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The Rewards of Integrating Behavioral Health & Mental Health into Primary Care and the PCMH 2.0 Charles Coleman, Ph.D. IBM Population Health Solutions Team Lead Behavioral and Mental Health May 26, 2016 Housekeeping 1. Using the control panel - Use the control panel on the right side of your screen to minimize and expand this panel by clicking on the arrow in the upper right corner. 2. Ask Questions - You can submit questions using the Question section located near the bottom of the control panel. We will take time to answer as many questions as we can during Q&A at the end of the presentation. If your question was not answered, we will respond to you individually after the event. 3. After the webinar - We want your feedback! Please take the short survey at the completion of the webinar. Also, all registrants will receive a copy of the presentation, and the recording for on-demand replay. 3 Does Your Population Health Strategy Integrate Behavioral Health? Part 1 of a two part Series. Population Health Holistic Integration Compass 4 Clinical Social / Family / Environmental Behavioral / Mental Genomics OVERVIEW OF THE SCOPE OF THE PROBLEM Disorders Disease Dollars Faces of Depression • Major depressive disorders affect 15 million American adults annually resulting in $70 billion in medical expenditures, lost productivity. • People with undiagnosed and untreated depression are 4x likely to suffer a heart attack. • 25% of all cancer patients suffer from depression • 10%-27% of post-stroke patients suffer from depression, about the same percent as those suffering from diabetes. Some FACTS about Behavioral/Mental Health… Source: NAMI, APA, CMS, Project Red mood disorders are treated by Primary Care doctors 29% Of all patients with chronic illnesses have a mental illness 26% Americans 18 and older suffer from a diagnosable mental disorder 40 million US adults (18-54) have an anxiety disorder in given year ~80% Of all mental health drug prescriptions are written by PCPs and family doctors. Majority Of Americans receive their mental health care through their PCP and Family Medicine doctor 28% of all patients re- admitted to hospitals suffer from mental illness Mental Health Affects Clinical Conditions and Outcomes in a BIG WAY Source: Druss, B.G., and Walker, E.R. (February 2011). Mental Disorders and Medical Comorbidity Research Synthesis Report No. 21. Princeton, NJ: The Robert Wood Johnson Foundation. Percentage of Adults with Mental Health Conditions and/or Medical Conditions, 2001-2003 Adults with Medical Conditions Behavioral Health + Co-Morbidities Have Significant Impact on Healthcare Costs $8,000 $9,488 $8,788 $9,498 $15,691 $24,598 $24,927 $24,443 $36,730 $35,840 Asthmaand/or COPD Congestive Heart Failure Coronary Heart Disease Diabetes Hypertension AnnualPerCa pita Costs No Mental Illness and No Drug/Alcohol Abuse With Undiagnosed and/or Untreated Mental Illness and Drug/Alcohol Abuse Source: OptumHealth Effect of Mental Health on Various Illnesses Illness Increased Risk Diabetes 2x risk of type 2 diabetes1 Hypertension Up to 3x risk of morbidity2 Stable coronary artery dis. 3x risk of MACE3 Major Adverse Cardiac Event Ischemia 3x risk of 1st ischemic event4 Unstable angina 3x risk of cardiac death, 6x risk of nonfatal MI5 Myocardial Infarction Stroke 3x risk of stroke6 Post-myocardial infarction 2-3x risk of mortality7 Congestive heart failure 8x risk of mortality8 MACE=major adverse clinical event (cardiac death, MI, nonelective revascularization) 1Golden SH, et al. Diabetes Care. 2004;27:429-435; 5Lespérance F, et al. Arch Intern Med. 2000;160:1354-1360; 2Jonas BS, et al. Arch Fam Med. 1997;6:43-49; 6 Larson SL, et al. Stroke. 2001;32:1979-1983; 3 Frasure-Smith N, et al. Arch Gen Psychiatry. 2008;65:62-71; 7 Carney RM, et al. Psychosom Med. 2009;71:253-259; 4 Bremmer MA, et al. Am J Geriatr Psychiatry. 2006;14:523-530; 8 Jünger J, et al. Eur J Heart Fail. 2005;7:261-267. None +MH +SU +MH+SU Diabetes Relative R isk Relative Risk of Medical Admission for Diabetics Without & With MH and SU comorbidity MH = Mental Health SU = Substance abuse Relative risk of medical admission with & without MH and SU comorbidity None +MH +SU +MH+SU COPD Asthma Pneumonia NOS Bronchitis Relative R isk -- Maryland Medicaid Adults, 2011 N=551 depressed pts 60+ yrs > randomized Reference 2008: Chronic conditions and comorbid psychological disorders For comorbid depression, increased healthcare costs “average $505 per comorbid member per month across all chronic medical conditions we analyzed, of which nearly $400 is higher medical costs.” 79% For comorbid anxiety conditions, they “average $651 per comorbid member per month across all chronic medical conditions we analyzed, of which nearly $538 is due to higher medical costs.” 