Saturday, October 11, 2014

#HCLDR Oct 14: Patient Centered Medical Home (PCMH) and Behavioral Health Integration

On Tuesday, October 14, 2014 (8:30-9:30 pm Eastern), the Healthcare Leaders (#HCLDR) group will hold this chat on Twitter. You can follow the live stream of the chat on Tuesday on Tweetchat using this link (for your local time, click here).

Healthcare in the United States has become so splintered and chaotic that most people would agree that our "system" is broken. People with chronic conditions, such as  may wind up having five or more practitioners -- primary care, cardiology, endocrinology, psychiatry, neurology, etc -- and the communication among them all is often not coordinated. This system of care is centered around each practitioner, not around the patient who must go to five different places to get care, not to mention different places for labs, tests, and medications.

The patient-centered medical home, or PCMH, is designed to be centered around the patient. This is typically a single place in which one can get much or all of their care. It is open during late hours and weekends to reduce the reliance on expensive emergency departments. You can get same-day appointments and don't need to wait weeks to see your doctor. There are over 8000 PCMHs around the country, and each carry recognition or certification for meeting standards that all PCMHs must follow.

One of the challenges for people who have mental health and/or substance abuse problems has been the even more chaotic manner that insurance companies have handled these "behavioral health" conditions. It is common for people to have a different "carve-out" insurance company that pays for these services, with different lists of mental health practitioners, different co-pays, and different rules. The two different payers often don't coordinate, nor do the primary care people communicate well with the mental health people. It's a mess.

PCMHs take a different approach to behavioral healthcare, taking responsibility for coordinating the care, making appointments, and ensuring the different practitioners communicate with each other. In fact, the latest 2014 standards from the National Council for Quality Assurance (NCQA), which has a rigorous formal recognition program for PCMHs, has added additional standards for behavioral health. Among them:
  • The practice has a process for informing patients/families about the role of the medical home and gives patients/families materials that contain information on the scope of services available within the practice including how behavioral health needs are addressed.
  • To understand the health risks and information needs of patients/families, the practice collects and regularly updates a comprehensive health assessment that includes:
    • Mental health/substance use history of patient and family.
    • Depression screening for adults and adolescents using a standardized tool.
  • The practice implements clinical decision support (e.g., point-of-care reminders) following evidence-based guidelines for a mental health or substance use disorder.
  • The practice establishes a systematic process and criteria for identifying patients who may benefit from care management, including consideration of behavioral health conditions.
  • The practice maintains agreements with behavioral healthcare providers.
  • The practice integrates behavioral healthcare providers within the practice site.

NCQA also has a program that evaluates vendors having solutions that help practices meet these standards. This Vendor Prevalidation Program has approved one behavioral health solution for PCMHs. The company, M3 Information, has a software solution called M3Clinician that makes it easy for a PCMH practice to conduct multidimensional screening for depression, bipolar disorder, anxiety disorders, post-traumatic stress disorder (PTSD), drug and alcohol abuse, using evidence-based guidelines and clinical decision support for primary care providers managing milder forms of behavioral health conditions that do not require a specialist referral. Their consumer app, WhatsMyM3, provides an advanced self-management tool to people with behavioral health conditions. [Note: Dr. Daviss is the Chief Medical Information Officer for M3 Information.]

The #HCLDR questions for Tuesday's chat are:

T1: Patient centered medical home #PCMH is WHOLE person care around pt needs. What's PATIENT-CENTERED CARE mean to you?

T2: What can a #PCMH or any physician/nurse do to broach the subject of #behavioralhealth with a patient?

T3: How should #brainhealth/#behavioralhealth be measured/monitored in #primarycare/#PCMH care over time?

T4: What can we do to encourage orgs to be more like #PCMH (patient-centered) to incorporate #behavioralhealth?

Why is it important to integrate behavioral health into primary care settings?
Go to the #HCLDR chat from February titled, "Behavioral Health Integration and Hospital Readmissions," to read the content that reviews the avoidable costs (financial, quality, and personal) associated with the status quo. DrDaviss has additional resources from that chat on his HITshrink blog. The questions from the February chat were:
  • T1: With shortage of #BHealth resources, what impacts do you see in your settings? 
  • T2: What can help PCPs better integrate #BHealth into their practice? 
  • T3: What can help to address impact of #BHealth on chronic health conditions?

Also, check out Dr Ann Becker-Shutte's double-header chat from July titled, "Psychologists, Behavioral Health and Primary Care – Oh My!," with more great information and discussion. This was a special two-hour chat with people from #HCLDR and #InnoPsy joining together to respond to these eight questions:
  • T1: Making lifestyle/healthy changes is hard. What tactics worked for you? How did you stay motivated? 
  • T2: If you could change one or two behaviors in healthcare to reduce costs what would they be? 
  • T3: What type of support (peer/clinical/admin/gov’t) or tech would have helped to make the T1 or T2 changes? 
  • T4: As a patient, would you be open to support for behavior change/lifestyle coaching via your primary care physician’s office? 
  • T5: What would make patients more comfortable with receiving help/support for +ve lifestyle changes via primary care office? 
  • T6: How do we start to shift health care culture to integrate behavioral health and physical health? 
  • T7: What kinds of training would help all health care providers collaborate more effectively?
  • T8: How can we foster more collaboration between Psychologists & other behavioral health pros & primary care providers?


