#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?

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FEB CHAT

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?

JUL CHAT
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?

RESOURCES

• Reasons for integrating behavioral health and primary care for patient-centered medical homes. Patient Centered Primary Care Collaborative (PCPCC), 2014.
• Behavioral health resources from the PCPCC (reimbursement for depression & alcohol; slide deck)
• Patient-centered medical home implementation effects on emergency room utilization: a case study. Hosp Top 92:59, 2014.
• Mental health, substance abuse, and health behavior services in patient-centered medical homes. J Am Board Fam Med 27:637, 2014.
• Joint principles: Integrating behavioral health care into the patient-centered medical home. Fam Syst Health 32:154, 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 tweetchat.com, 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.

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***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
  >> @MeganRanney: true for ER visits too
  >> @PracticalWisdom: We 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 Pri.care is key.  Paradigm shift for how this works required!
@PracticalWisdom: How many re-Admits every day b/c We left out Behavior Health.Huge #'s I say!
  >> @PerronServices: Why? How?
  >> @HITshrink: If pt too depr to take care of diabetes -> more admits
@ProfAmyE: Health promotion is about healthy behavior. This is what BH does best!
@StuartMarcusMD: R we seeing more violent pts in ED's & med/surg admits? Feels like it. Best practices needed
@TomVargheseJr: Standards for good surveillance & feedback systems? What are consensus best practices?
@MeganRanney: How to integrate #behavioralhealth into day-to-day clinical practice (constraints of time & access)
@MeganRanney: And many w/behav health issues have no other source of care  #emergencymedicine

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***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

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***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 WhatsMyM3.com.  [Disclaimer: Dr Daviss is CMIO for M3 Information.]

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

Psychiatrists have lowest EHR adoption rate of all specialties

Yikes! I've been silent here for close to a year. This is what happens when you get used to the appeal of short-form blogging (twitter). But you can only say so much in 140 characters.

Anyway, I tweeted yesterday about the low rate of electronic health record (EHR) adoption among psychiatrists (7%) and @ShellyVAdams asked for a link; so here is a bit more detail. Jonathan Wolfe has a piece in Psych News coming out next week with more details.

The HITECH Act's funding for EHR adoption for eligible providers does not cover most mental health professionals (eg, social workers, psychologists, counselors, community mental health centers (CMHCs), etc), other than psychiatrists and some nurse practitioners. Because many psychiatrists practice in CMHCs, it is not surprising that the rate is lower.

Click on the image below to go to the original source (page 38):

FYI: The average for solo practice physicians in 2012 is about 30%.

Public Comment by Feb 4: ONC Health IT Safety Plan

ONC recently released its Health IT Patient Safety Action and Surveillance Plan for public comments, which are due by Feb 4, 2013. Comments can be sent to ONC.Policy@hhs.gov.

The report can be found HERE, as well as a brief Fact Sheet.  The report is related to the IOM's 2011 recommendations from Health IT & Patient Safety: Building Safer Systems for Better Care.

Highlights

Patient safety objectives

1. Use health IT to make care safer 
2. Continuously improve the safety of health IT

Increase the quantity and quality of data and knowledge about health IT safety

1. Make it easier for clinicians to report patient safety events and risks using EHR technology.
2. Engage health IT developers to embrace their shared responsibility for patient safety and promote reporting of patient safety events and risks. 
3. Provide support to Patient Safety Organizations (PSOs) to identify, aggregate, and analyze health IT safety event and hazard reports.
4. Incorporate health IT safety in post-market surveillance of certified EHR technology through ONC-Authorized Certification Bodies (ONC-ACBs).
5. Align CMS health and safety standards with the safety of health IT, and train surveyors. 
6. Collect data on health IT safety events through the Quality & Safety Review System (QSRS).
7. Monitor health IT adverse event reports to the Manufacturer and User Facility Device Experience (MAUDE) database.

Target resources and corrective actions to improve health IT safety and patient safety

1. Use Meaningful Use of EHR technology to improve patient safety.
2. Incorporate safety into certification criteria for health IT products.
3. Support research and development of testing, user tools, and best practices related to health IT safety and its safe use.
4. Incorporate health IT safety into medical education and training for all health care providers.
5. Investigate and take corrective action, when necessary, to address serious adverse events or unsafe conditions involving EHR technology. 

Promote a culture of safety related to health IT

1. Develop health IT safety priority areas, measures, and targets.
2. Publish a report on a strategy and recommendations for an appropriate, risk-based regulatory framework for health IT. 
3. Establish an ONC Safety Program to coordinate the implementation the Health IT Safety Plan. 
4. Encourage state governments to incorporate health IT into their patient safety oversight programs.  
5. Encourage private sector leadership and shared responsibility for health IT patient safety.

HIMSS mHealth Summit 2012 in DC

I'm looking forward to the mHealth Summit in DC on Monday, Dec 3. I've not been to this conference before, but mobile health apps and and the use of mobile devices in the service of health care delivery and education has become such a game changer that one ignores this space with great peril.

