FRITS HUYSE

1
Integrale zorg een blijvende ontwikkeling

• FRITS HUYSE
• Psychiater, Consulent Integrale Zorg
• Afdeling Algemene Interne Geneeskunde
• UMCG GRONINGEN
• Lid council Academy of Psychosomatic Medicine USA

NFZP 9-6-2006 Universitair Medisch Centrum Utrecht
UMCG Groningen
2
(No Transcript)
3
Hoofdstuk 6 Complexe patienten Huyse Slaets de
Jonge
4

THE FUTURE OF CONSULTATION-LIAISON PSYCHIATRY

• Graeme C Smith
• Consultation-Liaison Psychiatry Research Unit
• Monash University Department of Psychological
  Medicine

Keynote speaker Anual meeting Dutch Psychiatric
Association Maastricht The Netherlands 2005
5
CONCLUSIONS

• Patients with physical/psychiatric comorbidity
  and somatisation continue to be discriminated
  against in the public sector, despite the
  acknowledgement of this in the Second National
  Mental Health Plan
• The implication for patients is both primary and
  secondary the context in which psychiatrists are
  training is helping perpetuate the problem
• Development of a seamless web of
  pre-admission/admission/post discharge functions
  is required if patients are to receive effective
  care and services are to be able to demonstrate
  efficacy

6
Zorg coördinatie in relatie tot zorgbehoefte

• Bezorgdheid
• Voorbijgaande ziekte
• Minder ernstige acute ziekte

Vraag gestuurd
Low

• Chronische ziekte
• Matig tot ernstige acute ziekte

Ziekte gestuurd
Medium

• Complexe medische patiënten
• Multi-morbiditeit, waaronder psychiatrische
• Meerder hulpverleners
• Psychologische, sociale en financiële ontregeling

Zorg coördinatie Ambulant/ Klinisch
High
Wie? Hoe?
Cartesian Solutions Kathol 2002
7
Results of ECLW Collaborative Study14470
patients 56 hospitals 11 countries
CONSULTATION EMERGENCY
equals PSYCHIATRY PSYCHIATRY

• Consultation psychiatry
• Rate 1 of all admissions
• Reactive (wait and see)
• Doctors and nurses needs driven
• Liaison
• Theory not practice

Huyse, Herzog, Lobo, Malt e.a. Gen Hosp
Psychiatry 23(3)124-132, 2001
8
General hospital population

Consults psychiatric, psychological,
social work
9

THE FUTURE OF CONSULTATION-LIAISON PSYCHIATRY

• Graeme C Smith
• Consultation-Liaison Psychiatry Research Unit
• Monash University Department of Psychological
  Medicine

Keynote speaker Anual meeting Dutch Psychiatric
Association Maastricht The Netherlands 2005
10
CONCLUSIONS

• Patients with physical/psychiatric comorbidity
  and somatisation continue to be discriminated
  against in the public sector, despite the
  acknowledgement of this in the Second National
  Mental Health Plan
• The implication for patients is both primary and
  secondary the context in which psychiatrists are
  training is helping perpetuate the problem
• Development of a seamless web of
  pre-admission/admission/post discharge functions
  is required if patients are to receive effective
  care and services are to be able to demonstrate
  efficacy

11

THE FUTURE OF CONSULTATION-LIAISON PSYCHIATRY

• Graeme C Smith
• Consultation-Liaison Psychiatry Research Unit
• Monash University Department of Psychological
  Medicine

Keynote speaker VJC NVvP Maastricht 2005
12
CONCLUSIONS 1

• Patients with physical/psychiatric comorbidity
  and somatisation continue to be discriminated
  against in the public sector, despite the
  acknowledgement of this in the Second National
  Mental Health Plan.

Huyse NRC mei 2005 Geef psychiaters in
ziekenhuizen de ruimte
13
(No Transcript)
14
De ziekenhuispsychiatrie kan mijns inziens een
belangrijke rol vervullen. In dit opzicht sluit
ik mij aan bij het standpunt van de heer Huyse.
De stelselwijziging in de zorg die nu
plaatsvindt, is mede bedoeld om de ontschotting
van de lichamelijke en psychische zorg te
verwezenlijken.
15
CONCLUSIONS 2

• The implication for patients is both primary and
  secondary the context in which psychiatrists are
  training is helping perpetuate the problem.

