Uniting the Field:The AHRQ Academy for Integrating Behavioral Health and Primary Care

Alexander Blount, EdD; Director, Center for Integrated Primary Care, Univ. of Massachusetts Medical School

Deborah Cohen, PhD; Associate Professor, Oregon Health and Science UniversityNeil Korsen, MD; Medical Director, Program to Integrate Medical and Behavioral

Healthcare, MaineHealthBenjamin Miller, PsyD; Assistant Professor, Dept. of Family Medicine, University

of Colorado School of MedicineC.J. Peek, PhD; Associate Professor, University of Minnesota

Collaborative Family Healthcare Association 14th Annual ConferenceOctober 4-6, 2012 Austin, Texas U.S.A.

Session #A1October 5, 2012

Faculty Disclosure

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

Objectives

• At the conclusion of this presentation, participants will be able to:– List three ways the Academy website can be a

resource for the integration community– Describe three projects funded by the federal

government addressing integration, and– Explain two ways the larger integration

community can become involved in these national efforts

Learning Assessment

A learning assessment is required for CE credit.

Attention Presenters:Please incorporate audience interaction through a

brief Question & Answer period during or at the conclusion of your presentation.

This component MUST be done in lieu of a written pre- or post-test based on your learning objectives to satisfy

accreditation requirements.

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

Uniting the Field: The AHRQ Academy

CFHA Annual Conference

October 5, 2012

Brilliance

Brilliance

Brilliance

Brilliance

Brilliance

• Lexicon (language critical)

• First and second steps for the field in research

• Metrics for evaluating integration

• Unite the field and move it forward

A RESOURCEBut wait….

Homepage

Literature repository

NIAC

http://integrationacademy.ahrq.gov/

• Academy– Workforce

– Survey

• IQM• Lexicon• Research agenda

The organized thinking

• Survey small and solo primary care providers to learn what they are doing for mental health– National survey

– Currently through OMB process

– Important group not often included within integration efforts

Survey

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Uniting the Field—The AHRQ Academy for Integrating Behavioral Health and Primary Care:

Developing and Applying a Consensus LexiconAHRQ Annual Meeting

September 10, 2012Bethesda, MD

C.J. Peek, PhDAssociate ProfessorDept of Family Medicine and Community HealthUniversity of Minnesota Medical School

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“Is there a Lexicon in the House?”2012 CFHA Annual Meeting

C.J. Peek, PhD; University of Minnesota

Normal confusion in a new field• “Are you saying integrated behavioral health and collaborative care are the same?”

• “Is that the same as co-located mental health or primary care behavioral health?”

• “What functions define the genuine article? What can be different from practice to practice?”

• “How can we implement, ask research questions (or write a book) if we can’t even get through a phone call without stumbling over the basic concepts in our field?

The archetypal experience: “We already do that. . .”

“. . . No you don’t”

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Communities this lexicon intends to unite:

Patients & families: • What do I want and expect as a standard of practice? • How would I recognize it if I saw it? • How would I know if what I see is up to standard?

Purchasers/plans: • What exactly am I buying? • What do I tell employees or members

what to expect for the cost?

Clinician & system implementers: • What exactly do I implement? • What are the core functions and what

do I locally adapt?

Policymakers & business modelers: • If asked to change rules of the game or business models, what

functions need to be supported?• Says who?

Researchers: • What comparisons of effectiveness? • What terms for asking consistently understood

questions across PBRN’s?

Requirements for lexicon development method:

A.Consensual but analytic(a disciplined process--not a political campaign)

B.Involving “native speakers” (in this case, 24 diverse)

(implementers and users)

C.Focused on what functionalities look like in practice

(not just principles, values, abstractions)

D.Amenable to gathering an expanding circle of “owners” and contributors

(not just an elite group coming with a declaration)

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Method: Paradigm Case Formulation and Parametric AnalysisOssorio (2006); The Behavior of Persons. Descriptive Psychology Press, Ann Arbor

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Defining clauses for genuine integrated BH:

B. The “How”:1. A practice team tailored to the needs of each patient and situation

(spelled out in 3 sub-clauses)

