Session B 4 October 29 2011 10

Session # B 4 October 29, 2011 10: 30 AM The Expanding Role of Care Managers in Integrated Primary Care and the Patient Centered Medical Home Alexander Blount, Ed. D Director, Center for Integrated Primary Care Professor of Family Medicine and Psychiatry Alexa Connell, Ph. D Assistant Director, Center for Integrated Primary Care University of Massachusetts Medical School Collaborative Family Healthcare Association 13 th Annual Conference October 27 -29, 2011 Philadelphia, Pennsylvania U. S. A. c. Certificate Program in Primary Care Behavioral Health

Faculty Disclosure • I (Alexander Blount) currently have or have had the following relevant financial relationships (in any amount) during the past 12 months: • Integrated Primary Care, Inc (consulting practice) • I (Alexa Connell) currently have or have had the no financial relationships (in any amount) during the past 12 months to disclose. c. Certificate Program in Primary Care Behavioral Health 2

Need/Practice Gap & Supporting Resources The evidence for the need for behavioral health services in primary has been well established. (Blount, A. (1998). Integrated Primary Care, The Future of Medical and Mental Health Collaboration, W. W. Norton. ) The best referral systems don’t approach co-locating behavioral health clinicians in primary care in providing access. (Bartels, S. , et. al. , Am J Psychiatry 161: 1455 -1462, August 2004 ) The 2011 Certification Standards require practices to insure delivery of mental health and substance abuse services to patients and to have one population based program for behavioral needs to become a Patient Centered Medical Home. (http: //NCQA. org) c. Certificate Program in Primary Care Behavioral Health 3

Objectives • 1. Participants will be able to identify duties and limits of historic roles of case manager, care coordinator and care manager. • 2. Participants will be able to list the role of care manager in relation to the other team members in a primary care setting. • 3. Participants will be able to list the different heritages of the intermediate role between the patient and the provider. • 4. Participants will be able to use complexity tools to assess the needs of a client. c. Certificate Program in Primary Care Behavioral Health 4

Care Management/Case Management/ Care Coordination • Different heritages, different current constituencies • In the space between the patient and the physician(s) • Now lots of new names: Navigator, health coach, what others? • We use the term “Care Advisor” • Many disciplines and training levels • Will be the biggest growth role in the foreseeable future. c. Certificate Program in Primary Care Behavioral Health 5

“Care Management” – What are we talking about? • Three distinct histories of the term that I can find. • Care Management (1) – Manage a system of care. • Care Management (2) – Manage the care (broadly defined) of one patient, usually who is living at home. • Care Management (3) – Protocol for treating depression in primary care. – When “disease management” was applied to depression, the ensuing process was called care management. c. Certificate Program in Primary Care Behavioral Health 6

Mental Health Case Management Generally the functions of case management have included: • • Obtaining basic supports Crisis prevention and intervention Assessment to determine need for services Outcome/function focused treatment planning Referral and linkage with chosen services Engagement and developing a helpful, trusting relationship Coordinating and adjusting service delivery Advocacy Tx to Barbara Mauer c. Certificate Program in Primary Care Behavioral Health 7

Care Coordinator • “Coordinates patient care including patient/family education and discharge planning to insure quality, cost-effective utilization of resources consistent with the hospital mission and Collaborative Patient Care Management goals and priorities. • Directs the daily and short-range goal setting and planning for the assigned case type and Group Practice. • Participates in the annual goal setting and planning for Group Practice. • Guides health care team members in designing collaborative teaching plans/programs and in planning/providing patient/family education and discharge planning within designated specialty. • Accountable for clinical and financial outcomes of assigned case types and the activities and accomplishments of the Group Practice. ” www. innovativecaremodels. com c. Certificate Program in Primary Care Behavioral Health 8

History of Care Management (3) for Depression • Wayne Katon and the U of Washington/Group Health Co-op hoards. • Ed Wagner, the Institute for Healthcare Improvement, and the Chronic Care Model • Foundations get it going, Robert Wood Johnson, JD&KT Mac. Arthur • It is the best “evidenced” and best worked out primary care BH intervention ever. c. Certificate Program in Primary Care Behavioral Health 9