Friday, February 14, 2014

#HCLDR Healthcare Leaders Tweet Chat on Behavioral Health Integration and Hospital Readmissions - Feb 18, 2014

Twitter has been a great medium for having discussions, or chats, about various healthcare topics. The original "tweet chat" is #HCSM or HealthCare & Social Media, which is still on Sunday evenings at 9pm ET.

One of the increasingly influential healthcare tweet chats is #HCLDR, Tuesday nights at 8:30 ET, which typically has a hundred or so participants, many of them being patients, hospital executives, physicians, nurses, and others involved in various aspects of quality standards, business, compliance, and related aspects of today's healthcare industry. #HCLDR is passionately and expertly organized by Lisa Fields (@practicalwisdom) and Colin Hung (@colin_hung). Each chat starts with introductions, then three topic questions are asked, each followed by about 15 minutes of discussion. Everyone gets a last word at the end. Each chat must have the #HCLDR hashtag in it to show up in the discussion, which people either use the native Twitter site or app for, or other tools. I tend to prefer, which will automatically refresh the screen to see new tweets, and it ensures you don't forget to add the hashtag.

Each week's tweet chat is documented on their Wordpress blog. Last week's chat was a very current topic regarding the increasing complex trade-offs between privacy and access to healthcare.

Lisa and Colin have asked me to be the guest host for next week's chat on Tue, Feb 18, 8:30-9:30pm ET. The topic will be about Behavioral Health Integration, and will touch on the impact of comorbid mental health and substance use disorders (referred to in the collective as behavioral health) on hospital readmissions.

To whet people's appetite and guide the focus, I've included an image below that shows the relative risk of hospitalization for several medical conditions for four groups of patients (this is 2011 Maryland Medicaid data):
  • patients without any comorbid behavioral health condition
  • patients with a comorbid mental health condition
  • patients with a comorbid substance abuse condition (drug and/or alcohol abuse or dependence)
  • patients who are comorbid for both a mental health AND a substance use disorder

(CELL-SEPT refers to cellulitis and septicemia; CHF is congestive heart failure; RESP//// refers to four respiratory conditions: asthma, COPD, bronchitis, pneumonia; and DM refers to diabetes)

I initially began with the following Topic questions:
  • T1: How can #BehavioralHealth (BH) be better integrated within primary health care? 
  • T2: What are the barriers to addressing the impact of #BehavioralHealth on chronic health conditions?
  • T3: How can primary care improve screening for BH conditions that impact chronic conditions?
But after talking with Lisa on a Google Hangout yesterday, we thought it might be useful to have people suggest their own topic questions before we finalize them.

So, please send a tweet over the weekend about what you want to ask. Include my name (@hitshrink) and also the #hcldr hashtag. I will update this post over the weekend and finalize it on Monday.

***UPDATE 2/16/2014 17:38 ET***
Great discussion on Twitter #HCLDR...
@StorkBrian: Access to Behavioral Health Services is Sorely Lacking in Most Communities
@TeamMDrs: most primary care visits have their basis in a bh issue
  >> @MeganRanneytrue for ER visits too
  >> @PracticalWisdomWe must change ~ some w/Beh/Health housed in ER ~ #noroomintheinn Not enough $ for Rehab
@TeamMDrs: the impact of depression on physical well being is profound and well studied
@StorkBrian: Behavioral Health is a Demanding Specialty Providers Need Support & Appropriate Compensation
@ProfAmyE: Integration of MH svcs in is key.  Paradigm shift for how this works required!
@PracticalWisdomHow many re-Admits every day b/c We left out Behavior Health.Huge #'s I say!
  >> @PerronServices: Why? How?
  >> @HITshrinkIf pt too depr to take care of diabetes -> more admits
@ProfAmyEHealth promotion is about healthy behavior. This is what BH does best!
@StuartMarcusMDR we seeing more violent pts in ED's & med/surg admits? Feels like it. Best practices needed
@TomVargheseJrStandards for good surveillance & feedback systems? What are consensus best practices?
@MeganRanneyHow to integrate #behavioralhealth into day-to-day clinical practice (constraints of time & access)
@MeganRanneyAnd many w/behav health issues have no other source of care  #emergencymedicine

***UPDATE 2/17/2014 09:22 ET***
After fine-tuning the Topic questions, based on above tweets over the weekend, here are the final questions for Tuesday night's #HCLDR tweet chat (using the shorter #bhealth for #behavioralhealth):

  • T1: With shortage of #BHealth resources, what impacts do you see in your settings? #HCLDR
  • T2: What can help PCPs better integrate #BHealth into their practice? #HCLDR
  • T3: What can help to address impact of #BHealth on chronic health conditions? #HCLDR

***UPDATE 2/17/2014 12:50 ET***
Below are some resources that are relevant to the discussion, including links and slides (slide images are linked to underlying source when possible, so click on them to go to Pubmed or wherever).

WSJ 2014 Jan 16 - Shortage of mental health professional blamed on Obamacare

University of Washington's AIMS Center (Advancing Integrated Mental Health Solutions) offers free training for their collaborative care model.

M3 Clinician is an NCQA-recognized screening and clinical decision support tool that helps PCPs identify and manage patients with depression, bipolar, PTSD, anxiety, and substance use disorders. Patient version is  [Disclaimer: Dr Daviss is CMIO for M3 Information.]

Shameless plug for our book [Kindle], from the Shrink Rap docs.