Mental Health as it Relates to Primary Care
The statistics are undeniable – behavioral health can no longer be considered apart from primary health care. Mental and emotional struggles impact the whole person, and result in higher medical costs, more frequent hospital visits and a greater probability that patients are only being treated for what some consider the “medical” part a diagnosis. Our approach is different and based on the belief that we can only get to the root of a patient’s problem by treating the medical and behavioral ailments.
What the Research Says
It is known that depressed persons utilize three times the amount of general health care services and that people reporting persistent depression have annual medical costs that are 70% greater than those who report not being depressed. (JOEM, 1998). Analysis of risk factors associated with health care insurance claims revealed that depression and stress were the two most significant factors in increased claims expenditures – greater than obesity, high blood pressure, high cholesterol and tobacco use. (Goetzel, et. al, 1998)
The statistical probability of death within six months of a heart attack is six times more likely if the patient has co-morbid depression (Jiang W, Glassman A, Krishnan R, O’Connor CM, Califf RM., 2005).
We know that anxiety disorders account for 6-12% of all outpatient medical visits and that panic disorder patients have 10 times the number of visits to hospital emergency rooms. Anxiety disorders co-morbid with asthma triple the hospitalization rate.
Selected populations with behavioral health issues are heavy users of primary care:
- Up to 50% of all visits to primary care physicians (PCPs) are due to conditions that are caused or exacerbated by mental or emotional problems.
- Over 90% of elderly patients receive behavioral health services in a primary care setting.
- Approximately 70% of community health center patients have behavioral and/or chemical dependency disorders.
- More than one-third of behavioral health visits by privately insured children are to a primary care physicians rather than to a specialist. (CFHC, Collaborative Family Healthcare Coalition, 1998)
At the Robert Young Center for Community Mental Health we are striving to remain at the forefront of bi-directional integration between primary and behavioral health care. We have begun a number of projects related to integration that are briefly described below:
This project was designed to improve the total health care for patients of the Robert Young Center for Community Mental Health and the local Federally Qualified Healthcare Center through the development of an integrated system of care. The target population was comprised of individuals with severe and persistent mental illness with a medical co-morbidity. Integrating the primary and behavioral health care provided a health care home for these individuals. This integration model was successful at improving the health of the whole person through coordination of care, collaboration of providers, and co-location of services. Specific outcomes included appointment attendance, rate of annual physicals completed, and identification of patients with medical co-morbidities receiving case management, improved quality of life and implementation of depression screening.
The Four Quadrant Integration Model was used as the basis for developing the service delivery. This provided a continuum of care that was able to meet the patients’ physical and mental health needs. Other components of this model included medical and allied health education, depression screening and a measurement patient perception of the overall health status. The PHQ-9 was used to screen for depression on each patient, along with the SF12v2 health survey, which measures the patient perception of their behavioral and medical health.
Going forward future research will focus on analysis of cost reduction associated with health care utilization. Maintaining a health care home for this target population will remain a focus to ensure total health care for the patient including behavioral and primary care.
The model universally employed a depression screen that identified patient whom were at risk for depression.
The model provides a process for consultation between the different agencies providers.
The co-location and integration of primary care and behavioral health services improves the coordination of care and the collaboration between primary care and behavioral health providers.
The Center has partnered with Iowa Health Physicians and the Federally Qualified Health Center to provide behavioral health and primary care integration through the placement of a Behavioral Health Specialist (Licensed Clinical Social Worker, Licensed Clinical Professional Counselor) into five primary care locations. The on-site clinician provides assessment, brief therapy, and consultation. In addition to the on-site Behavioral Health Specialist there is a built-in psychiatric consultation process that provides the opportunity for the primary care physician to have access to a psychiatrist for assistance with medication management issues. The PHQ-9 Depression screening is used to assist in identifying patients who are at risk for depression. Current integrated care sites are listed below:
- Geneseo Family Practice
- Trinity Residency Clinic – Bettendorf
- Trinity Health Partners – Moline
- Trinity Medical Clinics – Muscatine
- Federally Qualified Health Center - Moline
The Center has partnered with Trinity Health Partners for research to investigate the impact of primary care and behavioral health service integration. The purpose of the research is to demonstrate the positive impact of integrated behavioral and primary care service as it relates to reduced health care utilization, and improved clinical outcomes for patients suffering from behavioral health problems and medical co-morbidities.