Depression Care Management Protocol • Depression in primary care, RWJ and Mac. Arthur programs. – http: //www. depression-primarycare. org/ • Toolkit • Help in re-engineering practices • Develop screening for depression in collaboration with providers – Who – When – What triggers • Assure that assessment/diagnosis protocol is in place for positive screens and that all assessed positive are on a registry. • Protocol – Assures that patients know types of care offered – Makes phone calls to assess medication effect and side effects – Tracks visits – Re-screening/outcome • Brief face to face or telephone problem solving and behavior activation interventions. c. Certificate Program in Primary Care Behavioral Health 10

Four Quadrant Model (Mauer) Quadrant II high BH low PH Quadrant IV high BH high PH Quadrant I low BH low PH Quadrant III low BH high PH c. Certificate Program in Primary Care Behavioral Health 11

The complex “medical-only” patient is rare among complex patients. • The more somatic illnesses a person has, the more they are likely to have one or more psychiatric diagnoses. • Low income and “neuroticism” correlate with more somatic diagnoses as well as more psychiatric diagnoses. Neeleman, J. , Ormel, J. AND Bijl, R. V (2001). The distribution of psychiatric and somatic ill health: associations with personality and socioeconomic status, Psychosomatic Medicine 63: 239– 247 • Similar findings in large PCMH pilot done by Boeing Corp. www. integratedprimarycare. com • The sicker you are, the sicker you are. c. Certificate Program in Primary Care Behavioral Health 12

When depression is an important factor in a complex presentation, case managers without behavioral health training can be a poor fit. “Nurses, practice assistants, and HCAs complain of the psychological burden of providing mental health services in depression care. To avoid exhaustion, they prefer to work parttime. Reports of HCAs working in innovative depression care programs are still rare. " Genschen, J, et al, Health Care Assistants in Primary Care Depression Management: Role Perception, Burdening Factors, and Disease Conception. Annals of Family Medicine, Vol 7, no. 6. 2009. c. Certificate Program in Primary Care Behavioral Health 13

Merging Heritages: Mental Health Side Medical Care Management for SMI patients Intervention Group • Care managers/coordinators – communication and advocacy with medical providers – health education – support in overcoming systemlevel fragmentation and barriers to primary medical care. Control Group • Usual care • 21. 8% of recommended preventive services • No improvement. • 58. 7% of recommended preventive services • Significant improvement in SF-36 mental component and Framingham Cardiovascular Risk Index. c. Certificate Program in Primary Care Behavioral Health 14

Care Coordination-2011 PCMH 2011 Standards attempt to rectify the oversight related to behavioral health • Develops written care plans for 75% of patients in 3 population protocol programs (one behavioral) and for high risk complex patients. • Arranges or provides treatment for MH and SA disorders. • Monitors and assures that patients and families receive offered (referred) resources. • Supports patients and families in self-management, selfefficacy and behavior change with education, counseling for healthy behavior and goal setting. c. Certificate Program in Primary Care Behavioral Health 15

Why should behavioral health be a core service of PCMH? • 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 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 c. Certificate Program in Primary Care Behavioral Health 16

Behavioral role in CVD risk factors H E A R T S high blood pressure existing CAD age, gender relatives (family hist) tension/stress smoking alcohol, exercise health literacy L O A D lipids, HDL, LDL obesity aerobic physical act. diabetes - nutrition, exercise monitor, nutrition, exercise, adherence family support relaxation cessation c. Certificate Program in Primary Care Behavioral Health 17

What does all this mean? • The PCMH model is going to be everywhere, even in mental health centers. • Bits from all the heritages, case manager, care manager for depression, behavioral health consultant and care coordinator will probably be recognizable in the future version of the job. • It is likely to be a role for which we will need thousands of properly trained people. c. Certificate Program in Primary Care Behavioral Health 18

The Story of “Joan” MEDICAL DIAGNOSES: 1. Chronic thrombocytopenia probably secondary to chronic ITP. 2. Coronary artery disease. Status post CABG in 1993. 3. Chronic obstructive pulmonary disease. The patient is intermittently oxygen dependent (and a smoker). 4. Insulin requiring diabetes associated with neuropathy. 5. Osteoarthritis. 6. Bipolar disorder. 7. Recurrent urinary tract infections. c. Certificate Program in Primary Care Behavioral Health 19