83% Slide courtesy of Wayne KatonMD Mitchell et al, J Hosp Med 2010 Depression Increases 30-Day Readmission Risk by Nearly 40% Poor Care Coordination: $12 Billion Avoidable Costs Poor coordination of care cost an estimated $25 billion to $45 billion dollars per year (Donald M. Berwick, 2012). At least $12 billion of that total is considered avoidable (Health Affairs, 2012) Mental Disorders Top The List Of The Most Costly Conditions In The United States: $201 Billion Charles Roehrig1,* Abstract Estimates of annual health spending for a comprehensive set of medical conditions are presented for the entire US population and with totals benchmarked to the National Health Expenditure Accounts. In 2013 mental disorders topped the list of most costly conditions, with spending at $201 billion. MAY, 2016 MENTAL DISORDERS BY THE NUMBERS LATEST CHANGES IN CARE MODELS AND DELIVERY SYSTEMS Preventive medicine Medication refills Acute care Nursing Test results Source: Southcentral Foundation, Anchorage AK Clinical Specialists Case Manager Medical Assistants Chronic disease monitoring Practice Transformation: Moving Away from Provider- Centric Episode of Care & Fee for Service Doctor to . . . . To an Evolving PCP-based Patient-Centered Medical Home and Value-Based Payments for Patient/Member Care Point of care testing Acute mental health complaint Chronic disease compliance Healthcare Support Team Source: Southcentral Foundation, Anchorage AK Behavioral health RN/Case Manager Clinician Medical Assistants Preventive medicine Medication refills Acute care Test results Chronic disease monitoring Medical Specialists Example Value Stream Defined by the 2014 Standards: Behavioral Health Integration Sequence in PCMH Team- Based Care PHM-- Assess PHM-- Engage Care Mgt and Support Care Coordination Measure Performance Standard 2: Team-based care includes behavioral health providers and services Standard 3: Assesses each patient and the population for behavioral health issues Standard 3: Implements point of care reminders related to behavioral health conditions Standard 4: Provides coaching and self- management support for behavioral health conditions Standard 5: Coordinates and tracks referrals to behavioral health services Think Horizontally: Create Customer- Centric Processes How Do Daily Huddles and Pre-Visit Prep Fit In this Sequence? Standard 6: Measure, evaluate, take action, improve, re-measureNCQA PCMH 2014 Technology PHM and Engagement EMR Analytics People Knowledge, Skills, Teams, Leadership, Culture Processes Efficient Ways of Working, Scale Requirements to Optimize PHM Training LEAN & Process Design Automation 23IBM Phytel Current PCMH for Collaborative Care for Diabetes Source: Unutzer, UW 24 Diabetes Care Manager Consulting Endocrinologist Engagement Programs Administrator Other Community-Based Resources PCMH: 2.0 Integrated Behavioral and Primary Care Model 25 Adapted from Unutzer PCMH: 2.0 Integrated Behavioral and Primary Care Model Managing a Chronic Disease and Mental Health Disorders 26 Adapted from Unutzer Consulting Endocrinologist & Psychiatrist Primary Care Physician Healthcare Coaches T2 Diabetic with Depression and Bipolar Disorders Other Specialists and Health Aids Substance Treatment Centers/ Clinics Rehabilitation Centers / Home Health Care Agencies / State Agencies BEHAVIORAL HEALTH AND MENTAL HEALTH RISK STRATIFICATION, DIFFERENTIAL ASSESSMENT AND DIAGNOSTIC TOOLS At-Risk Populations with Co-Morbidities and Identified Mental Health Disorders 680 452 370 225 190 164 85 52 45 38 36 21 12 0 100 200 300 400 500 600 700 800 Selected Conditions 1.Diabetes Mellitus Type 2 & Unspec Type Maintenance 2.Hypertension 3.Cancer 4.Congestive Heart Failure 5.COPD 6.Depression 7.Anxiety 8.Bi Polar Disorder 9.PTSD 1 2 3 4 5 6 7 8 9 N = 1917 Patients with Chronic Conditions N = 346 Patients Diagnosed with Mental Health Disorder 18% of this Patient Population has co- morbidities that include one or more diagnosed mental illnesses. How many remain undiagnosed? How will we know? IBM Analysis of Sample Population Data—2014 Based on this patient’s personalized profile … • Find the most similar patients (or dynamic cohort) from entire population • Analyze what happened with the cohort and reasons why (30,000+ dimensions) • Predict the probability of the desired outcome for this patient • Create personalized care plan based on unique needs of this patient Desired Outcomes Historical Observation Window Prediction Window This Patient’s Longitudinal Data Predicted Outcome For This Patient Dynamic Cohort Longitudinal Data with Outcomes Summary View of How Similarity and At-Risk Analytics Work Risk of Missed Behavioral Health Diagnoses is High Among Three of the Standard Screening Tests DEPRESSION ANXIETY BIPOLAR ANXIETY DEPRESSION BI-POLAR PTSD M3 is a new test sensitive to 4 primary Conditions in one test. Gaynes et al, Ann Fam Med 2010 Anxiety disorders are twice as common as depression