A quick search of the mhealthsummit.org site for the terms behavioral or mental or psychiatry or psychology gets 75 hits! While a lot of these terms are in the bios for speakers and such, this is still quite a bit when compared to other medical specialty terms, such as cardiology (6), surgery (5), neurology (2), dermatology (3), and radiology (5).  Granted, psychiatry only gets you 4 hits compared with 23 for psychology and 50 for behavioral, but considering all of these terms provides a lot more hits compared to other specialty areas. Even the term mental appears in 24 hits. Why is that that behavioral health is so represented?

I expect it is because the speakers and topics in the mhealth area will reflect three major components of healthcare:

• patients currently coalesce around disease interests, especially those conditions that lend themselves to peer support
• providers who treat or speak about these disease interests will naturally follow
• healthcare costs: because mhealth is likely to be most disruptive in the disease areas that are most costly, it makes sense that these areas will be more heavily represented at this conference. Example: 2011 Maryland Medicaid data shows that people with chronic medical problems are admitted 8-15 times more often if they have comorbid mental health and substance abuse diagnoses. 8-15 times!! (data available on request)

AHRQ listed the top 10 most expensive conditions (2008 data). Here they are with the mean annual expenditures (averaged for men & women combined) and the number of hits on the mhealthsummit.org website.

1. Cancer $4678... 515 hits (cancer|oncology)
2. Heart disease $4043... 510 hits (heart|cardiac|cardiovascular)
3. Diabetes $2173... 505 hits (diabetes)
4. Trauma $2555... 4 hits (trauma)
5. Back problems $1973... 4 hits (pain; not easy to search)
6. Mental disorders $1857... 75 hits (behavioral|psychiatry|psychology|mental)
7. Osteoarthritis $1648... 4 hits (arthritis)
8. COPD/Asthma $1284... 15 hits (copd|asthma)
9. Hyperlipidemia $871... 0 hits (hyperlipidemia|hypercholesterolemia|cholesterol)
10. Hypertension $858... 4 hits (hypertension|"blood pressure")

Okay, so this is hardly a scientific study, right? In fact, it is a bit silly. But it backs my point that for chronic conditions where people seek out management and coping tools and supportive communities, mhealth buzz is circling these conditions. I can see why trauma might not have much here as it is more of an acute problem, albeit with chronic sequelae. I am surprised to see very few mentions of pain. HIV is not in the top 10 but has 502 hits.

Diving deeper into the mental health stuff, there are a few mentions of depression, anxiety, addiction and PTSD, but nothing on bipolar disorder (people often don't think of bipolar disorder even though it can be more costly than diabetes). There is an interesting talk on Tuesday evening at 5pm called "Open mHealth - Integrating mHealth Apps & Devices to Enable Better Health:"

"Imagine a world where a person with Post Traumatic Stress Disorder (PTSD) is able to share with their clinician--in real-time--their mood, behavior and medication data so they can collaboratively get to a richer, data-driven view of how they’re improving between clinical visits." 

I won't be able to make it to that one, unfortunately, but if you attend, please tweet or blog or comment here about it. (thanks!)

Maryland Medicaid: Behavioral health problems predict skyrocketing medical hospitalizations

Earlier this summer the Maryland Department of Health and Mental Hygiene released four years of aggregated data on Maryland Medicaid patients and some measures of health care utilization, such as hospitalizations. The data can be found here (look at the July 11 meeting materials called Data Book). This is in the context of Maryland's attempts to integrate mental health, addictions, and somatic health (see Crazy Busy for more details).

The data show hospital admissions for the top 25 conditions -- such as stroke, diabetes, pneumonia, etc -- and further break up these data into four groups of people:

• people who also have a mental health disorder
• people who also have a substance use disorder
• people who have both a mental health and a substance use disorder
• people who have neither of these conditions (ie, just a somatic disorder, like asthma or diabetes)

Taking this data and analyzing it in more detail led to some amazing discoveries that are buried in the data tables. For example, in 2011, adult patients in Maryland Medicaid's HealthChoice program who had co-occurring mental health (MH) and substance use (SU) disorders were admitted to hospitals 800-1500% more often than those without these co-occurring conditions -- hospitalized 8-15 times more often for things like pneumonia, asthma, diabetes, epilepsy, and cellulitis.

That is worth saying one more time:

Patients with both mental health and substance use disorders were hospitalized 8-15 times more often for things like pneumonia, asthma, diabetes, epilepsy, and cellulitis.

Here is a graph demonstrating this amazing connection. People with co-occurring mental health problems were admitted 2-4 times more often for these 6 types of medical conditions, and people with co-occurring substance use problems were admitted 4-7 times more often. This is based on claims data submitted to Medicaid and analyzed by the Hilltop Institute. The data are normalized such those without mental health or addiction comorbidity have a relative risk of 1 for hospitalization

The six conditions are the primary diagnoses as indicated by the Medicaid data: epilepsy; HIV-related illness; cellulitis/septicemia; congestive heart failure; respiratory conditions (bronchitis, pneumonia, asthma, and COPD); and diabetes mellitis.

It's no wonder there is data that people with chronic mental health conditions treated in the public health system die 25 years earlier.