2. With a shared population and mission—with responsibility for total health outcomes

3. Using a systematic clinical approach (spelled out in 5 sub-clauses)

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Based on Peek, C.J. and the National Integration Academy Council (AHRQ—in press). A consensus lexicon or operational definition: Integrated behavioral health and primary care. 2011 version available at:http://www.ahrq.gov/research/collaborativecare/

C. “Supported by”:4. A community or population expecting that BH and PC will be appropriately

integrated as a standard of care5. Supported by office practice, leadership alignment, and business model

(spelled out in 3 sub-clauses)6. And ongoing QI and measurement of effectiveness (spelled out in 2 sub-clauses)

A. The “What”—a two-sentence definition; a glossary at the end

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Parameters—how practices might differ (examples)1. Range of team functions available

Foundational:(9 functions)

Foundational plus Extended functions

2. Type of spatial arrangement

Mostly separate space

Co-located space Fully shared space

5. Level shared workflows & protocols are followed

Less than 50%(Not acceptable)

More than 50%, less than 100%

Nearly 100%(standard work)

7. Level of systematic followup & tx adjust.

Less than 40%(not acceptable)

More than 50% Nearly 100%(standard work)

3. Type of collaboration

Referral-triggered exchange

Regular commun. & coordination

Full collaboration / integration

8. Community expectation for integrated BH / PC

Little or none

Expected in pockets

Widely understood and expected

9. Level of office practice design & reliability

Non-systematic(not acceptable)

Partially routinized

Standard work

11. Level of leadership alignment

Misaligned(not acceptable)

Partially aligned Fully aligned

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Implementation: Lexicon Applications(Behavioral health integrated in primary care)

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Implementation Application User or product

“What functions do I need to build?”(“What is required, what can vary?”)

Full operational description plus derivative summaries

Practice “checklists”(to describe and compare practices over time)

AHRQ practice surveys and multiple others

Workflows and team functions(Like “specifications” for shared workflows)

Implementers such as U of MN family medicine clinics

Project milestones(“X functions at Y levels by Z date”)

implementers

Patient engagement & demand(what functions should I expect and demand as a standard of practice?)

AHRQ Academy; Institute for Clinical Systems Improvement

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Lexicon Applications(Behavioral health integrated in primary care)

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Application Sponsor or product

Measures: Quality of integration (Integration of behavioral health & prim care)

AHRQ Atlas of Measures(Academy for Integration of BH & PC)

Workforce competencies(For practices and individuals)

AHRQ(Academy for Integration of BH & PC)

Research: Asking consistently understood research questions, esp in PBRN’s

Collaborative Care Research Network (AAFP NRN)

Patients and citizen representatives(what should I expect? How do I recognize it?)

AHRQ, Institute for Clinical Systems Improvement (MN)

Publications and training(A unified field with consistent language)

Edited book (Talen & Valeras)AHRQ Academy web portal, other

Policy and business model development(What functions do new rules and business models need to support?)

AHRQ Academy, Milliman, others interested in policy and business models

• What areas of the field (or your own work) could most benefit from more common language and definition?

Question

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

WorkforceAlexander Blount, EdD

• Develop competencies for both behavioral health and primary care providers– Different method, different approach

– Studying the exemplars

– National team of experts

– Develop plan for technical assistance

Workforce

• What counts as an exemplar?– Do we go with the ones we know and love?

– Do we use the definitions of the Lexicon?

– Is the Lexicon definition somewhat aspirational?

• Aren’t competencies a moving target based on the maturity of the setting?– Mature settings have more of the competencies

represented as regular practices and protocols.

– Competencies move from the skills of the provider to the standard practice of the team.

Workforce

• How would you define an exemplar?

Question

Integration Quality Measurement Atlas

Neil Korsen, MDAHRQ Annual MeetingSeptember 10, 2012

Purpose of Atlas Project

• To create a resource for those doing research, evaluation, or quality improvement related to behavioral health integration in primary care

• To collect quality measures related to integration in one convenient website

• To identify domains related to integration for which new measure development would be desired

Atlas Development Process

LEXICON PERFORMANCE DOMAINS

MEASUREMENT CONSTRUCTS

MEASURES

Environmental Scan

• Search strategy was guided by the following:– Lexicon definition

– Measures in the public domain; and

– Measures published since 2001

• 28 measures identified

Challenges

• Why behavioral health and not mental health?

