Uniting the Field

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Slide 1

Uniting the Field

The Academy: Integrating Behavioral Health and Primary Care

Funded under contract #HHSA290-2010-000021 by the Agency for Healthcare Research and Quality.

Benjamin F. Miller, PsyD
University of Colorado Denver
Department of Family Medicine

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Primary care has become the "de facto" mental health system (Regier et al, 1993)

Reiger, D. A., Narrow, W. E., Rac, D. S., Manderscheid, R. W., Locke, B., & Goodwin, F. (1993). The de facto U.S. mental health and addictive disorders service system: Epidemiologic Catchment Area prospective. Archives of General Psychiatry 50, 85-94.

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"The health care delivery system is incapable of meeting the present, let alone the future needs of the American public." ( Institute of Medicine [IOM], 2002)

"We have developed a health care system that is unable to deal with the varied roles that mind and body play in so-called physical illness." (Levant, May, & Smith, 2006)

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Image: A cartoon shows a muddled-looking man with the caption "When asked 'would you rather work for change or just complain?'" 81% of the respondents replied, "Do I have to pick? This is hard."

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Image: A map of the United States shows "Brilliance" located in New York, Tennessee, Nebraska, Texas, and California.

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Fragmentation as a Parallel Process

• What we do (models).
• What data we collect (clinical).
• What we call ourselves (integrated).
• What we need for sustainability (money).
• Who we talk to (ourselves).
• What we want (change).

Slide 7

Fragmentation has spread

Physical Health
Mental Health
Care Delivery
Payment
Training and Education
Public Perception

____________________________

Primary Care

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• Lexicon (language critical).
• First and second steps for the field in research.
• Metrics for evaluating integration.
• Unite the field and move it forward.

Image: The cover of A National Agenda for Research in Collaborative Care is shown.

Slide 9

But wait...

A RESOURCE

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Image: A screenshot shows The Academy Web site.

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Image: A screenshot of The Academy Web site shows a sample search for literature by publication title.

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Image: A screenshot of The Academy Web site shows the Project Team biography for Macaran Baird, MD, MS.

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http://integrationacademy.ahrq.gov/

Slide 14

The organized thinking

• Academy:
  • Workforce.
  • Survey.
• IQM.
• Lexicon.
• Research agenda.

Slide 15

Workforce

• Develop competencies for both behavioral health and primary care providers:
  • Different method, different approach.
  • National team of experts.
  • Develop plan for technical assistance.

Slide 16

• Survey small and solo primary care providers to learn what they are doing for mental health:
  • National survey.
  • Currently through OMB process.
  • Important group not often included within integration efforts.

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Uniting the Field—The AHRQ Academy for Integrating Behavioral Health and Primary Care:  Developing and Applying a Consensus Lexicon

AHRQ Annual Meeting
September 10, 2012
Bethesda, MD

C.J. Peek, PhD
Associate Professor
Dept of Family Medicine and Community Health
University of Minnesota Medical School

Image: The logo of the University of Minnesota is shown.

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Normal confusion in a new field

Example from AHRQ research agenda development conference 2009.

• "Are you saying integrated behavioral health and collaborative care are the same thing?"
• "Is that the same as co-located mental health or primary care behavioral health?"
• "What functions define integrated behavioral health—the genuine article? And what can be different from practice to practice?
• "How can we create a research agenda for PBRNs if we can't even get through a phone call without stumbling over the basic concepts in our field?

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The archetypal experience in meetings and phone calls

"We already do that..."

"... No you don't"

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To what extent can you relate to the experience of being on phone calls and meetings that get stuck on language and concepts and what is essential in a subject matter?

Image: A bar graph shows the following responses:

1. This happens all the time: 28%.
2. Happens enough to be a problem: 52%.
3. Happens enough to be a problem, but quickly resolved: 20%.
4. Rarely happens: 0%.

"Clicker" data from AHRQ presentation 2010.

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"Uniting the field" means:

• Ability to go to a meaningful scale (rather than remain in limited pockets for a few patients).
• Clarify/pull together the field so it attracts the interest of policymakers, researchers, and business modelers.
• Enough consistency of shared language across multiple stakeholders or communities so they can act in concert—or pinpoint what they disagree about).

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Communities this lexicon intends to unite:

Patients & families:

• What do I want and expect as a standard of practice?
• How would I recognize it if I saw it?
• How would I know if what I see is up to standard?

Clinician & system implementers:

• What exactly do I implement?
• What are the core functions and what do I locally adapt?

Purchasers/plans:

• What exactly am I buying?
• What do I tell employees or members what to expect for the cost?

Policymakers & business modelers:

• If asked to change rules of the game or business models, what functions need to be supported?
• Says who?

Researchers:

• What comparisons of effectiveness?
• What terms for asking consistently understood questions across PBRN's?

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For research and practice development—deal with both the empirical and the pre-empirical

Empirical:

The cat is on the mat—Is it in fact the case?

Image: A photograph show a cat sitting on a mat.