Huyse FJ, van der Mast RC, Boenink AD De
psychiater als medisch specialist de psychiatrie
een zorg? Tijdschrift voor Psychiatrie
44795-802, 2002
16
CONCLUSIONS 3

• Development of a seamless web of
  pre-admission/admission/post discharge functions
  is required if patients are to receive effective
  care and services are to be able to demonstrate
  efficacy.

Integrated care for the complex medically ill.
Editors Huyse FJ, Stiefel FC Medical clinics of
North America Elsevier Juli 2006
17
Crossing the Quality Chasm

• Quality problems occur typically
• not because of failure of goodwill,
• knowledge, effort or resources
• devoted to health care, but because
• of fundamental shortcomings in the
• ways care is organized
• Trying harder will not work
• changing systems of care
• will!

a new HEALTH system for the 21st century (IOM,
2001)
18
The Crossing the Quality Chasm Series

• To Err is Human (1999)
• Crossing the Quality Chasm - A New Health System
  for the 21st Century (2001)
• Leadership by Example (2002)
• Fostering Rapid Advances in Health Care (2002)
• Priority Areas for National Action (2003)
• Health Professions Education (2003)
• Keeping Patients Safe Transforming the Work
  Environment of Nurses (2004)
• Patient Safety Achieving a New Standard for
  Care (2004)
• Quality through Collaboration the Future of
  Rural Health (2005)

19
Improving the Quality of Health Care for Mental
and Substance-Use Conditions

• A Report in the Quality Chasm Series

• Ensure that multiple providers care
• of the same patient is coordinated
• Plea for integration and removal of
• dysfunctional barriers

Commission of Quality of Care, Institute of
Medicine, USA 2005
www.nap.edu
20
Six Aims of Quality Health Care

• Safe avoids injuries from care
• bijvoorbeeld psychopharmaca en electieve
  chirurgie
• Effective provides care based on scientific
  knowledge and avoids services not likely to help
• bijvoorbeeld Pathway- (diabetes and depression)
  en IMPACT-studies (ouderen met somatische ziekten
  en depressies)
• 3. Patient-centered respects and responds to
  patient preferences, needs, and values
• bijvoorbeeld algemeen ziekenhuis setting en geen
  RIAGG

Crossing the Quality Chasm a new HEALTH system
for the 21st century (IOM, 2001)
21
(No Transcript)
22
(No Transcript)
23
De berg naar Mohammed of
24
of de psychiatrie naar de AGZ !
25
Six Aims (cont.)

• Timely reduces waits and sometimes harmful
  delays for those receiving and giving care
• bijvoorbeeld geïntegreerde consulten bij
  onbegrepen klachten poli interne UMCG
  gelijktijdig consult internist en psychiater
• 5. Efficient avoids waste, including waste
  of equipment, supplies, ideas and energy
• bijvoorbeeld rechtstreekse verwijzing naar
  collega snuffel-consult
• Equitable care does not vary in quality due to
  personal characteristics (gender, ethnicity,
  geographic location, or socio-economic status)
• bijvoorbeeld psychiatrische patient heeft
  gelijke toegang tot somatische zorg vv

Crossing the Quality Chasm a new HEALTH system
for the 21st century (IOM, 2001)
26
Ten Rules for Achieving the Aims

• Old Rules
• 1. Care is based on visits
• 2. Professional autonomy drives variability
• 3. Professionals control care
• 4. Information is a record
• 5. Decisions are based upon training and
  experience

• New Rules
• 1. Care is based upon continuous healing
  relationships
• 2. Care is customized to patient needs and values
• 3. The patient is the source of control
• 4. Knowledge is shared and information flows
  freely
• 5. Decision making is evidence-based

Crossing the Quality Chasm a new HEALTH system
for the 21st century (IOM, 2001)
27
Ten Rules for Achieving the Aims

• Old Rules
• Do no harm is an individual clinician
  responsibility
• Secrecy is necessary
• The system reacts to needs
• Cost reduction is sought
• Preference for professional roles over the system

