Integrated Care The Inseparability of the Mental and the Medical CFHA Summit San Diego, California...
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Transcript of Integrated Care The Inseparability of the Mental and the Medical CFHA Summit San Diego, California...
Integrated CareThe Inseparability of the Mental and the Medical
CFHA SummitSan Diego, California
Frank deGruyOctober 22, 2009
“…responsible for providing for all the patient’s health care needs…”
“Care is coordinated and/or integrated across all elements…”
Joint Principles of the Patient Centered Medical Home
American Academy of Family Physicians (AAFP)American Academy of Pediatrics (AAP)American College of Physicians (ACP)American Osteopathic Association (AOA)
February 2007
A Medical Home is:
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Without mental and behavioral healthcare, the PCMH fails.
Fails!
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Mental DisordersSymptoms, Stress, Concerns
Substance Abuse
Health Behavior Change
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Mental Disorders
5
6Number of physical symptoms
Personal Health CostsMedical CarePharmaceutical costsWorkers’ Compensation Costs
Productivity Costs
Presenteeism
OvertimeTurnover
Temporary StaffingAdministrative Costs
Replacement TrainingOff-Site Travel for Care
Customer DissatisfactionVariable Product Quality
Absenteeism
Short-term Disability Long-term Disability
The Full Cost of Poor Health to Employers
Iceberg of Full Costs to
Employers from Poor Health
Iceberg of Full Costs to
Employers from Poor Health
Sources: Loeppke, R., et al., "Health and Productivity as a Business Strategy: A Multi-Employer Study", JOEM.2009; 51(4):411-428. and Edington DW, Burton WN. Health and Productivity. In McCunney RJ, Editor. A Practical Approach to Occupational and Environmental Medicine. 3rd edition. Philadelphia, PA. Lippincott, Williams and Wilkens; 2003: 40-152
Sources: Loeppke, R., et al., "Health and Productivity as a Business Strategy: A Multi-Employer Study", JOEM.2009; 51(4):411-428. and Edington DW, Burton WN. Health and Productivity. In McCunney RJ, Editor. A Practical Approach to Occupational and Environmental Medicine. 3rd edition. Philadelphia, PA. Lippincott, Williams and Wilkens; 2003: 40-152
70
%3
0 %
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Top 10 Health Conditions Driving Med + Rx Costs per 1000 FTEs
Loeppke, R., et al., "Health and Productivity as a Business Strategy: A Multi-Employer Study“. JOEM. 2009;51(4):411-428.
Loeppke, R., et al., "Health and Productivity as a Business Strategy: A Multi-Employer Study“. JOEM. 2009;51(4):411-428. 8
Top 10 Health Conditions Driving Full Costs for Employers (Med + RX + Absenteeism + Presenteeism) Costs/1000 FTEs
Loeppke, R., et al., "Health and Productivity as a Business Strategy: A Multi-Employer Study“. JOEM. 2009;51(4):411-428.
Loeppke, R., et al., "Health and Productivity as a Business Strategy: A Multi-Employer Study“. JOEM. 2009;51(4):411-428. 9
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The Comorbidity Story
Robert Graham Center, “Why there must be room for mental health in the medical home; NBGH: An Employers’ Guide to Behavioral Health Services
Health Behavior Change
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12McGinnis JM, Foege WH. Actual Causes of Death in the United States. JAMA 1993;270:2207-12.Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual Causes of Death in the United States, 2000. JAMA 2004;291:1230-1245.
Myopia Psoriasis Hypothyroidism Allergies
Depression Multiple Sclerosis Epilepsy
Chronic Back PainInfertility Crohn’s Disease GERD
Ulcerative Colitis
Sickle Cell Disease
Type I Diabetes
Parkinson’s
Cystic Fibrosis CAD
Chronic Hep B
Osteoporosis Cerebrovascular Dz Hypertension Hyperlipidemia
Asthma CHFSchizophrenia Type II DM
Alzheimer’s Obesity
Bipolar Disorder Addictions
Requirement for behavior change
Moti
vatio
n to
cha
nge
So What Does A Comprehensive Medical Home Look Like?
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And where do we get the behavioralhorsepower we need for it?
The Shape Of Practices Today:
A solo doc in a micropractice A doc and a nurse
Three partners, four staff …joined by a care coordinator
…joined by a psychologist Eight partners, three care coordinators, a clinical pharmacist, two
psychologists, and a partridge in a pear tree Staff HMO office with a full complement of resources
FQHC with a different full complement of resources
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Possible Structuresfor Integrated, Comprehensive Care
A psychologist who does CBT both in her office and in the PCMH
A psychiatrist who is in the medical home one afternoon a week
A CMHC staff who are available any time by phone
An MFT who works part time in the practice
A Depression Center that consults by teleconferencing hookup
A psychiatrist who spends one long breakfast a week with the PCPs and the Care manager reviewing charts
A psychologist who works with the care coordinator .25 FTE on motivational interviewing and other health behavior change
modalities
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Principles
Specify the job to be donePay for outcomes
Offer ideas and options about meansEncourage local solutions
Support the cost of changeClosely evaluated case studies and demos
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