The Story of “Joan” Medications: • Norvasc, famotidine, furosemide, metformin, Neurontin, diazepam, fluconazole, insulin, and Mellaril. Other Statistics: • Rank in calls to on call line: #1 (>1 x night) • Rank in ER utilization (out of 22, 000 pts): #1 (>2 x wk) • Rank in eliciting frustrated comments from nurses and residents: #1. c. Certificate Program in Primary Care Behavioral Health 20

Joan Gets a “Plan Based” Case Manager • Blue Cross, trying desperately to contain costs, assigns her a telephone case manager for her diabetes. • She tells the case manager how verbally abusive her husband is to her, initiating a referral for elder abuse. It is not substantiated. • The case manager stops calling. • ER use unchanged c. Certificate Program in Primary Care Behavioral Health 21

A Change of Pattern for Joan • Family systems thinking teaches us that recurrent patterns can be understood as circular. • If they seem unidirectional, look for the hidden influence going the other direction. • Arthur was always taking care of Joan, with more or less success. • How could it be seen as the other way around? • Joan and Arthur engage in occasional couples visits. ER visits down significantly after meetings. Strategies for night call devised, though not consistent across residents. • Program was missing the outreach and connection (Care Advisor) needed to sustain gains and maintain improvement. c. Certificate Program in Primary Care Behavioral Health 22

Options arise when we develop new descriptions or stories of familiar events. • When the health system is stuck in recurrent unhelpful patterns with a “complex” patient, we need to look for another story. • The details that support a new story could be anywhere in the interactions of the person in their social network, but their family is usually the richest source. • PCMH care managers need access to skills in family interviewing and systems thinking in addition to skills in CBT, relaxation therapies and Motivational Interviewing. c. Certificate Program in Primary Care Behavioral Health 23

How can the necessary skills be broadly available? • Behavioral Health Clinician in Primary Care practices willing to do more active outreach, i. e. care management, than has traditionally been asked. • Properly trained clinician (usually psychiatrist or health psychologist) with PCP provides supervision for care manager who has some behavioral health training (IMPACT model) • Special training programs for the emerging roles, e. g. , Care Managers and Navigators Course of the Center for Integrated Primary Care at UMass Medical School. c. Certificate Program in Primary Care Behavioral Health 24

We need to develop “integrated care management”. • Need to be able to address mental health, substance abuse and behavior change/activation needs • Need an “undifferentiated” assessment measure for identification and tracking outcomes for most complex people. c. Certificate Program in Primary Care Behavioral Health 25

Complexity measures are proving very useful. Peek, Baird & Coleman, Families, Systems, & Health, 2009, Vol. 27, No. 4, 287– 302. Roger Kathol, The Integrated Case Management Manual, Springer, 2009. Let’s look over the Peek et. al. form. c. Certificate Program in Primary Care Behavioral Health 26

Routines We Can Build In for Transparency • Patient owns the health record (Shared Care, WA) • Reading the note at the next visit • Sharing the screen of the EMR • Patient signs all MH treatment plans • Family involvement when possible • Patient at their team meetings in primary care whenever possible 27 c. Certificate Program in Primary Care Behavioral Health 27

Care Manager’s Toolkit • • Patient Registries EHR Lists of community resources Lists of referral sources Relationships with PCPs and nursing staff Relationship with patients and their family The internet (aka Google is your friend) c. Certificate Program in Primary Care Behavioral Health 28

What is a Registry? “A patient registry is an organized system that uses observational study methods to collect uniform data (clinical and other) to evaluate specified outcomes for a population defined by a particular disease, condition, or exposure, and that serves one or more predetermined scientific, clinical, or policy purposes. ” AHRQ. Registries for Evaluating Patient Outcomes: A User’s Guide c. Certificate Program in Primary Care Behavioral Health 29

Registries For Care Management • Important resource to make sure patients don’t “fall through the cracks • Practice Registries are different from EHRs because they manage selected information related to patients with particular conditions. They do not contain information such as patient history or other health problems. • Computerized practice registries are “tools that capture and track key patient information to assist physicians and their team members in proactively managing patients” – California Health care Foundation. “Chronic Disease Registries: A Product Review, ” ihealth Reports, NAS Consulting Services, May 2004 c. Certificate Program in Primary Care Behavioral Health 30