If there was ever a reason to better integrate mental health care, addiction treatment, and primary care, this is it.

Crazy busy

So I noticed it's been 4 months since I last posted on HIT Shrink. Lots of things going on. I've had a few people ask me about what I've been working on, so thought I'd put it up here... if only for me to keep track of, including all the links to these areas.

• Epic Implementation
  After about 15 months of planning, meeting, coding, optimizing, and preparing, we went live on Epic a week ago. We had Cerner before that, and a homegrown CIS before that. The initial CIS was mostly labs, rads, and dictations as I recall. With Cerner PowerChart and FirstNet, we added nursing documentation, MAR, and some clinical documentation, though we had a hybrid system that included a paper chart for all non-dictated physician documentation (mostly progress notes, as H&Ps, consults, and DC summaries were dictated) and paper physician orders. A handful of small, contained areas (Peds, OB, Psych, ED) did do CPOE, but expanding that to the rest of the hospital, and our many community-based physicians, was untenable.
  
  Now we have (mostly) abandoned paper documentation, with all physician documentation being done by either phone dictation, templates (using Notes and/or Notewriter plus/minus partial dictation), or Dragon. We are piloting Dragon Enterprise with a small number of physicians, otherwise they are using their own licenses. Still having network connectivity problems with wireless devices, especially BYODs -- particularly those of the Apple persuasion. And ironing out printing issues.
  
  Overall, the switch has gone amazingly well. I attribute this to excellent executive support, mandatory classroom (not online) physician training (8-12 hours), extensive clinician involvement in the build, and heavy at-the-elbow support.
  
• Maryland's Behavioral Health Integration
  In 2011 we kicked off an effort to combine the Department of Health and Mental Hygiene's two administrations -- Mental Hygiene Administration and Alcohol and Drug Abuse Administration -- into an integrated administration which is expected to be called the Behavioral Health Administration. The Joint Chairman's Report lays out much of the rationale, as well as the challenges. Health Secretary Joshua Sharfstein MD MPH, previously Baltimore City commissioner, then a stint at FDA, has led an admirably open, transparent, stakeholder-rich effort to shape this integration effort.
  
  The past 3 months have been heavy with 2-to-3-hour long Workgroup meetings. I've been attending many of these meetings (maybe a third to a half), representing the Maryland Psychiatric Society. The main points I've been making mostly revolve around ensuring mental health parity and integration of primary care. Besides the large overall Workgroup, there have been four, more focused, workgroups (links have meeting agenda, minutes, resource documents). Their charges are as follows:
  
• Systems Linkage:
  Purpose: To make a recommendation on those factors that should be present to promote "integration." For example, should there be a shared electronic health record among all providers within an MCO? What factors indicate “integrated” care, and what factors indicate “collaborative” care?
  
• State/Local and Non-Medicaid Workgroup: Purpose: To make a recommendation on what services/financing should be left outside a “Medicaid” integrated care model to accommodate non-Medicaid eligible populations, or non-Medicaid-eligible services. This Workgroup will also make a recommendation on the roles that state and local government should perform depending on which services/financing are left outside of the Medicaid financing model, as well as how to support and interface with selected model.
  
• Evaluation and Data WorkgroupPurpose: To determine what data is available and relevant to the ultimate recommendation on the model, and to make a recommendation on potential measures to evaluate any selected model.
  
• Chronic Health Homes Workgroup
Purpose: To make a recommendation on a new “Health Home” service under the Affordable Care Act, and make a recommendation on how the new service could be developed to support any integration model. For example, this workgroup would help define the service; define the population eligible for the service; and define the provider qualifications to deliver the service.

• Maryland Health Benefit Exchange
  Maryland is among the earliest states to respond to the ACA's requirement of health insurance exchanges that include qualified health plans (QHPs) which must include a minimum set of essential health benefits (EHBs). This process has been unfolding extremely quickly over the past three months, with several meetings per week across all the advisory committees, as well as the governing Board. I've served on the Plan Management Advisory Committee, which has completed its work and submitted a Summary to the Board and to the legislature. Over 200 pages of public comments have been submitted to the Board, which met last week. Ensuring that there are requirements to demonstrate Parity compliance, as well as adequate provider network standards, has been the main focus of mental health advocates.
  
  The other advisory committees include Navigator, Continuity of Care, Financing, and Exchange Implementation.
  
• Maryland Health Information Exchange
  The MHCC Policy Board continues to slog through its policy discussions. The current list of policies is in a .pdf document here. We've also been working on draft regulations for HIEs in Maryland. Initial public comments on these draft regulations are available on the HIE website.

Other things I've been working on include APA's Committee on Electronic Health Records, M3Clinician (a clinician portal for the M3 mental health screening tool), and mental health parity. This last thing includes working with folks in the Parity Implementation Coalition, testifying at a Congressional parity hearing, and even appearing on the Diane Rehm Show.

I'll try to post a bit more often here, but you can also keep an eye on Shrink Rap, Clinical Psychiatry News, and a new column on health IT to start soon in Psychiatric News.

Thank you for reading.