Module 1 Introduction to Collaborative Care modified RT · Learning Objectives: Module 1 By the end...
Transcript of Module 1 Introduction to Collaborative Care modified RT · Learning Objectives: Module 1 By the end...
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Resident Rotation:Collaborative Care Consultation Psychiatry
Anna Ratzliff, MD, PhDRamanpreet Toor, MDJames Basinski, MD
With contributions from:Jürgen Unützer, MD, MPH, MAJennifer Sexton, MD, Catherine Howe, MD, PhDDeborah Cowley, MD
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Module 1: Introduction to Collaborative Care
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Learning Objectives: Module 1
By the end of this module, the participant will be able to:• Understand the case for Collaborative Care and be familiar
with the growing evidence base for Collaborative Care.• Recognize the basic elements and principles of Collaborative
Care and be ready to further explore both in later modules.• Examine their own experiences and opinions of existing
outpatient mental health systems while considering Collaborative Care psychiatry’s potential for delivering more integrated and population based care.
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Why Make Any Change in the Existing Psychiatric Care?
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The Challenge
Behavioral Health• Psychiatric disorders cause • 25% of all disability
worldwide*• 10% of Years Lived with
Disability (YLD) from depression alone
• 3x diabetes, 10x heart disease, 40x cancer
• In the US, one suicide every 14 minutes– Ex: WA State has 2‐3 suicides
per day
Health Behaviors• Behavior determines ≈ 50 % of
all mortality and morbidity• Unhealthy behaviors are
major drivers of health care costs
• 40 – 50% struggle with treatment adherence
• Employers struggle with absenteeism and presenteeism
*C. Murray, GBD Study, Lancet 2012
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Who Gets Treatment?
Wang et al., 2005
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Who Gets Treatment?No Treatment Primary Care Provider
Mental Health ProviderWang et al., 2005
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Traditional Consultation
Limited access
• There will never be enough psychiatrists to refer all patients for consultation.
Limited feedback
• PCPs experience psychiatry consultation as a ‘black box’.
Expensive
• All MH referrals require full intakes, often leaving little time and energy for follow‐up or ‘curbside consultation’.
‘One Pass’
• Works best for one‐time or acute issues that don’t need follow‐up.
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Services are Poorly Coordinated.
9
Other Community Based Social Services
SocialServices
Vocational Rehab
Alcohol & Substance Abuse
Treatment
Community Mental Health
Centers
PrimaryCare
“Don’t you guys talk to each other?”
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Why Behavioral Health Care in Primary Care?
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Why Behavioral Health Care in Primary Care?1. Access to care and reach:
• Serve patients where they are
2. Patient‐centered care:• Treat the ‘whole patient’
3. Effectiveness of care:• Make sure patients get better
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What is Collaborative Care?
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AIMS Center Definition of Collaborative Care• Collaborative Care is a specific type of integrated care that operationalizes the principles of the chronic care model to improve access to evidence based mental health treatments for primary care patients.
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Collaborative Care
Better access •PCPs get input on their patients’ behavioral health problems within a days /a week versus months
• Focuses in‐person visits on the most challenging patients.
Regular Communication•Psychiatrist has regular (weekly) meetings with a care manager
•Reviews all patients who are not improving and makes treatment recommendations
More patients covered by one psychiatrist•Psychiatrist provides input on 10 – 20 patients in a half day as opposed to 3‐4 patients.
Shaping over time•Multiple brief consultations
•More opportunity to ‘correct the course’ if patients are not improving
Caseload‐focused psychiatric consultation supported by a care manager
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Principles of Effective Integrated Behavioral Health CarePatient Centered CarePatient Centered Care• Team‐based care: effective collaboration between PCPs and Behavioral Health Providers.
Population‐Based CarePopulation‐Based Care• Behavioral health patients tracked in a registry: no one ‘falls through the cracks’.
Measurement‐Based Treatment to TargetMeasurement‐Based Treatment to Target• Measurable treatment goals and outcomes defined and tracked for each patient.• Treatments are actively changed until the clinical goals are achieved.
Evidence‐Based CareEvidence‐Based Care• Treatments used are ‘evidence‐based’.
Accountable Care• The delivery system is accountable and reimbursed for quality of care, clinical outcomes, and patient satisfaction, not just the volume of care provided.
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Who is Involved?
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New Roles
Collaborative Care Team
PCP
Psychiatric Consultant
BHP/Care Manager
Patient
© University of WashingtonCommunity resources
Other supportive clinic
staff
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Does Collaborative Care Work?
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Collaborative CareThe 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
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IMPACT Trial
• 1998 – 2003• 1,801 depressed adults • 18 primary care clinics
– 8 health care organizations in 5 states• Diverse health care systems
–Urban & semi‐rural settings– Capitated (HMO & VA) & fee‐for‐service
• 450 primary care providers• Two groups compared:
– Usual Care– Collaborative Care
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IMPACT: Summary
1) 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
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How Well Does It Work With Other Disorders?Evidence Base Established Emerging Evidence
• Depression‐ Adolescent Depression‐ Depression, Diabetes and Heart
Disease‐ Depression and Cancer‐ Depression in Women’s Health
Care• Anxiety• Post Traumatic Stress Disorder• Chronic Pain• Dementia
• Substance Use Disorders• ADHD• Bipolar Disorder
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Reflection Questions
1) In your previous medical training, what have you observed around primary care delivery of mental health care services?
2) What have been your experiences in finding effective dispositions for patients from acute mental health settings?
3) Are there unmet needs in my community or clinic that could be addressed with a more effectively integrated behavioral health program?