• New Rule
• Safety is a system responsibility
• Transparency is necessary
• 8. Needs are anticipated
• 9. Waste continuously decreased
• Cooperation among clinicians is a priority

Crossing the Quality Chasm a new HEALTH system
for the 21st century (IOM, 2001)
28
Achieving Aims and Rules Requires

• News ways of delivering care
• Effective use of information technology (IT)
• Managing the clinical knowledge, skills, and
  deployment of the workforce
• Effective teams and coordination of care across
  patient conditions, services and settings
• Improvements in how quality is measured
• Payment methods conducive to good quality

Crossing the Quality Chasm a new HEALTH system
for the 21st century (IOM, 2001)
29
Interdisciplinaire Opleidingen
Een kans voor Interne Geneeskunde en Psychiatrie?
ROB Gans Hoogleraar Interne UMCG VJC NVvP
Amsterdam, April 4, 2003
Thisbee en .
30
Mental health services in the general hospital

• 1. Emergency services
• Attempted suicide
• Acute behavioral disturbances
• Deliria
• Withdrawal
• 2. Integrated services
• Screening and integrated assessment
• Patient tailored multidisciplinary care
• (horizontal integration) and care trajectories
  (vertical integration)

31
Arie Querido (1901-1983) A Dutch psychiatrist
his views on integrated health care.
Boenink AD, Huyse FJ. J Psychosom Res.
1997 Dec43(6)551-7.
32
Visie Querido

• 1935 Psychiatrie durgence
• Naast gestichtspsychiatrie moet ambulante
  psychiatrie ontwikkeld worden tbv voor en nazorg
• Dit is de motor achter de RIAGG vorming (70er
  jaren) en zorgcircuitgedachte (negentiger jaren)
  geweest
• 1955 Integrale geneeskunde
• Populatie gebaseerde studie in Weesperplein
  ziekenhuis waarin hij als een van de eersten
  aantoonde dat PS-comorbiditeit leidt tot slechte
  uitkomsten van somatische zorg

33
Ontwikkeling integrale geneeskunde
Querido verliet de psychiatrie en werkte
uiteindelijk in de sociale geneeskunde
Rooijmans, voormalig voorzitter van de NVvP,
zette de ziekenhuispsychiatrie op de kaart De
huidige academische psychiatrie heeft geen visie
op dit vakgebied
34
Ontwikkeling integrale geneeskunde
Querido verliet de psychiatrie en werkte
uiteindelijk in de sociale geneeskunde
Rooijmans, voormalig voorzitter van de NVvP,
zette de ziekenhuispsychiatrie op de kaart De
huidige academische psychiatrie heeft geen visie
op dit vakgebied
USA 1980 alle kernhoogleraren psychiatrie zijn
psychoanalytici 1990 geen kernhoogleraar is
psychoanalyticus
35
Ontwikkeling integrale geneeskunde
Querido verliet de psychiatrie en werkte
uiteindelijk in de sociale geneeskunde
Rooijmans, voormalig voorzitter van de NVvP,
zette de ziekenhuispsychiatrie op de kaart De
huidige academische psychiatrie heeft geen visie
op dit vakgebied
USA 1980 alle kernhoogleraren psychiatrie zijn
psychoanalytici 1990 geen kernhoogleraar is
psychoanalyticus 2004 Ziekenhuispsychiatrie
subspecialisatie in USA
36
Ontwikkeling integrale geneeskunde
Querido verliet de psychiatrie en werkte
uiteindelijk in de sociale geneeskunde
Rooijmans, voormalig voorzitter van de NVvP,
zette de ziekenhuispsychiatrie op de kaart De
huidige academische psychiatrie heeft geen visie
op dit vakgebied
USA 1980 alle kernhoogleraren psychiatrie zijn
psychoanalytici 1990 geen kernhoogleraar is
psychoanalyticus 2004 Ziekenhuispsychiatrie
subspecialisatie in USA Nederland 2006 Geen
hoogleraren ziekenhuispsychiatrie 2010
Kernhoogleraren psychiatrie zijn
ziekenhuispsychiaters
37
General hospital population
Multidisciplinary care Physical High
acuity/intensity no artificial
respiration Psychiatric High acuity no
severe behavioral dist