• Isn’t this just measuring ‘good health care’?

• Why aren’t we listing all the behavioral health outcome measures?

• What help do you need with measurement of the impact of integration?

Question

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

Evaluation and MeasurementDeborah Cohen, PhD

Oregon Health & Science University

• Observations from the field– Integrating care takes time, energy and passion

– Most practices do not track or measure important data

– Learning how to do integration is a process

• Implications for Assessment– The process is more important than what you

measure

– Measurement requires engagement

• How can the Academy help

Overview

Observations from the field

What are the challenges in changing to an integrated practice?– Core team resilience and adaptability

– Creating space for teamwork

– Culture and identity change

– Creating a sustainable business model

– Information technology

– Tracking and measuring care

How do practices learn how to do this work?

– Try something

– Have an experience

– Observe what happens (data)

– Reflect on experience

– Try out something new

How can tracking and

measurement support this learning process?

Where to start?

• What does your organization and its members want to accomplish? Passion for change?

• What patients do you want to impact?• How are we going to have an impact on those

patients?– How will we identify these patients?

– What treatment will patients receive (type, length)?

– What will have to change in the practice to make this happen?

• How will I know if the practice is changing?– How will I know if I am reaching all of the patients with this

need?

– How will I know if they’re improving?

• Reach• Effectiveness• Adoption• Implementation• Maintenance

A Framework for Assessment - REAIM

RE-AIM. (Reach, Effectiveness, Adoption, Implementation, Maintenance). See http://www.re-aim.org/

• Most practices struggle with answering the following questions:– How many people are served by my practice?

– What proportion of my patients have behavioral health (or physical health needs)?

– What percentage of these patients do we screen for physical or behavioral health needs?

– What % of patients receive the need behavioral health (or physical health) services?

Reach – some questions to answer

Effectiveness - Possible Measures

Physical health domain 

Process measuresGeneral Annual cholesterol screening Annual influenza vaccination Height and Weight for BMIDiabetes Follow-up Care Hemoglobin A1c testing every 6 months Retinal examination Foot examination LDL-C everry 12 months

 Outcome measuresGeneralBMI – outside normal rangeDiabetes•Hemoglobin A1c > 9%•LCL-C < 100 mg/dl•BP > 130/85 mmHg

Mental health domain Process measures Depression PHQ 9 screening / monitoring On medication – for moderate / severe depression Referral for counseling – 6-8 sessionsFollow-up visits for monitoring

Anxiety GAD7 screening / monitoring On medication – for moderate / severe depression Referral for counseling – 6-8 sessionsFollow-up visits for monitoring

Alcohol Use AUDIT screening / monitoring Referral for counseling – 6-8 sessions Follow-up visits for monitoring Outcome measuresMeasure improvement in above scores

Observe– Physically watch how things are done

– Look at patterns unobtrusively

Talk– Talk to people about what’s working and what’s

not

Implementation

The value of answering these questions

• Answering these questions is important.– Diagnose strengths / weakness of care processes

– Foster learning and innovation

– Engage patients and the practice

– Collect data that helps you evaluate what works and what doesn’t

Nelson, EC. et al. Using Data to Improve Medical Practice by Measuring

Processes and Outcomes of Care. Journal on Quality Improvement.

26(12) 667.

• Literature• Measures• Examples

How the Academy website can help

• What else could be included on the the Academy website to help me do quality improvement and measurement?

Resources available via The Academy

• What else could be included on the Academy website to help me do quality improvement and measurement?

• What help do you need with measurement of the impact of integration?

• How would you define an exemplar? • What areas of the field (or your own work)

could most benefit from more common language and definition?

Questions

Session Evaluation

Please complete and return theevaluation form to the classroom monitor

before leaving this session.

Thank you!