I am like a stinging fly. I am just trying to get you to consider what is right. Socrates to the Athenians 39

1. I am like a stinging fly. I am just trying to get you to consider what is right.Socrates to the Athenians 399 BC

2. WE Collaborative Care

4. COLLABORATIVE CARESOLUTION OR PROBLEM:WHERE ARE WE GOING?CFHA October 2011 Rodger Kessler Ph.D. ABPP Director, Primary Care Behavioral Health Fletcher Allen Health Care Assistant Professor University of Vermont College of Medicine Director, Collaborative Care Research Network, NRN/AAFP Fellow, Jeffords Center for Health Care Policy University of Vermont

5. Every truth passes through three stages before it is recognized. In the first, it is ridiculed. In the second, it is opposed. In the third, it is regarded as self-evident. Schopenhauer

6. Collaborative care is: Brilliant Irrelevant It is its own silo - outside of mainstream primary care, substance abuse and health behavior Not evidence cost or outcome driven Not engaged with commercial insurers, thus creating a 2-tiered health care system. Again. • Lots of it • Creative people and programs • Getting great public relations • Has much greater penetration than other health care disciplines like pharmacy or dentistry • The national organization is rapidly growing

7. “The significant problems we face cannot be solved by the same level of thinking that created them.” A. Einstein

8. Do not ask for more - You need to: • Improve quality at no additional cost or demonstrate reduced cost • Provide results demonstrating outcomes to policy makers and decisions makers based on rigorous data and research • Identify the processes that are crucial for success Melinda Abrams Vice President of the Commonwealth Fund Speaking October 21st at PCPCC meeting

9. How to do it? At a minimum… • Missouri Health Home Medicaid Integrated Primary Care Behavioral Health Project • 23.9% net program savings Sub sample of 50 patients • $180 dollars PMPM annual overall total health care costs Peikes and Mertz PCMH What do we know? AHRQ Annual Meeting

10. The Field Needs: Common, Agreed Upon Metrics • Measurements that produce summarized data for various stakeholders that describe the function or performance of a group of patients, a practice or group of practices or elements of practice or patient activity around which to make decisions on policy, funding, resource allocation and their continued use.

11. Clinical, Operational and FinancialDimensions: Integrated PCBH care is… All three at the same timeC.J. Peek

12. What Is Primary Care Behavioral Health? • A method of organizing care delivery to specific clinical populations with specific interventions • The organization and delivery of care using the same processes as the primary care practice (i.e. Time of sessions, Scheduling, EHR, metrics) • Evidence based clinical care • Provided by clinicians with specific training in primary care behavioral health • Operates within the existing work flow of the care delivery site

13. Which Populations Should Be Served?

14. Panel Based Range of Need for Collaboration in the Patient Centered Medical Home (Kessler & Miller, 2009)

15. Mental Health Substance Abuse Health Behavior

16. Silos • Exist in the specialty care system • Exist in collaborative care • Exist in training and clinician recruitment • Exist in primary care perception • Are expensive • Ignore greatest impact and cost areas of care • Exist at NIH where SAMHSA and HRSA are generally not even at the table • The Silo of Health Behavior and its inattention within collaborative care is a significant reason for the disconnect between NIH focus and cc • In general, CC is certainly not taken seriously in PCMH’s

17. Results - PCMH Support Systems for MH, SA & Health Behavior • Clinician part of practice Psychiatry 16% Psychology 22% Social Work 25% SA 09% Care Manager 62% • Scheduling same as other providers 36% • Same day appointments 28% • EB protocols for MH,SA 20% • EB protocols for HB rated as working well Headaches 11% Insomnia 13% Obesity 23% Smoking 37% • MH,SA, HB results in EHR rated as working well35% Kessler et al., in preparation

18. Cost • Cost of delivering the intervention • Cost because of delivering the intervention • Costs savings in the future if intervention is effective

19. The Ultimate Question • What are the cost and clinical consequences of responding to patient behavioral and health behavior needs done by whom to which patients generating what outcomes at what cost?

20. The Paradigm Case of Collaborative Care Metrics

21. The Elements of the Paradigm CasePeek Kessler Miller 2011 • A defined team • Shared population and mission • A defined clinical system • Office practice and financial system support • Evidence of continuous quality improvement and effectiveness measurement

22. Elements to be measured and metrics Miller BF, Kessler R, Peek CJ. A National Agenda for Research in Collaborative Care: Papers From the Collaborative Care Research Network Research Development Conference. AHRQ Publication No. 11-0067. Rockville, MD: Agency for Healthcare Research and Quality. June 2011

24. If you are going to measure with metrics you need to first know what you are measuring…The NIH core measures

25. Identifying Practical Patient-Report Measures for the Electronic Health Record • Rationale: One thing is missing from all the investment and advances in EHRs—patient reports • Scope: 13 areas most commonly encountered in adult primary care related to: • Health Behaviors: tobacco, healthy eating, medication adherence, physical activity, substance use • Psychosocial Factors: • Outcomes: quality of life, depression, anxiety, sleep, stress/distress • Influences: health literacy/numeracy, patient goals and preferences, demographics • Glasgow 2010

26. RECOMMENDED Common Data Elements

27. You Gotta Walk the Walk – Work in progress

28. For Futurists and Early Adapters:What We Did in New York City There are ongoing conversations with originally 9, now 14, national commercial insurance executives about: • What would we all agree behavioral health in primary care should look like? • What would it take in a multi-company project to design, pilot and test a common model of primary care behavioral health? • My colleague Bill Hancur from Rhode Island BC and I are heading this up and will: • Identify primary care practices or systems of practices who want to collaborate and – • Turn the idea into Foundation proposal to generate support for the project

29. The Collaborative Care Checklist v 1.0Kessler and Colleagues

30. The Collaborative Care Checklist v 1.0Kessler and Colleagues

31. Primary Care Behavioral Health Implementation Research Project • NIH R-01 application between the University of Vermont, the Robert Wood Johnson Medical School, The National research Network of the AAFP, and the CCRN • Mixed method Pragmatic Clinical Trial • Two conditions, PCBH and IMPACT • Full RE-AIM evaluation • 3 dimension economic analysis cost, cost effect/offset, projected future cost savings

32. Rodger, this seems a little daunting…What are the next steps??

33. The Kessler 555 Plan

34. The 5 5 5 Plan A Five Year Moratorium on Five Areas of Collaborative Care • New Collaborative Care Practices • New hiring of Collaborative Care Clinicians • Consultants advising practices on Collaboration • Collaborative Care Training programs • National Collaborative Care Meetings Unless any of the above can meet the following Five Criteria

35. Minimum Five Activities for Collaborative Care Practice, Consultation and Training • Evidence of continuous process and quality improvement training and projects • PCBH seamless inputting and cross sharing of EHR data • PCBH clinicians trained in process improvement • PCBH clinicians trained in substance abuse and co-occurring disorders and evidence based Health Behavior interventions • PCBH clinicians trained in and participating in clinical research and business and financial management

36. The Benefits of the 5 5 5 Plan • It will create new jobs and eliminate those that are not producing • It will impact the health care economy and lower some costs of care • Finally - it will get us on the right track and restore the greatness that is the promise of collaborative care So in closing I say to you in this great city of Philadelphia

37. Pass This Plan! Pass this plan in your thinking Pass this plan in your practices Pass this plan in your hiring Pass this plan in your training programs Pass this plan in your professional organizations

39. Questions and Comments ? Rodger Kessler, Ph.D. ABPP Rodger.Kessler@uvm.edu http://www.aafp.org/online/en/home/clinical/research/natnet/get-involved/ccrn-info.html