MPU
MPU Medical- Psychiatric- Unit
Screening for complexity Indicator-INTERMED
Nurse specialist Multidisciplinary
care Integrated assessment Psychiatrist/geria
trician Nurse specialist psychiatry Psycho
logist Social work
38
Chronische ziekte en depressie

• Verhoogde prevalentie
• Versterkt de symptomen van de somatische ziekte
• Vergroot de functionele beperkingen
• Vermindert de compliance met somatische
  behandeling
• Gaat gepaard met negatief gezondheidsgedrag
  (dieet, lichamelijke oefening, roken)
• Gaat gepaard met een verhoogde mortaliteit

39
Adverse Bidirectional Interaction
Physical illness

• Smoking
• Sedentary lifestyle
• Obesity
• Lack of adherence to medical regimens

• Medical illness at earlier age
• Poor symptom control
• ? functional impairment
• ? complications of medical illness

Major Depression
After Katon
40
DOES TREATMENT of the DEPRESSED MEDICALLY ILL
HELP ?

• SYSTEMATIC REVIEW OF ANTIDEPRESSANTS IN THE
  PHYSICALLY ILL
• N of RCTs 18
• Adverse reactions
• No differences of placebo
• No difference between drugs
• Number needed to treat 4

Gill and Hatcher Cochrane Review 2001
41
Behavioral change can be considered according to
a hierarchy of behavioral challenge, ranging
from those that are least difficult (i.e., the
initiation of new practices in which there is no
preexisting habit that needs to be broken) to the
most difficult (i.e., breaking addictive habits
which satisfy physiological drives).
Rozanski Psychosom Med
2005 67 Suppl 1 s67-s73
42
MODELLEN VOOR INTEGRALE ZORG
43
MODELLEN VOOR INTEGRALE ZORG

• Depressie en somatische ziekte

44
Multifactorial Interventions for Depression in
Primary Care

• Literature synthesis
• 12 RCTs involving 6,274 patients
• Most trials had 3-4 components
• All 12 had care management 7 had augmented
  mental health
• 10 studies ? improved outcomes

45
(No Transcript)
46
Stepped Care

• Patient self-management
• Primary care provider
• Care manager
• Collaborative care
• Indirect (TCM) MHS supervises CM
• Direct MHS sees pt in consultation
• Referral to Mental Health Specialist

PC
MH
47
PHQ - 9
More than Nearly Not
Several half the every at all
days days day 0
1 2 3
Over the last 2 weeks, how often have you
been bothered by the following problems?
a. Little interest or pleasure in doing
things b. Feeling down, depressed, or hopeless
c. Trouble falling or staying asleep, or
sleeping too much d. Feeling tired or having
little energy e. Poor appetite or overeating
f. Feeling bad about yourself, or that you are a
failure . . . g. Trouble concentrating on things,
such as reading . . . h. Moving or speaking so
slowly . . . i. Thoughts that you would be better
off dead . . .
Subtotals 0 3 4 9
TOTAL 16
48
PHQ-9 as Severity Measure

• Cutpoints proposed on PHQ-9 for depression
  severity are
• ? 5 mild
• ? 10 moderate
• ? 15 moderately severe
• ? 20 severe
• Response to therapy 5 point ?
• Remission score lt 5

49
Translating PHQ-9 Scores into Action
0 4 No action (community norms)
5 9 Watchful waiting in most
10 14 Education, counseling, active rx based upon diagnosis, duration, impairment, patient preferences
15 19 Active treatment in most
20 May need combination of Rx and/or referral
50
The Pathway Study

• RCT depressie en diabetes mellitus
• Verbetert diabetes door verbeterde depressie
  zorg?
• Intervention stepped care Tx depression
• N329 (int 164 CAU 165)
• 9 primary care klinieken
• Outcomes
• Verbetering depressie 6 en 12 mnd
• Verbetering algemeen gevoel na 6 en 12 mnd
• Meer satisfactie met type zorg na 6 en 12 mnd
• HBA-1C gelijk in interventie en controle groep

