Integration of Mental Health and Primary Health Care for the Older Patient - PowerPoint PPT Presentation

Loading...

PPT – Integration of Mental Health and Primary Health Care for the Older Patient PowerPoint presentation | free to view - id: 7caa15-MGRhM



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

Integration of Mental Health and Primary Health Care for the Older Patient

Description:

Integration of Mental Health and Primary Health Care for the Older Patient Stephen J. Bartels, M.D., M.S. Professor of Psychiatry and Community and Family Medicine – PowerPoint PPT presentation

Number of Views:291
Avg rating:3.0/5.0
Slides: 67
Provided by: Herm138
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Integration of Mental Health and Primary Health Care for the Older Patient


1
Integration of Mental Health and Primary Health
Care for the Older Patient
  • Stephen J. Bartels, M.D., M.S.
  • Professor of Psychiatry and Community and Family
    Medicine
  • Co-Director Dartmouth Center on Aging

2
Overview
  • Background Mental Health, Primary Care, and the
    Older Patient
  • Outcomes Integration of Mental Health Services
    in Primary Care and the Older Patient
  • Policy Implications for The Presidents
    Commission on Mental Health

3
Estimated Prevalence of Major Psychiatric
Disorders by Age Group
Jeste, Alexopoulus, Bartels, et al., 1999
4
Prevalence of Depression and Other Disorders in
Primary Care
Major All All Study
Depression Depression Disorders Hoeper et
al. 5.8 19.9 26.7 Schulberg et
al. ---- 9.2 30.3 Von
Korff et al. 5.0 8.7 26.5 Barrett
et al. 0.4 10.0 26.4 Coyne et
al. 13.5 22.0 ---- ECA (highest)
3.5 (6mo) 6.5 (6mo) 8.8
(2wk)
5
Depression Associated with Worse Health Outcomes
  • Worse outcomes
  • Hip fractures
  • Myocardial infarction
  • Cancer (Mossey 1990 Penninx et al. 2001 Evans
    1999)
  • Increased mortality rates
  • Myocardial Infarction (Frasure-Smith 1993, 1995)
  • Long term Care Residents (Katz 1989, Rovner 1991,
    Parmelee 1992 Ashby1991 Shah 1993, Samuels
    1997)

6
Suicide and the Older Patient
  • Older adults Highest risk of suicide of any age
    group
  • 70 of elderly completing suicide have seen their
    primary care physician in the prior month, 40
    prior week, 20 same day (Conwell et
    al., 1994)
  • Screening all primary care patients impractical.
    But identification of higher risk patients
    important

7
Primary Care Elderly with Depression, Anxiety, or
At-risk Alcohol Use
  • 27.5 Report Death Ideation
  • 10.5 Report Active Suicidal Ideation
  • Greatest Suicidal Ideation Depression with
    Anxiety (18), Poor Social Support
  • Suicidal Ideation NOT associated with increased
    visits to the PCP Bartels et al., Am J.
    Geriatric Psychiatry 2002, 10417-427

8
Quality of Mental Health, Care and the Older
Patient
  • Fragmentation of the Mental Health service
    delivery system for older persons
  • Primary Care as the de facto mental health
    system of care for the older person

9
Quality of Mental Health Care for Older Primary
Care Patients
  • The older primary care patient with depression
    compared to younger
  • More likely to receive benzodiazepines
  • Less likely to receive SSRIs
  • Less likely to receive psychotherapy Bartels et
    al., International J. Psychiatry in Medicine 27
    (3)215-231, 1997.

10
Health Service Use and Costs Associated with
Depression for Older Primary Care Patients
11
Cost of Outpatient Services in Depression
Unutzer, et al., 1997 JAMA
12
Cost of Prescriptions
13
Number of Medical Visits
14
Hospitalized
15
Admitted to Emergency Room
16
Depression as a Costly Chronic Disease
Individuals with these 5 conditions account for
49 of total health care costs, 42 of
illness-related lost wages
Health Care Costs (per capita/total) Work Loss Costs For Individuals with Condition Health care and Total Costs for Individuals with Condition
Mood Disorders 3 1 2
Diabetes 4 3 3
Heart Disease 1 5 4
Hypertension 2 1 1
Asthma 5 4 5
17
Summary of Findings
  • Comorbid Depression in Medical Disorders Commonly
    Affecting Older Patients
  • Greater Use and Costs of Medications
  • Greater Use of Health Services (medical
    outpatient visits, emergency visits, and
    hospitalizations)

18
The Research Question
  • What is the Most Effective Way to Organize and
    Deliver Mental Health Services to Older Persons
    in Primary Care Settings?

19
Primary Care Research in Substance Abuse and
Mental Health for the Elderly
20
A Comparison of Two Service Models
  • Integrated/Collaborative Care
  • Co-Located
  • Concurrent
  • Collaborative
  • Enhanced Referral to Specialty Mental Health and
    Substance Abuse Clinics
  • Preferred Providers and Facilitated appointments,
    transportation, payment

21
Primary Hypotheses
  • Engagement Hypothesis
  • Participation Hypothesis
  • Outcomes Hypothesis
  • Cost Hypothesis

22
  • Is the Integrated Model More Likely to Result in
    Engagement in Mental Health Care by Older Persons?

