Advocating for Collaboative Care

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Advocating for Collaboative Care
Collaborative Family Healthcare
Association National Conference November 6-8,
2008 Alexander Blount, EdD
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What do we have to sell?

• Primary cares track record already
• Data on behavioral health needs in primary care
• Data on evidence of care management programs for
  depression in primary care
• Data on improvement of productivity of people who
  get effective treatment for depression

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Primary care is our best venue for improving
population health and for controlling medical
cost. The Impending Collapse of Primary Care
Medicine and Its Implications for the State of
the Nations Health CareA Report from the
American College of PhysiciansJanuary 30, 2006
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Why do we need the concept of Medical Home

• We already know that primary care the way we
  teach people to do it is hot stuff.
• The Medical Home evidence is really describing
  well-run primary care.
• This is the first model that has drawn large
  physician groups, insurance companies and
  government agencies into agreement.
• http//www.pcpcc.net/

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Hierarchy of Evidence
Strength
Jenicek, 2006, Med Sci Monit 12 241-251
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Hierarchy of Influence
Strength
Blount, unpublished musings
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What we need is a new familiar
idea.Home is the place where when you have to
go there they have to take you in.
The Death of the Hired Man by
Robert Frost
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US News World ReportJuly 14, 2008

• Six Pennsylvania insurers, including Independence
  Blue Cross and Aetna, in May said they would
  spend 13 million over three years to pay doctors
  in 32 primary care practices to help them set up
  medical homes.
• Minnesota's governor in May signed a law that
  will use state and private funds to pay primary
  care doctors who create medical homes.
• Nationwide, 27 of 39 Blue Cross Blue Shield
  insurers are testing pilots of the model.
• Employers such as IBM, Dow Chemical and General
  Motors joined doctors, insurers and the AARP to
  advocate medical homes.

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Evidence is accruing

• When adults have a medical home, their access to
  needed care, receipt of routine preventive
  screenings, and management of chronic conditions
  improves substantially.
• A medical home can reduce or even eliminate
  racial and ethnic disparities in access and
  quality for insured persons.
• Patients with chronic diseases like diabetes,
  congestive heart failure, and adult asthma have
  fewer complications, leading to fewer avoidable
  hospitalizations.
• Medical Home well run primary care office
• Commonwealth Fund report (Beal, Doty, Hernandez,
  et al, June 2007)

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Medical Home well run primary care office in CF
survey

• Patients who reported all 4 were considered to
  have a medical home
• I have a regular doctor or source of care.
• Not difficult to contact provider over the phone
• Not difficult to get care or medical advice after
  hours
• Doctors office visits are usually well organized
  and running on time

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And PCMH looks like a fiscal winner.

• The North Carolina Medicaid program enrolls
  recipients in a network of physician-directed
  medical homes. A Mercer analysis showed that an
  upfront 10.2 million investment for North
  Carolina Community Care operations in SFY04 saved
  244 million in overall healthcare costs for the
  state. Similar results were found in 2005 and
  2006.

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The (Public) Bottom Line

• Care delivered by primary care physicians in a
  Patient-Centered Medical Home is consistently
  associated with
• better outcomes
• reduced mortality
• fewer preventable hospital admissions for
  patients with chronic diseases
• lower utilization
• improved patient compliance with recommended care
• lower Medicare spending.

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The (Private) Bottom Line

• The concept of the Medical Home gives us a shot
  at re-branding primary care.
• Maybe we can remake the image of primary care
  after the era of gatekeeping.
• We may have found a mechanism get payments not
  tied to service by the physician.
• Unlike capitation, a PMPM that gives no
  incentive to restrict care
• We have to get beyond hamster care.
• Unless we fix access (urgent care, off hours
  phone, on time appointments), it isnt a home
  anyone will want.

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The Patient Centered Medical Home DefinedACP,
AAFP, AAP, AOA

• Personal physician - each patient has an ongoing
  relationship with a personal physician trained to
  provide first contact, continuous and
  comprehensive care.
• Physician directed medical practice the
  personal physician leads a team of individuals at
  the practice level who collectively take
  responsibility for the ongoing care of patients.
• Whole person orientation the personal physician
  is responsible for providing for all the
  patients health care needs or taking
  responsibility for appropriately arranging care
  with other qualified professionals. This includes
  care for all stages of life acute care chronic
  care preventive services and end of life care.
• Care is coordinated and/or integrated across all
  elements of the complex health care system (e.g.,
  subspecialty care, hospitals, home health
  agencies, nursing homes) and the patients
  community (e.g., family, public and private
  community-based services). Care is facilitated by
  registries, information technology, health
  information exchange and other means to assure
  that patients get the indicated care when and
  where they need and want it in a culturally and
  linguistically appropriate manner
• http//www.pcpcc.net/content/joint-principles-pati
  ent-centered-medical-home

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Why Should Behavioral Health Be a Core Service?

• Access At least 50 better access to MH care if
  offered in primary care. (different from
  managing care across medical specialties)
  (Bartels, Coakley, Zubritsky, et al. Am J Psych,
  2004)
• Complex patients with chronic illnesses needing
  behavioral health care are more likely to be
  designated for Medical Home level of care.
• Care in medical setting is a better cultural fit
  for many patients.
• Behavioral Health Clinicians free up time for
  PCPs to spend with other patients, while
  enhancing patient satisfaction and self-efficacy.
• Care management is more effective when done by
  professionals with behavioral health skills.
  (Pincus, Pechura, Keyser, et al. Administration
  Policy in Mental Health. 33(1)2-15, 2006

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What are we missing

• Evidence of impact of integrated practices rather
  than targeted integrated programs
• A name/concept/description of integrated care
  that would make patients demand it
• Implementation instructions that solves
  administrative and financial barriers (Everyone
  re-invents the same wheel).
• Understanding of primary care behavioral health
  by most payers and administrators
• An agreed upon list of necessary changes to
  remove barriers. (Somewhat different in
  different states)

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It Will Take Advocacy

• With the exception of Medicare, healthcare is
  done state by state.
• Tell us a story.
• I have a story.
• Make some friends.
• AAFP
• APA
• NAMI
• Who else?

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It May Take Struggle

• Johns story of threatening litigation
• Anyone else have a story?

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It Will Surely Take Information Sharing

• Resources
• What should we have?
• Peer exchange
• Web chat thread or backchannel Web chat thread or
  backchannel
• Can we get an Editor?

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Who are our natural allies?

• Disease focused groups that want best care.
• Advocates for mental health access and parity
• Mental health guilds who want opportunities
• Enlightened physicians and physician groups who
  want to improve primary care
• Enlightened health administrators (HRSA, VA)
• Employers who want a better deal for their health
  dollar.

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What are we asking for?

• That people would learn how important
  collaborative care can be in healthcare.
• Adding in-practice behavioral health care to the
  definition of the medical home services
• This may be more a task of exegesis than getting
  new text.
• That they help us construct/target our message
• That they would connect us to other interested
  folks
• That they would do what they can to eliminate
  barriers (regulatory, financial, personnel, lack
  of information)

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Lets get to work!

• Get in a group and identify whom you think you
  might approach, and how.
• Assemble the categories
• Re-group by category and make a plan to keep in
  touch and report back.
• Give the lists and the minutes to us.
• Agree on information exchange format

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For further information

• www.CFHA.net
• www.IntegratedPrimaryCare.com
• Blounta_at_ummhc.org