Funded under contract #HHSA290-2010-00002i by the Agency for Healthcare Research and Quality

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Pilot Survey of Approaches to Integrated Care in Solo & Small Primary Care PracticesCollaborative Family Healthcare Association 16th Annual

Conference

October 16-18, 2014 Washington, DC

Session 3b October 17, 2014

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• Vasudha Narayanan, MA, MBA, MS. Associate Director Westat

• Paul Weinfurter, MSPH Sr. Study Director Westat

• Benjamin F. Miller, PsyD Department of Family Medicine University of Colorado School of Medicine

• Garrett Moran, PhD Vice President Westat

Co-Authors

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• National Integration Academy Council• Agency for Healthcare Research and Quality

Acknowledgements

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Faculty Disclosure

• We have not had any relevant financial relationships during the past 12 months.

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Learning Objectives

At the conclusion of this session, the participant will be able to:

• Identify potential barriers to behavioral health integration due to lack of access to behavioral health providers

• Discuss what steps can be taken to overcome these barriers

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Learning Assessment

• We will hold a question and answer/ discussion at the end of this presentation.

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Integrated behavioral health care is the care a patient experiences as a result of a team of primary care and behavioral health clinicians, working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population.

This care may address mental health and substance abuse conditions, health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stress-related physical symptoms, and ineffective patterns of health care utilization

What is Integrated Care

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To understand how PCPs in solo and smaller practices manage behavioral health conditions

Goal Of This Study

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• 72 percent of all Americans make an average of 6 office visits to an ambulatory primary care setting each year (Bernstein et al 2003)

• Primary care is the logical basis of an effective health care system (IOM 1996)

• Ultimately good care is “whole person” care

Why Is This Important

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o Qualitative methods to design a pilot survey

o Mixed method data collection

• Quantitative data from survey

• Qualitative data from in-depth follow-up interviews

Study Methods

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• Sample frameo National Plan and Provider Enumeration System

• Providers with a National Provider Identifier (NPI) value

o Subset to 10 states

o Primary Care Practices

• Restricted to Internal Medicine and Family Medicine Practitioners

o Solo and Small

• Defined a “small” practice as a practice with fewer than 10 total health care providers

Who did we talk to?

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• 33% response rate – 215 completed eligible surveys

– 21 in-depth follow-up interviews

• Data have been weighted– Results should not be used to make inferences

about physicians across the country.

Response

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Profile of Responding PhysiciansSize of practice Family medicine Internal medicine General practice All

One/solo practice 11% 18% 2% 32%

2-5 physicians 41% 8% 0% 49%

6-10 11% 7% 1% 19%

All 64% 33% 3% 100%

Total population of PCPs in sampled states*

27,082 13,920 1,387 42,389

Source: 2013 Survey of Behavioral Health Care in Solo and Smaller Primary Care Settings.

Colorado, California, Maine, North Carolina, Texas, Maryland, Virginia, Louisiana, Illinois, Kansas

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• 87% of PCPs include other, non-physician health care providers

• 21% share practice with behavioral health providers

Physicians’ Practice Staffing

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oNearly all PCPs• treat with medication

• refer patient to a behavioral health provider

oPCPs also treated patients by counseling them

Treatment

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• 79% systematically screen for behavioral health conditions

• 87% systematically screen for chronic physical conditions

• 74% have a systematic process to screen for both chronic physical and behavioral health conditions

• 8% have no systematic process for either conditions

Screening

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Treatment: Adoption of evidence-based standards

Condition % of PCPs

Diabetes 62%

Cardiovascular disease 53%

Asthma 48%

Depression 28%

Anxiety 25%

Substance abuse 21%

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Steps taken by PCPs during care of patients with behavioral health care needs

Steps taken Usually or Always

Screen patients periodically 71%

Adjust the treatment approach based on response to treatment 88%

Involve behavioral health specialists in challenging cases that do not quickly respond

76%

Follow U.S.P.S Task Force guidelines for depression 55%

Follow U.S.P.S Task Force guidelines for alcohol misuse 53%

Follow U.S.P.S Task Force guidelines for tobacco use 73%

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Treatment: Referral

15%

79% refer to an offsit

e BHCP

6% refer to

an onsite BHCP

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o69% of PCPs require their patients to be responsible for their own coordination and follow-up

o11% have a care manager or social worker in place to coordinate needed care for patients

o20% coordinate the follow-up directly with the behavioral health provider

o53% of practices with an onsite behavioral provider have a process for care coordination

o25% practices with no onsite behavioral provider have a process for care coordination

Treatment: Care Coordination

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oA quarter of PCPs do not work in care teamsoOf those who do work in care teams:• 88% agreed that collaboration within teams results

in better decisions around patient care

• 68 % disagreed that involvement of multiple team members increases the likelihood of medical errors

• 66% disagreed that the team process creates a burden for the care team

• Almost all PCPs agreed they are responsible for behavioral care of patients

Working in Care-Teams

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oAn onsite behavioral care provider improveso frequency of feedback

• 99% of the time vs. 70% of the time

o frequency of verbal conversations

• 64% vs. 28%

Feedback loop– Referral and Care Coordination

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oAn onsite behavioral provider does not appear to change how PCPs share decisions with patient and/or patient’s families• 57 % vs. 54%

Providing Behavioral Care – Shared Decision Making

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oPCPs agreed they are responsible for behavioral care of patients

oCo-location improves the ability of the PCP and behavioral care provider to communicate and collaborate• However, co-location alone does not equal

integrated care

oThis pilot study will be able to guide the development of a national survey of PCPs

Conclusions

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oThe results are not generalizable to the entire United States

oThe small sample size prohibits analyzing subsets of the data and doing specific meaningful analyses

Limitations

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• When you refer patients to behavioral health providers what is the system for care coordination and follow-up?

• How do you receive feedback from the psychiatrist or other behavioral health provider?

• How often do you and the behavioral health provider work together to make decisions about the patient’s treatment plan?

• There are a number of other standardized models for treating behavioral health conditions. Do you use any standardized model?

Q&A

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• Vasudha Narayanan email: VasudhaNarayanan@WESTAT.com; phone: 301-294-3808

• Paul Weinfurteremail: PaulWeinfurter@WESTAT.com; phone: 714-262-1856

Contact information

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Thank you for participating.