23
STUDY TARGET CONDITIONS
  • Major Depression
  • Dysthymic Disorder
  • Minor Depression
  • Depressive Disorder NOS
  • Generalized Anxiety Disorder (GAD)
  • Panic Disorder
  • Anxiety Disorder NOS
  • At-risk Alcohol Use

24
Sample Characteristics (n2022)
Mean Age 73.5 6.2 26 Female
Diagnoses
Ethnicity
25
Overall Engagement by Model
  • Integrated 71 (709/999)
  • Referral 49 (499/1023)
  • Relative Risk 1.45
  • RR engaged integrated / engaged referral

26
Rates of Engagement in MHSA Care By
Diagnosis/Condition
27
Rates of Engagement in MHSA Care By Level of
Suicidal Ideation
RR1.53
RR1.19
RR1.71
28
Physical Proximity between Primary Care Clinic
and MH/SA Clinic
Rates of engagement are significantly different
across all four practice arrangements for the
total sample (?2(3)103.15, plt.001) and across
the three referral practice arrangements
(?2(2)7.76, p.02).
Bartels et al., American Journal of Psychiatry,
1611455-1462, 2004.
29
Outcomes
  • Integrated Care (compared to specialty referral)
    Associated with Greater Engagement in Treatment
  • .Similar Outcomes (slightly better for
    major depression in specialty referral)
  • Are Integrated Services with Depression Care
    Management (including use of specified treatment
    protocols) Better than Usual Care?
  • IMPACT (Hartford Foundation)
  • PROSPECT (NIMH)

30
The IMPACT Treatment Model
  • Collaborative care model includes
  • Care manager Depression Clinical Specialist
  • Patient education
  • Symptom and Side effect tracking
  • Brief, structured psychotherapy PST-PC
  • Consultation / weekly supervision meetings with
  • Primary care physician
  • Team psychiatrist
  • Stepped protocol in primary care using
    antidepressant medications and / or 6-8 sessions
    of psychotherapy (PST-PC)

31
Antidepressant Use
Plt.0001
Plt.0001
Plt.0001
P.6995
Unützer et al, JAMA 2002 2882836-2845.
32
Mental Health / Psychotherapy / PST-PC
Plt.0001
Plt.0001
Plt.0001
P.2375
Unutzer et al, JAMA 2002.
Unützer et al, JAMA 2002 2882836-2845.
33
Collaborative Management of Late-Life Depression
in Primary Care
P.55
Plt.001
Plt.001
Plt.001
IMPACT Study Unutzer, et al., 2002 - JAMA
34
IMPACT Unutzer et al, 2002
1,801 patients 60 yrs in 18 Primary care clinics
in 8 Health care organizations.
Cadillac
model of
system change
Patients in REMISSION (HSCLlt0.5)
35
PROSPECT
  • USUAL CARE vs. INTERVENTION
  • Clinical Algorithm for Geriatric Depression
    Consisting of Citalopram or IPT (based on
    patient preference)
  • Depression Care Manager Social Workers, Nurses,
    Psychologists in Primary Care Depression
    recognition, guideline based treatment,
    monitoring of response to treatment, follow-up

36
PROSPECTImprovement in Depression (50 Drop
on HDRS Depression Score from Baseline)
Plt.05
Plt.05
Plt.001
4
8
12
Bruce, et al., 2004 - JAMA
37
PROSPECT Depression Specialist with Treatment
Algorithm
  • Practices with Depression Specialist Using
    Treatment Algorithm for Depression had Greater
    Reduction in Depression Compared to Usual Care
    Practices
  • However, Better Outcomes Only For Major
    Depression, Not for Minor Depression

Bruce, et al., 2004 - JAMA
38
Conclusions Integrated Mental Health Services in
Primary Care
  • Better engagement .similar outcomes compared to
    referral care (perhaps slightly less effective
    for major depression)
  • Better engagement and outcomes compared to usual
    care..especially with care management,
    standardized screening and outcome tracking, and
    treatment protocols

39
Summary of 1st 2nd Generation Studies
  • Multiple component interventions
  • Lectures /or distributing guidelines do not
    change behavior nor outcomes
  • Adding patient tracking with a care manager
    significantly improves outcomes
  • Including a mental health specialist in an
    integrated treating or consulting role improves
    outcomes the most

40
From Simon
41
Greater Patient Improvement with System Changes
vs. Usual care
42
Summary of 1st 2nd Generation Studies
  • Multiple component interventions
  • Lectures /or distributing guidelines do not
    change behavior nor outcomes
  • Adding patient tracking with a care manager
    significantly improves outcomes
  • Including a mental health specialist in an
    integrated treating or consulting role improves
    outcomes the most