in primary care. Anxiety Depression Bipolar PTSD n = 41 (6.3%) This is an mock up ensemble array used in prediction. This is a patient with depression, anxiety and T2 diabetes. Pt is on X meds. The horizontal bars with the black dashes is the target window for all variables according to care plan XYZ. The variables being measured are the colored lines along the x axis. The blue vertical = a change in one medication and dosing in an effort to correct for the radical drop overall (except for red= depression score) that results in an immediate improvement except solid green and dotted blue (i.e. weight gain and dizziness) and a brief spike in HgA1c (black) for which dosing is changed. The green “box” is a slide bar that predicts the most likely results from these adjustments based on all historical evidence from like-patient cohort records. In the prediction widow we can now clearly see a yoyo causal relationship between the red variable and the blue (i.e. depression score and the dosage of [Brand name drug] to control appetite which makes the patient nauseous and depressed. Prediction window slide bar COGNITIVE MENTOR INTEGRATES CLINICAL WITH BEHAVIORIAL, MENTAL HEALTH AND SOCIAL HAPPENED HAPPENING LIKEY TO HAPPEN Mental Health Test Score hgA1c IBM NLP and UDMH • Content Analytics Healthcare Accelerators drive overall time to value through the following: • Annotators focused on extracting medical terms • Approximately 800 pre-built rules developed in IBM Content Analytics Studio • Extracted concepts, including diagnoses, procedures, labs, and population health measures • The transformation of unstructured data to CPT, ICD-9, and SNOMED-CT codes • The detection of negations • The identification, coding and uploading of family histories Watson Healthcare Content Analytics: Configurable Healthcare Accelerators provide comprehensive NLP IBM Graphic Structured EHR Data Meaningful Use Compliance Enhanced Clinical Reporting Accurate and Comprehensive Care Plan Design Predictive Modeling though Cognitive Computing enables Proactive Interventions IBM Watson Healthcare Content Analytics: Enhancing EHR usability through advanced natural language processing (NLP) enables Watson Cognitive Care mentor to leverage all data Unstructured Free Text: Clinical Notes, Self-Reported Data Watson Content Analytics Watson Content Analytics Until now structured EHR data has required manual entry. IBM software changes this. It analyzes doctors’ notes, extracting structured clinical findings for upload into patient records, automatically adding industry standard diagnoses, clinical observations, and treatment codes. This will significantly simplify administrative processes and improve patient outcomes. IBM Unified Data Model for Healthcare includes Behavioral Health & Mental Health Terms Used to create an enterprise-wide vocabulary and to help identify data structures that need to be modeled. Supportive Content Used to identify data structures for regulatory reports, standards and vendor interfaces. Analytical Requirements Used to identify the data structures required for data marts and reports. Data Model Specifies the data structures required to represent the concepts defined in the Business Terms Data Warehouse Models Used for designing an enterprise-wide data warehouse with history management. Data Mart Models Used for designing structures suitable for deploying data mart solutions for analytics. • Clinical Patient History • Mental Health History • Substance Abuse History • Criminal Justice History • Socioeconomic History Data Warehouse Operational Data Store Big Data IBM UDMH Data Marts Analytical RequirementsBusiness TermsSupportive Content Business Data Model Data Warehouse Models Data Mart Models UDMH provides pre-defined data structures which help accelerate data warehouse and business intelligence projects. Information Integration & Governance IBM Unified Data Model for Healthcare includes Mental Health, Substance Abuse and some Social Determinates Healthcare Data Models are often used as foundational prerequisite frameworks for accessing, integrating, staging and managing comprehensive healthcare-related data across the spectrum of care to include mental health disorders and substance abuse. Content that describes mental health has been added to IBM’s UDMH to cover: • Clinical Patient History • Mental Health History • Substance Abuse History • Criminal Justice History • Socioeconomic History Updates to the existing model content have been made under: • Care Plan • Care Team • Discharge • Episode of Care • Risk Assessment • Program Activity • Care Interaction • Care Management Crisis Plan • Contingency Plan and Actions • Court Ordered Care CCD – New Behavioral Health The Continuity of Care Document (CCD) specification is an XML-based markup standard intended to specify the encoding, structure, and semantics of a patient summary