Sea Mar Community Health Centers Presents9th Annual Latino Health Forum

Proven Strategies to Advance Integrated Care in the Latino Community

Anna Ratzliff, MD, PhDAssistant Professor

Associate Director for Education, Division of Integrated Care & Public HealthDepartment of Psychiatry & Behavioral Sciences

University of Washington

Disclosures

• Consulting Psychiatrist Contract, Community Health Plan of Washington

• Supported from contracts and grants to the AIMS Center at the University of Washington

Daniel

Mental health disorders are common – who gets treatment?

The other 9 patients. No Treatment Primary Care Provider

Mental Health Provider

Wang et al 2005

Disparities in Depression Care for Minority

Populations• Worse access to mental health

treatment1

• Less likely to be identified2

• Less likely to receive antidepressant medications 3

• Have worse outcomes 4

1- Miranda et al. Am J Psychiatry. 2008 Sep;165(9):1102-8. 2- Borowsky et al J Gen Intern Med. 2000 Jun;15(6):381-8.3- Miranda J, Cooper L. J Gen Intern Med 2004; 19: 120-6.4- Van Voorhees et al Med Care Res Rev. 2007 Oct;64(5 Suppl):157S-94S.

Why not just refer?

½ do not follow through

2 visit mean

Grembowski, Martin et al. 2002 Simon, Ding et al. 2012

Why not just refer?

Thomas KC et al, 2009

1 in 5: unmet need for non-prescribers96%: unmet need for prescribers

Is there a better way?Yes - Collaborative Care!

http://aims.uw.edu/daniels-story-introduction-collaborative-care

Principle 1: Patient Centered Team Care

PCP

Patient BH CareManager

Psychiatric Consultant

CoreProgram

New Roles

Principle 2: Population Based Treatment

Principle 3: Measurement Based Treatment To Target

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

Principle 5: Accountable Care

Pay-for-performance cuts median time to depression treatment response in half.

0.0

00.2

50.5

00.7

51.0

0

Estim

ate

d C

um

ula

tive P

rob

ab

lility

0 8 16 24 32 40 48 56 64 72 80 88 96 104 112 120 128 136

Weeks

Before P4P After P4P

Unützer et al. 2012.

Collaborative Care: The Research Evidence • Now over 80 Randomized Controlled Trials (RCTs)

• Meta analysis of collaborative care (CC) for depression in primary care (US and Europe)

Consistently more effective than usual care

• Since 2006, several additional RCTs in new populations and for other common mental disorders• Including anxiety disorders, PTSD

Archer, J. et al., 2012

Doubles Effectiveness of Care for Depression

%

Participating Organizations

50 % or greater improvement in depression at 12 months

Unützer et al., JAMA 2002; Psych Clin North America 2004

1 2 3 4 5 6 7 80

10

20

30

40

50

60

70 Usual Care IMPACT

White Black Latino0%

10%

20%

30%

40%

50%

60%

43%

54%

42%

19%23%

14%

IMPACT Care

Care as Usual

IMPACT Care BenefitsDisadvantaged

Populations

Arean et al. Medical Care, 2005

50 % or greater improvement in depression at 12 months

IMPACT: Summary1) Improved Outcomes:

• Less depression• Less physical pain• Better functioning• Higher quality of life

2) Greater patient and provider satisfaction

3) More cost-effective

“I got my life back” THE TRIPLE

AIM

MHIP: > 30,000 clients served across Washington State

•Funded by State of Washington and Public Health Seattle & King County (PHSKC)• Administered by Community Health Plan of Washington and PHSKC in partnership with the UW AIMS Center

2008Pilot initiated in King &

Pierce Counties

2009Expanded state-wide to over 100 CHCs and 30

CMHCs

MHIP High-Risk Mothers Program

• Low income women who are pregnant or parenting

• Community health clinics in King County• Identified by primary care provider with

mental health care need• Enrolled in Collaborative Care

MHIP High-Risk Mothers Program Outcomes

All Latina White Black Asian0

10

20

30

40

50

60

70% of Population with Depression

Improvement

Huang et al. Family Practice 2012 20:394-400.

What could you do?

Daniel’s Mom

“I believe it it’s made all the difference for him.”

Menu of Inspiration Options

Patient Centered Team

Population Based Care

Measurement-Based Treatment

to Target

Evidence-Based Treatment

Accountable Care

•Use patient centered goals.•Communication with other providers.

•Track patient outcomes.•Set a practice improvement goal.

•Participate in continuing ed.•Form a learning collaborative.

• Use screeners regularly.•Track patient goals regularly.

•Use a registry.•Lead efforts for implementation.

Acknowledgments:

Daniel and his familyAnnie McGuireAngel MathisRebecca SladekJürgen UnützerAIMS Center Staff

www.aims.uw.edu