Katon, Von Korff (2004) Arch Gen Psych
611042-1049
51
IMPACTImproving Mood Promoting Access to
Collaborative Treatment for Late-Life Depression
1801 depressive elderly (gt/60 years) 18
clinical practices 8 healthplans
Funded by John A. Hartford Foundation California
HealthCare Foundation California Geriatric
Education Center (via the Bureau of Health
Professions, HRSA)
Unutzer J, Katon W, Callahan CM ea. IMPACT. JAMA
2002288(22)2835-45
52
IMPACTImproving Mood Promoting Access to
Collaborative Treatment for Late-Life Depression
1801 depressive elderly (gt/60 years) 18
clinical practices 8 healthplans
Funded by John A. Hartford Foundation California
HealthCare Foundation California Geriatric
Education Center (via the Bureau of Health
Professions, HRSA)
3.8 chronic conditions
Unutzer J, Katon W, Callahan CM ea. IMPACT. JAMA
2002288(22)2835-45
53

• In the IMPACT study the patients had 3.8 chronic
  conditions in
• addition to depression
• e.g. cardiac
• diabetes
• parkinson
• ....

54

• In the IMPACT study the patients had 3.8 chronic
  conditions in
• addition to depression
• e.g. cardiac
• diabetes
• parkinson
• ....

What about patients with psychiatric
co-morbidities? As comorbidity is rather the rule
then the exception! Kroenke and Rosmalen
Symptoms, syndromes and psychiatric diagnosis
in Huyse and Stiefel Integrated care for the
complex medically ill
55

• In the IMPACT study the patients had 3.8 chronic
  conditions in
• addition to depression
• e.g. cardiac
• diabetes
• parkinson
• - add
• anxiety
• substance abuse
• somatization
• xx
• - managers!

What about patients with psychiatric
co-morbidities? As comorbidity is rather the rule
then the exception! Kroenke and Rosmalen
Symptoms, syndromes and psychiatric diagnosis
in Huyse and Stiefel Integrated care for the
complex medically ill
56
Chronic Disease Focused Depression Care New
Grant

• Nurse will provide depression, heart disease and
  diabetes case management
• Behavior intervention-especially exercise,
  positive life activities
• Optimize medication for depression, heart disease
  and diabetes
• Supervision of nurses by psychiatrists and PCPs

Katon and Unutzer
57
Chronic Disease Focused Depression Care New
Grant

• Nurse will provide depression, heart disease and
  diabetes case management
• Behavior intervention-especially exercise,
  positive life activities
• Optimize medication for depression, heart disease
  and diabetes
• Supervision of nurses by psychiatrists and PCPs

Katon and Unutzer
Complexity management
58
MODELLEN VOOR INTEGRALE ZORG

• Depressie en somatische ziekte
• Ziekte specifiek

59
MODELLEN VOOR INTEGRALE ZORG

• Depressie en somatische ziekte
• Ziekte specifiek
• Complexiteit

60
MODELLEN VOOR INTEGRALE ZORG

• Depressie en somatische ziekte
• Ziekte specifiek
• Complexiteit
• Generiek

61
INTERMEDc

• PROGRAM GROUP
• RESEARCH COORDINATOR
• Groningen Peter De Jonge
• PARTICIPATING CENTERS
• Lausanne Fritz Stiefel
• Groningen Frits Huyse
• Groningen Joris Slaets
• Nürnberg Wolfgang Söllner
• CONSULTANTS
• John Lyons Chicago
• Corine Latour Amsterdam
• Roger Kathol Burnsville

CHuyse, Lyons, Stiefel, Slaets, De Jonge ea
Gen Hosp Psychiatry 2139-48, 1999
www.vumc.nl/INTERMED
62
Step wise method for detection and assessment of
COMPLEXITY
63
Step wise method for detection and assessment of
COMPLEXITY

• Possible indicators
• Excess utilization
• Non-Compliance
• Questionnaires
• COMPRI)1
• Groningen Frailty
• Index
• Type of illness
• Transplant
• Cancer
• Research
• Etcetera

filter
64
Step wise method for detection and assessment of
COMPLEXITY

Integrated health risks and needs
65
(No Transcript)
66
(No Transcript)
67
(No Transcript)
68
Intervention studies