clinical document for exchange. It provides a snapshot in time containing the pertinent clinical, demographic, and administrative data for a specific patient. This standard helps to promote interoperability between participating systems/organizations such as Personal Health Record Systems (PHRs), Electronic Health Record Systems (EHRs), Practice Management Application, Criminal Justice System, Education System. The CCD Behavioral Health uses all of the subjects plus other subjects which are important in behavioral health such as substance of abuse, criminal justice, homelessness, income etc. A new supportive content package called Continuity of Care Document (CCD) – Behavioral Health has been added with mappings to IBM UDMH content. Standardized Mental Health Screening & Assessments-- M3, PHQ-9— should be intro- duced and ad- ministered as part of SOP of Dx and treatment. Analytics are used to segment and stratify. Sophisticated analytics and data from NLP aid Care Coaches focused on Risk- Stratified Cohorts and Equipped with Advanced Care Coordination Technologies and integrated Care Plans. Multiple, Networked points of access to coordinated care are connected with all care- givers at multiple sites working from the same master patient record. Inclusive of care givers knowledge- able of mental health and behavioral health strategies who can perform tests and educate teams to include preventive interventions. System-wide data and process management required for fully- integrated care provisioning, delivery, assessment, care coordination, outcomes analysis and quality and cost reporting. Solving the Problem Requires Integrated Care—Clinical, Physical, Social, and Mental Template Adapted from Kaiser.org & Stratification PUBLIC POLICY AND NEW PAYMENT / REIMBURSMENT LAWS FOR MENTAL HEALTH, BEHAVIORIAL HEALTH, SUBSTANCE ABUSE The Five Pillars www.thekennedyforum.org Mental Health Parity and Addiction Equity Act (MHPAEA) Millions of Americans with mental health or substance use disorders, including individuals participating in the Medicaid program do not have adequate insurance protection against the costs of treatment for mental and substance use disorders. The Mental Health Parity and Addiction Equity Act (MHPAEA) makes it easier for those Americans to get the care they need by prohibiting certain discriminatory practices that limit insurance coverage for behavioral health treatment and services. MHPAEA requires many insurance plans that cover mental health or substance use disorders to offer coverage for those services that is no more restrictive than the coverage for medical/surgical conditions. Mental Health Parity and Addiction Equity Act The Mental Health Parity and Addiction Equity Act (MHPAEA) requires group health plans to ensure that the financial requirements and treatment limitations that are applicable to mental health or substance use benefits are no more restrictive than the predominant financial requirements and treatment limitations applied to substantially all medical and surgical benefits covered by the plan. • Collaborative Care is a specific type of integrated care that treats common mental health and substance use conditions such as depression and anxiety in primary care settings. In usual primary care, the treatment team has two members: the primary care provider and the patient. Collaborative Care adds two additional vital roles: a care manager (typically embedded) and a psychiatric consultant (typically engaged by phone or video link). Pillar 3: Integration and Collaborative Care Collaborative Care is: • Team‐based • Population‐based • Patient‐centered • Measurement‐based • Evidence‐based • Practice‐tested • Accountable Kennedyforum.org Medicare’s Vision for Comprehensive Primary Care (CPC): New Directions for Care Delivery CPC and CPC+ are both payment and care delivery models. Similar to CPC, practices selected to participate in CPC+ will use defined, stepwise requirements to guide them through care delivery changes required to provide 5 comprehensive primary care functions: (1) access and continuity, (2) risk- stratified care management, (3) planned care for chronic conditions and preventive care, (4) patient and caregiver engagement, and (5) comprehensiveness and coordination of care. CPC+ will have a separate track (“Track 2”) for practices that have more experience delivering advanced primary care, and these practices will be expected to provide enhanced services within these 5 functions for patients with complex needs, including identification of psychosocial needs and resources and supports to meet those needs. Pillar 4: Technology We are aware of a number of key challenges that, if addressed, can lead to faster adoption: • Best Practices. How can we identify, track and analyze these emerging technologies and the companies that support these initiatives? • Evidence-Based. How can we