Mental Healthcare and Psychosocial Stuff In The Medical Home

1
Mental Healthcare and Psychosocial StuffInThe
Medical Home

• PCPCC
• Center for Public Payer Implementation - Federal
  Programs Conference Call
• Frank deGruy
• June 2, 2009

2
In these few minutes, we will address three
questions

• Can a patient-centered medical home exist without
  the inclusion of behavioral and mental
  healthcare?
• Who provides the behavioral and mental
  healthcare, and how much is needed?
• How do we structure it?

3
A Medical Home is
responsible for providing for all the patients
health care needs Care is coordinated and/or
integrated across all elements
Joint Principles of the Patient Centered Medical
Home American Academy of Family Physicians
(AAFP) American Academy of Pediatrics
(AAP) American College of Physicians
(ACP) American Osteopathic Association
(AOA) February 2007
4
Lets start simple what common problems in
primary care account for most of the costs?

• Diabetes
• Congestive Heart Failure
• Coronary Artery Disease
• Asthma/COPD
• Depression

5
From an employers perspective

• When considering medical and drug costs alone,
  the top five conditions driving costs are cancer,
  back/neck pain, coronary heart disease, chronic
  pain, and high cholesterol.
• But when health-related productivity costs are
  measured along with medical and pharmacy costs,
  the top five chronic health conditions driving
  these overall health costs shift significantly,
  to depression, obesity, arthritis, back/neck pain
  and anxiety.

6
Warning!Theres more to chronic diseasesthan
meets the eye.Way more.
7
What is the Psychosocial Stuff?
8

• Mental Disorders
• Symptoms, Stress, Concerns
• Substance Abuse
• Health Behavior Change

9
Who Says They Go Together?
10
The IOM does.I do.
11
Mental distress, symptoms, and disorders are
usually embedded in a matrix of explained of
unexplained physical symptoms. The more
pronounced the physical symptomatology, whether
or not the symptoms have a physical explanation,
the greater the likelihood that the patient has a
mental diagnosis. Conversely, psychologically
distressed patients experience increased physical
symptomatology.
deGruy. Primary Care Americas Health In A New
Era. IOM 1996
12
Systems of care that force the separation of
mental from physical problems consign the
clinicians in each arm of this dichotomy to a
misconceived and incomplete clinical reality that
produces duplication of effort, undermines
comprehensiveness of care, hamstrings clinicians
with incomplete data, and ensures that the
patient cannot be completely understood.
deGruy. Primary Care Americas Health In A New
Era. IOM 1996
13
Mental health care cannot be divorced from
primary health care, and all attempts to do so
are doomed to failure. Primary care cannot be
practiced without addressing mental health
concerns, and all attempts to do so result in
inferior care.
deGruy. Primary Care Americas Health In A New
Era. IOM 1996
14
Contemporary Evidence

• Depression as a freestanding chronic disease
• Depression complicating CAD
• Depression complicating diabetes

15
Back to the second initial question

• 2. Who provides the behavioral and mental
  healthcare, and how much is needed?

16
What isa primary care practice?

• Chronic diseases Mixed multispecialty solution
  shop
• Acute and straightforward diseases Algorithm
  shop
• Prevention, self-management Network facilitator

17
Dx/Rx Work By Disease

• Multidisciplinary Solution Shop
• Asthma
• Depression
• Obesity
• Back Pain
• Renal Failure
• Allergies
• Alzheimers

• Algorithm Shop
• Myopia
• Hypothyroidism
• Onychomycosis
• Hypertension
• Diabetes
• CAD
• CHF

18
Motivation to change
Requirement for behavior change
19
To the third initial question

• 3. How do we structure it?

20
The SettingThe Shape Of Teams

• A solo doc in a micropractice
• A doc n a nurse
• Three partners, four staff
• joined by a care coordinator
• joined by a psychologist
• Eight partners, three care coordinators, a
  clinical pharmacist, two psychologists, and a
  partridge in a pear tree
• Staff HMO office with a full complement of
  resources
• FQHC with a different full complement of
  resources

21
If your practice is small, you will either become
a predominantly algorithm shop, or you will
develop high-bandwidth connections to
collaborators.