Psychiatry in an ACOAn Example from the Frontlines

Arthur E. Kelley, MDMedical Director, Partnership for Community Care (CCNC)

Psychiatric Consultant, Cornerstone Healthcare, High Point, NC

The Context

Source: naviglinlp.blogspot.com

Primary Care: the De Facto Mental Health SystemNational Comorbidity Survey Replication

Treated in Primary Care 23%

Treated in

MH System 18%

Wang et al, Arch. Gen. Psychiatry, 63, June ,2005

Untreated59%

Co-Morbidity Percentages 2001-2003

University of Washington AIMS Center

DEPRESSION

Chronic Pain

40-60%

CANCER10-20%

NEUROLOGIC

DISORDERS10-20 %

GERIATRIC SYNDROME

S20-40 % HEART

DISEASE20-40%

DIABETES10-20 %

No Health Without Mental HealthFrom: Center for Health Care Strategies, 2010

LACK OF ACCESSHalf of the Counties in US Have No Practicing Psychiatrist or Psychologist

Source: Unutzer, Psychiatric News, November 1, 2013

Changing Healthcare Environment

Source: www.wcorha.org

PCMHThe main vehicle for the coming change.

PCSPThe medical

“neighborhood”

Impact Model for Collaborative Care of Depression in Primary Care

Source: www.uwaims.org

Core Components of Collaborative Depression Care

Two Processes Care Manager Role Consulting Psychiatrist Role

Systematic diagnosis and

outcomes tracking (facilitated by PHQ-

9)

1.Diagnostic Assessment2.Patient Education/self management support

3.Close follow-up to prevent patients from “falling through the cracks”

Caseload consultation

Diagnostic consultation on difficult cases

Stepped CareChange treatment

according to evidence based algorithm if

patient not improving

Relapse prevention once patient is

improved

Support antidepressant treatment by the PCP

Brief Counseling

Facilitate treatment change

Triage to community

Relapse prevention

Consultation is focused on patients who are not

improving as expected

Recommendations for additional

treatment/referral according to

evidence-based guidelines

Adapted from AIMS Center, Univ. of Washington

Collaborative Care Improves Outcomes

“ Comparative Effectiveness of Collaborative Care Models For Mental Health Conditions Across Primary, Specialty and Behavioral Health Settings: Systematic Review and Meta-Analysis” Am. J. Psych.,169(11), Aug 2012

Statistically Significant Effects Across All Mental Disorders For:

1. Clinical Symptoms2. Mental Quality of Life3. Physical Quality of Life4. Social Role Functioning WITH:

NO NET INCREASES IN TOTAL HEALTH CARE COSTS

Lowers Healthcare Costs for Patients with Depression

Impact Study : $841 per annum/per patient over 4 years

Diamond Study: $1300 per annum/per patient over 4 years

Unutzer, Harbin, Schoenbaum. and Druss, CMS Information Resource Center Brief,, 2013

Lowers Costs for Other Disorders

Diabetes and Depression

Panic Disorder

SPMI Patients

Katon et al, Diabetes Care. June 2008:31(6): 1155-1159Katon et al, Archives of General Psychiatry. December 2002: 59(12): 1098-1104Druss et al, American J. of Psychiatry. November 2011: 168(11): 1171-1178

Cornerstone Care Outreach ClinicOur Team

David Talbot, MD, DirectorEileen Weston, NP, Clinician Mary Keever, LCSWA, Behavior Health Care

Mgr.Art Kelley, MD, Consulting Psychiatrist

Our Patients: Medicaid, Medicare, or Dually Eligible Current Enrollment: 360 (10/31/2013)

Other Clinicians

Our Experience

Importance of our tweaked EHR (Allscripts)

Screening Issues

The Registry

Triage Issues

Our Statistics: Definitions

Positive PHQ-9 : score of > 10

Response: 50% improvement in PHQ-9 score

Remission: PHQ-9 score of < 5

Usual care: 20% of treated patients achieve a response.

Source: Rush et. al., Biological Psychiatry. 2004: 56(1): 46-53

Our Results

# ACHIEVING RESPONSE 7 (21%)

# ACHIEVING REMISSION 9 (27%)

# ACHIEVING NEITHER 17 (51%)

PROTOCOL PATIENTS (N=33)

48% achieved response or remission

Non-Protocol Patients88 (73%) of patients with positive PHQ-9 did

not enter the depression protocolReasons:

1. Depression comorbid with another disorder too complicated for primary care

2. Already under psychiatric care3. Refused4. Lost to follow-up

Future Issues for CCOCIs response/remission in 48% good enough?

How to improve medication/psychotherapy adherence.

What are the characteristics of good community partners in terms of referral?

Can we improve our numbers in regard to patients accepting Impact Model care?

Can we improve the medical numbers?