best study and validate in a more timely and cost-effective manner the science behind these emerging products? • Regulatory Requirements. What are the regulatory barriers that could be changed to speed up the review process? • Reimbursement. How can we encourage enhanced payment mechanisms for these emerging technology applications that promote more robust treatment interventions? • Immediate Public Health Issue. The Kennedy Forum and others see the systematic non- or under-treatment of MH/SU disorders as a public health emergency adding significantly to the financial and emotional costs to our nation. Kennedyforum.org Population-Based Payment (PBP) Model: A payment model in which a provider organization is given a population-based global budget or payment and accepts accountability for managing the total cost of care, quality, and outcomes for a defined patient population across the full continuum of care. PBP models discussed in this paper correspond to payment models in Categories 3 and 4 of the LAN’s APM Framework (refer to Figure 1). Total Cost of Care (TCOC): A broad indicator of spending for a given population (i.e., payments from payer to provider organizations). In the context of PBP models, in which provider accountability spans the full continuum of care, TCOC includes all spending associated with caring for a defined population, including provider and facility fees, inpatient and ambulatory care, pharmacy, behavioral health, laboratory, imaging, and other ancillary services. Subject: MACRA NPRM—April 28, 2016 HHS/CMS just released the Notice of Proposed Rule Making on MACRA (Medicare Access and CHIP Reauthorization Act), which is an Act that Congress passed to move from fee-for-service to APMs (alternative payment models). “Charlie” U.S. Army Canine Corps / Warrior Canine Connections warriorcanineconnection.org Warrior Canine Connections enlists recovering Warriors in a therapeutic mission of learning to train service dogs for their fellow veterans. WCC is a 501-C3 non-profit organization. QUESTIONS? THANK YOU! The recording and handouts will be sent to you via email within 2 business days Any questions can be sent to firstname.lastname@example.org. ions applied to substantially all medical and surgical benefits covered by the plan. • Collaborative Care is a specific type of integrated care that treats common mental health and substance use conditions such as depression and anxiety in primary care settings. In usual primary care, the treatment team has two members: the primary care provider and the patient. Collaborative Care adds two additional vital roles: a care manager (typically embedded) and a psychiatric consultant (typically engaged by phone or video link). Pillar 3: Integration and Collaborative Care Collaborative Care is: • Team‐based • Population‐based • Patient‐centered • Measurement‐based • Evidence‐based • Practice‐tested • Accountable Kennedyforum.org Medicare’s Vision for Comprehensive Primary Care (CPC): New Directions for Care Delivery CPC and CPC+ are both payment and care delivery models. Similar to CPC, practices selected to participate in CPC+ will use defined, stepwise requirements to guide them through care delivery changes required to provide 5 comprehensive primary care functions: (1) access and continuity, (2) risk- stratified care management, (3) planned care for chronic conditions and preventive care, (4) patient and caregiver engagement, and (5) comprehensiveness and coordination of care. CPC+ will have a separate track (“Track 2”) for practices that have more experience delivering advanced primary care, and these practices will be expected to provide enhanced services within these 5 functions for patients with complex needs, including identification of psychosocial needs and resources and supports to meet those needs. Pillar 4: Technology We are aware of a number of key challenges that, if addressed, can lead to faster adoption: • Best Practices. How can we identify, track and analyze these emerging technologies and the companies that support these initiatives? • Evidence-Based. How can we best study and validate in a more timely and cost-effective manner the science behind these emerging products? • Regulatory Requirements. What are the regulatory barriers that could be changed to speed up the review process? • Reimbursement. How can we encourage enhanced payment mechanisms for these emerging technology applications that promote more robust treatment interventions? • Immediate Public Health Issue. The Kennedy Forum and others see the systematic non- or under-treatment of MH/SU disorders as a public health emergency adding significantly to the financial and emotional costs to our nation. Kennedyforum.org Population-Based Payment (PBP) Model: A payment model in which a provider organization is given a population-based global budget or payment and accepts accountability fo