administrative and clinical practices; e.g.. use of CPG, panel sizes, provider profiling; guidelines for referral outside of primary care
- All levels of the organization need education including management, primary care providers, behavioral health providers, clerical staff and patients

## Future directions

- Potential areas of growth include greater involvement in the disease management programs for other chronic conditions.
- Continued expansion of primary prevention lifestyle intervention.
- Development of provider agreements with specialty mental health.
- Continued review of the cost/benefits of mainstreamed primary care for women veterans versus Women’s Health Center.

## Continuing Obstacles

- Lack of consistent application across the VISN settings
- Lack of understanding of financial implications by managers
- Misinterpretation of goals of integration by several levels of the organization outside of primary care

## References

**Blount, A. (1998).  Introduction to primary care.  In A. Blount (Ed.) *****Integrated Primary Care: the Future of Medical and Mental Health Collaboration.  *****New York: W.W. Norton & Co.**
**Borus, J.F., Olendzki, M.C., et al (1985). The offset effect of mental health treatment on ambulatory medical care utilization and charges.  *****Archives of General Psychiatry, 42, *****573-5580*****.***
**Kroenke, K., Arrington, M.E., & Mangelsdorff, A.D. (1990).  The prevalence of symptoms in medical outpatients and the adequacy of therapy.  *****The Archives of Internal Medicine, 150,***** 1685-1689.**

## Pincus, H.A. (1990).  Assessing the effects of physician payment on treatment of mental disorders in primary care.  General Hospital Psychiatry, 12,23-29.
Reiger, D., Narrow, W., Rae D., Manderscheid, R., Locke, B. & Goodwin, F. (1993).  The de facto US mental and addictive disorders service system: Epidemiologic Catchment Area prospective 1 year prevalence rates of disorders and services.   Archives of General Psychiatry, 50, 85-94.
Schuster, J.M. (1992).  A cost-effective model of consultation-liaison psychiatry.  Hospital and Community Psychiatry, 43, 330-332.
Strosahl, K. (1998).  Integrating behavioral health and primary care services: the primary mental health care model.  In A. Blount (Ed.) Integrated Primary Care: the Future of Medical and Mental Health Collaboration. New York: W.W. Norton & Co.

**Reiger, D., Narrow, W., Rae D., Manderscheid, R., Locke, B. & Goodwin, F. (1993).  The de facto US mental and addictive disorders service system: Epidemiologic Catchment Area prospective 1 year prevalence rates of disorders and services.   *****Archives of General Psychiatry, 50, 85-94******.***
**Schuster, J.M. (1992).  A cost-effective model of consultation-liaison psychiatry.  *****Hospital and Community Psychiatry, 43, 330-332.***
**Strosahl, K. (1998).  Integrating behavioral health and primary care services: the primary mental health care model.  In A. Blount (Ed.) *****Integrated Primary Care: the Future of Medical and Mental Health Collaboration. *****New York: W.W. Norton & Co.**