• Pre/post internal medicine IP (NL)
• Reduction of LOS in elderly (16 -gt 11 days)
• Improvement in psychological functioning
• RCT prevention readmission post discharge (NL)
• No effects restricted funding and lack of
  cooperation/integration

69
Intervention Study Internal Medicine Vumc

• Effect on QoL specifically Mental Health (SF36)
• P 0.03 (Z -2.17)
• Effect on LOS specifically in elderly
• P 0.05 (Z -1.95) from 16 to 11.5 days
• Costs of the intervention
• 1 nurse specialist
• 1/4 C-L psychiatrist

de Jonge P, Latour CH, Huyse FJ. Implementing
psychiatric interventions on a medical
ward Psychosom Med. 2003 Nov-Dec65(6)997-1002
70
(No Transcript)
71
Intervention studies

• Pre/post internal medicine IP (NL)
• Reduction of LOS in elderly (16 -gt 11 days)
• Improvement in psychological functioning
• RCT prevention readmission post discharge (NL)
• No effects restricted funding and lack of
  cooperation/integration
• RCT depression and DM or Rheuma (SU)
• In analysis positive effects on most outcomes

72
A randomised psychiatric intervention in complex
medical patients Effects on depression

• Outpatients of department of
• endocrinology and rheumatology
• University center
• Complexity screen with INTERMED inclusion gt 20
• Assessment of depression with MINI and CES-D
• Randomisation
• Intervention based on risks and needs
• as assessed with the INTERMED

Stiefel F, Bel Hadj B, Zdrojewski C, Boffa D,
(announcement poster) de Jonge P
Dorogi Y, Miéville JC, Ruiz J, So A. J
Psychosomatic Res 2004,56578-9
73
Sample
No INT CAU
Age 50.9 (14.1) 53.1 (15.3)
INTERMED 24.6 (3.7) 26.1 (4.6)
EuroQuol 44.7 (22.2) 45.1 (21.2)
CES-D 27.1 (11.4) 27.5 (10.8)
SF-36 physical 31.8 (10.9) 29.6 (10.0)
SF-36 mental 34.8 (11.6) 35.4 (10.4)
Female sex 58.3 57.5
Major depression 60.5 55.8
No significant differences
Stiefel, ... , So Lausanne Suisse
74
Sample
No INT CAU
Age 50.9 (14.1) 53.1 (15.3)
INTERMED 24.6 (3.7) 26.1 (4.6)
EuroQuol 44.7 (22.2) 45.1 (21.2)
CES-D 27.1 (11.4) 27.5 (10.8)
SF-36 physical 31.8 (10.9) 29.6 (10.0)
SF-36 mental 34.8 (11.6) 35.4 (10.4)
Female sex 58.3 57.5
Major depression 60.5 55.8
No significant differences
Stiefel, ... , So Lausanne Suisse
75
Intervention (N120)
Psycho education 43.3
Emotional expression 72.6
Psychodynamic 47.2
Pragmatic 70.8
of Follow-ups (median) 7
Stiefel, ... , So Lausanne Suisse
76
Effects on general health perception (Euroqol)
77
Effects on physical health (SF-36)
78
Effects on prevalence () of major depression
(MINI)
T3 P0.06 T6 P0.12 T9 P0.15 T12 P0.01
79
9 praktijken in Minnesota hebben interesse oa
huisartsen geneeskunde Univ of Mineapolis RCT in
voorbereiding
2 zorgverzekeraars hebben interesse
7 talen Engels, Nederlands, Frans, Duits,
Spaans, Italiaans, Turks

• Jaarlijkse Cursussen
• NL Wenckebach Groningen
• EU EACLPP satelite
• USA Chicago CANS satelite

80
Developments

• Several studies on their way and in preparation
• Transplant MC outcome prediction study Europe
• MC RCT in oncology Germany
• Preassessment in elective surgery Groningen
• RCT depression and rheuma/diabetes Minneapolis
  USA
• RCT Functional neurologic complaints AMC NL
• Touchscreen module for patient self
  assessment Groningen

• INTERMEDFoundation January 2006
• INTERMED BV Beginning 2007
• webbased training
• webbased clinical support

81
(No Transcript)
82
(No Transcript)
83
Staatsecretaris voor Integrale zorg
84
Na regen komt zonneschijn!