Health care utilization outcomes being measured include emergency room visits, admission/re-admissions, prescription costs, and physician office visits. Also, clinical outcomes for patients with depression, hypertension and diabetes are being measured.
Trinity was one of 42 Magnet Hospitals throughout the United States selected to participate in an “Improving Heart Failure Outcome” research study from Johns Hopkins and the University of Maryland School Of Nursing. The objective of the research is to test nursing interventions with a direct effect on improved heart failure patient outcomes.
During the study several assessment tools were administered to patients admitted with a heart failure diagnosis. One of the screening tools administered was the Beck Depression scale. Patients who scored high on the depression scale were linked with behavioral health services in an effort to further decrease unnecessary readmissions.
The Robert Young Center has been participating in the Quad Cities Health Initiative (QCHI). The QCHI emerged out of the interest of over 300 community members and leaders in improving the health of the Quad-Cities region. In 1999, the QCHI established an Executive Board and a community Board, including over 30 representatives of local health departments, providers, insurers, social service agencies, educators, businesses, media, law enforcers, foundations and governments and ILLOWA Partners in nursing.
One key area of interest in the QCHI has been mental health. Dr. David Deopere, President of RYC, has chaired the Medical Integration Committee. The Committee has coordinated the offering of three successful community-wide symposiums on the integration of primary and behavioral health care during the past three years.
In 2012, Dr. Leo Pozuelo of the Cleveland Clinic will be the keynote speaker and will present “Clinical Overview and Treatment Strategies of the Depressed/Anxious Cardiac Patient” during a morning symposium and will present a C.M.E. event for local physicians entitled, “Behavioral Cardiology: Why and How to Treat Your Depressed/Anxious Cardiac Patient.”
In June 2011, the Illinois Department of Human Services conducted a highly successful “Statewide Policy Summit on Advancing Bidirectional Behavioral Health and Primary Care Integration.” Speakers from across the nation addressed various topics related to integration such as: conceptual models, evidence-based and best practice models, payment models and the impact of health reform on integration. The Robert Young Center was honored to be one of three Illinois behavioral health organizations who were spotlighted as an example of “Current Illinois Models of Bi-Directional Integration.” Dr. Deopere presented, “A Model of Community Integration between a CMHC, FQHC and Health System.”
Robert Young Center, in collaboration with Trinity Regional Health System, Community Healthcare, Inc. (FQH C) and Precedence, Inc. are applying to IDHFS to implement a care coordination model. The proposal integrates primary healthcare and behavioral healthcare for individuals with severe mental illnesses and/or substance abuse disorders and co-morbid medical conditions such as diabetes, hypertension, asthma, heart disease, and obesity (defined as having a body mass index greater than 25. This model builds on the work of the Center’s current DFI-funded project and fully involves Trinity into the collaboration. Additionally, the project seeks to extend the collaboration into several rural counties in Illinois thorough the inclusion of two additional mental health centers and their respective hospitals and primary care providers.
The individuals enrolled into the Innovations model will have a “Health Care Home” that addresses treatment, care coordination and access to other community services. Precedence, Inc., a taxable not-for-profit PPO, will serve as the lead agency. The Lead Agency is responsible for executing the contract and managing care for the population through the use of healthcare analytics. The three year project will assume a tiered case coordination fee based on risk and severity of chronic conditions; the model also proposes a shared savings with IDHFS that assumes no down-side risk.
IHA Quality Care Institute is designed to inform, inspire and support hospitals on their journey to provide the highest quality care and patient safety. The Robert Young Center was one of three behavioral health organizations to be included in the Fall Quality Quest issue that focused The issue’s cover article focuses on reducing readmissions and improving quality by integrating behavioral health with primary care. You can read the article at: http://www.ihatoday.org/uploadDocs/1/qualityquestfall2011.pdf
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