43
3rd Generation Depression System Change
Interventions
44
Sustainability of Interventions?
Lin et al 1997
Appropriate Antidepressant Rx
45
Long-term Depression Rx System Need
Remission
Recovery
Normalacy Symptoms Syndrome
Recurrence
Relapse
Only 25 Have 3 Visits
Relapse
Response
Severity
gt 50 STOP Rx
65 to 70 STOP Rx
Continuation Phase
Maintenance Phase
Acute Phase
Time
46
Non-adherence to Antidepressants
47
NCQA HEDIS Measure Long-Term Treatment
Adherence
 
  • Rates Across Plans (2000 Results)

100
Follow-up with MD After Diagnosis of Depression 3
acute Phase visits
80
59
60
Percentage
42
Acute Phase Treatment (84 Days Continuity)
40
21
Treatment (6 Months Continuity)
20
0
Mean
National Committee for Quality Assurance (of
Managed Care Organizations) annual database of
Health Plan Employer Data and Information Set
(HEDIS)
http//www.ncqa.org
48
Usual Care
PRIMARY CARE CLINICIAN
PATIENT
MENTAL HEALTH SPECIALIST
49
MacArthur InitiativeThree Component Model (TCM)
PRIMARY CARE CLINICIAN
PHQ-9
CARE MANAGER
PATIENT
PHQ-9
PHQ-9
MENTAL HEALTH SPECIALIST
50
Care Manager
Encourage Adherence Problem Solve Barriers
Communicate with Clinicians
Measure Treatment Response
Monitor Remission
51
Two Question ScreenU.S. Preventive Services Task
ForceAnn Intern Med 2002136760-4
  • Over the past 2 weeks, have you
  • Felt little interest or pleasure in doing things?
  • Felt down, depressed, or hopeless?

52
PHQ-9
  • Spitzer R, et al. Validation and utility of a
    self-report version of PRIME-MD the PHQ Primary
    Care Study. JAMA 1999 282 1737-1744
  • Kroenke K, et al. The PHQ-9 validity of a brief
    depression severity measure. Journal of General
    Internal Medicine 2001 16 606-613

Sensitivity 73 Specificity 94 Correlation
between PHQ self-report and psychiatrist
interview .84
53
PHQ - 9 Symptom Checklist
1. Over the last two weeks have you been
bothered by the following problems?
More than Nearly Not Several half the
every at all days days day 0 1 2 3
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 . . .
2. ... how difficult have these problems made it
for you to do your work, take care of things at
home, or get along with other people?
Subtotals 4 6 6
TOTAL 16
54
Typical Frequency of Patient Contacts
Care Manager Phone Call
Primary Care Clinician Visit
PCC
CM
Acute Phase
Continuation Phase
PCC
PCC
PCC
PCC
PCC
CM
CM
CM
CM
CM
1 5 6 9 12
18 24 32
36
WEEK
55
Conceptual Treatment Algorithm
56
Conceptual Treatment Algorithm- I
57
Conceptual Treatment Algorithm- II
58
Conceptual Treatment Algorithm- III
59
TCM Phase Two Remission (HSCL lt0.5) Outcomes
(p.05) n323 pts 55 practices
(p.04) n335 pts 56 practices
60
Differences Between System Changes Usual Care
61
3rd Generation Depression System Change
Interventions
IMPACT RESPECT PRISMe PROSPECT
Change Depression Specialist TCM Integrated Mental health Depression Specialist
Care Mgmt On-site Off-site N/A On-site
Patient Education Yes Yes Variable Yes
Psychiatric supervision Face to face Telephone N/A Face to face
Psychotherapy supervision Telephone N/A N/A Face to face
Rx algorithm Yes No No Yes
62
Implications for Applied Policy and Practice
63
Leon Eisenberg
SOUNDING BOARD TREATING DEPRESSION AND ANXIETY
IN PRIMARY CARE. Closing the gap between
knowledge and practice  N Engl J Med 1992
3261080-1084, Apr 16, 1992 7th Annual Rosalyn
Carter Symposium on Mental Health Policy,
Atlanta, Nov 21, 1991
  • Depression is common in primary care, with
    substantial morbidity
  • Under recognized - not because of curriculum, but
    values of patients
  • and physicians, inappropriate DSM nosology
  • Target physicians in practice, involve patient,
    more follow-up
  • consider special nurses, improve payment -
    reward time, assess quality

64
  • Subcommittee on Mental Health and Aging
    Recommendations on Policy
  • Subcommittee on the Mental Health Interface with
    General Medicine
  • Integrating Mental Health and General Health Care
  • Implementing Evidence-based Medicine

65
  • The Federal Government should add evidence-based
    collaborative care services for psychiatric
    disorders to the list of covered services through
    the Medicare National Coverage Process

66
Evidence-Based Chronic Disease Management
Approaches for Treating Depression Are Effective
Ed Wagner Institute for Healthcare Innovation
(IHI)
Health System
Community
Health Care Organization
Resources and Policies
ClinicalInformationSystems
Self-Management Support
DeliverySystem Design
Decision Support
Informed, Activated Patient
Prepared, Proactive Practice Team
Productive Interactions
Functional and Clinical Outcomes
About PowerShow.com