Pre-empirical:

Do we agree enough about:

• What counts as a cat?

Image: A photograph show a dog sitting on a mat.

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Pre-empirical

Do we agree enough about:

• What counts as "is on"?

Do we agree enough about:

• What counts as a mat?

Images: Photographs show a cat sprawled on the floor, partially on a mat, and another curled at the center of large Persian carpet.

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Requirements for "lexicon" development method:

1. Consensual but analytic
   (a disciplined process—not a political campaign).
2. Involving "native speakers" (in this case 24 diverse)
   (implementers and users).
3. Focused on what functionalities look like in practice
   (not just principles, values, abstractions).
4. Amenable to gathering an expanding circle of "owners" and contributors
   (not just an elite group coming with a declaration).

Method: Paradigm Case Formulation and Parametric Analysis

Ossorio (2006); The Behavior of Persons. Descriptive Psychology Press, Ann Arbor.

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Defining clauses for genuine integrated BH: A vocabulary for the uniformities

"What and how" clauses:

1. A practice team tailored to the needs of each patient and situation:
   1. With suitable range of BH and PC expertise & role functions to draw on.
   2. With shared operations, workflows and practice culture.
   3. Having had formal or on-the-job training.
2. With a shared population and mission—a panel in common with responsibility for total health outcomes.
3. Using a systematic clinical approach:
   1. Employing methods to identify individuals who need integrated BH.
   2. Engaging patients and families in need for care, kinds of care, team.
   3. Using shared decisionmaking in preparing care plans.
   4. Using an explicit unified care plan for all facets of care—in electronic record.
   5. With systematic followup and adjustment of care plans if patients not improving as expected.

Based on Peek, C.J. (2011). A collaborative care lexicon for asking practice and research development questions. One of three papers in: A National Agenda for Research in Collaborative Care: Papers From the Collaborative Care Research Network Conference. http://www.ahrq.gov/research/collaborativecare/

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Defining clauses for genuine integrated BH: A vocabulary for the uniformities

"Supported by" clauses:

4. With a community or population expecting that BH and PC will be appropriately integrated as a standard of care.
5. Supported by office practice, leadership alignment, and business model (3 subclauses).
6. And ongoing QI and measurement of effectiveness:
   1. Routinely collecting and using practice-based data to improve outcomes.
   2. Periodically examine and report provider and program level outcomes for care, experience, cost.

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"How" Parameters (examples)

1. Range of team function available:

• Foundational: (9 functions).
• Foundational plus others for the target population.
• Extended functions.

5A. Shared workflows & protocols in place?

• Protocols and workflows not in place (Not acceptable).
• Protocols and workflows in place.

5B. Level that protocols are followed:

• Less than 50% (Not acceptable).
• More than 50%, less than 100%.
• Nearly 100% (standard work).

6B. Degree that care plans implemented and followed:

• Less than 40% (Not acceptable).
• More than 50%.
• Nearly 100%.

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"Supported by" Parameters (examples)

8. Level of community expectation for integrated BH/PC:

• Little or none (defined).
• Expected in pockets (defined).
• Widely understood and expected.

9. Level of office practice design & reliability:

• Non-systematic (not acceptable)
  Non-standard processes vary by individual & day.
• Partially routinized
  Some standards set for some processes.
• Standard work
  Whole system operates in standard expected way.

11. Level of business model support:

• Integrated BH not fully supported (defined).
• Integrated BH fully supported (defined).

12. Scale of practice data collected, used:

• Minimum (defined).
• Partial (defined).
• Full/standard work.

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Lexicon Applications

(Behavioral health integrated in primary care)

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Implementation: Lexicon Applications

(Behavioral health integrated in primary care)

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Lexicon/operational definition projects to date

What's next?

• Adaptive leadership (Heifetz) applied to patient self-management (Duke)?
• Team care?
• Essential convening functions of regional convening QI organization (ICSI and others)?

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Integration Quality Measurement Atlas

Neil Korsen, MD
AHRQ Annual Meeting
September 10, 2012

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Purpose of Atlas Project

• To create a resource for those doing research, evaluation, or quality improvement related to behavioral health integration in primary care.
• To collect quality measures related to integration in one convenient Web site.
• To identify domains related to integration for which new measure development would be desired.

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Atlas Development Process

Image: Four text boxes in a row show the following process: Lexicon → Performance Domains → Measurement Constructs → Measures.

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Environmental Scan

• Search strategy was guided by the following:
  • Lexicon definition.
  • Measures in the public domain.
  • Measures published since 2001.
• 28 measures identified.

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Web Functionality

• Interactive and engaging:
  • Walk through for user.
  • Links among measures, domains, and constructs.
  • Information provided for each measure.

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Challenges

• Why behavioral health and not mental health?
• Isn't this just measuring 'good health care'?
• Why aren't we listing all the behavioral health outcome measures?

Slide 39

Additional NIAC-related projects

• Workforce competencies:
  • Observation of exemplary integrated practices.
• Survey of small primary care practices.