Considerations for Registry Use and Design • What information is relevant for tracking? – Necessary or just desirable? • Where will your data come from? – Personnel data entry? Querying an EHR? – Initial data entry is time consuming. • Will the registry interface with your EHR? • Who will be able to access the registry? – Generally everyone, but will some have restricted access? – Who is responsible for maintaining registry accuracy? c. Certificate Program in Primary Care Behavioral Health 31

Considerations for Registry Use and Design • What resources (financial and personnel) can we dedicate to registry creation and maintenance? • What do we need this registry to do? • How will we use this information in the future? • Registries are only fully searchable and useful if they are standardized. c. Certificate Program in Primary Care Behavioral Health 32

What is the Relevant Information? • Demographics: Name, address, phone number, email • Provider Information: PCP, BH consultant (if any), Care manager – Anyone involved in the patient’s care • Health Data: Screening results, diagnoses, clinical outcomes (lab results, BMI), preventative medicine • Interaction Data: – – Who was present? Who needs to receive an update? Which conditions/goals addressed? Which interventions? What is the current plan? When is the next contact/screening/appointment? c. Certificate Program in Primary Care Behavioral Health 33

An Example: Care Advising at UMass • Who: Graduate students in psychology/ mental health counseling, LICSWs, Social workers, Nurses, MAs, Psychologists • Located at 3 Family Medicine practices: – 1 Adult Internal Medicine practice – 2 Pediatric practices – 3 Family Medicine practices c. Certificate Program in Primary Care Behavioral Health 34

Care Advising Resources at UMass • Between 10 -50 hours Care Advising time per practice, per week. • Patient registry built in MSAccess, populated by – querying our EHR for demographic, screening, diagnosis and dates of preventative medicine interventions – Manual data entry to record Care Advisor interactions • Searchable lists of referral sources – Mental Health, Support groups, Massage, Chiropractic, Acupuncture, Yoga, Fitness centers, Shelters, Vocational Rehab, Adult Ed, Volunteer organizations • Relationships with community organizations c. Certificate Program in Primary Care Behavioral Health 35

What are Our Care Advisors Doing? • Care advising team meets on a weekly basis to discuss cases, share resources etc. • Develop and implement protocols for the Care Advisor’s role in disease management • Facilitated more than 200 mental health referrals at a single health center • Attended home visits • Completed patient transportation paperwork • Contacted patients with reminders for colonoscopy screening • Accompanied patient to apply for disability • Advocated for patients with health insurance coverage difficulties • Delivered CBT and MI interventions over the phone • Provided peace of mind to providers c. Certificate Program in Primary Care Behavioral Health 36

What Have We Learned So Far? • Physicians do not refer the most complex cases. • Without a “push” from some sort of population based risk assessment, or disease based protocol, care advisors get a lot of “low level” referrals. • The ongoing meeting among Care Advisors to refine role definition, refine expertise and share resources is crucial, folks in supervisory roles are not expert at new integrated approaches. c. Certificate Program in Primary Care Behavioral Health 37

UMass Patient Registry in MSAccess c. Certificate Program in Primary Care Behavioral Health 38

UMass Patient Registry c. Certificate Program in Primary Care Behavioral Health 39

UMass Preventative Medicine Tracking c. Certificate Program in Primary Care Behavioral Health 40

UMass Intervention Tracking c. Certificate Program in Primary Care Behavioral Health 41

Learning Assessment Questions and Discussion c. Certificate Program in Primary Care Behavioral Health 42

Session Evaluation Please complete and return the evaluation form to the classroom monitor before leaving this session. Thank you! c. Certificate Program in Primary Care Behavioral Health 43

Center for Integrated Primary Care Alexander Blount, Ed. D Alexander. Blount@umassmemorial. org Alexa Connell, Ph. D Alexa. Connell@umassmemorial. org Center for Integrated Primary Care PCBH@umassmed. edu 44 c. Certificate Program in Primary Care Behavioral Health 44