Rodger Kessler Ph.D. ABPP Director, Primary Care Behavioral Health Fletcher Allen Health Care

1. 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 Mental Health, Substance Use and Health Behavior Services in the Patient Centered Medical Home: A National SurveyPCPCC Behavioral Health Working Group, December 2011

2. Additional authors Wilson Pace M.D., Debbi Graham M.P.H. National Research Network Benjamin Miller Psy.D. Collaborative Care Research Network Sarah Scholle Ph.D.,Manasi Tiradkar Ph.D. NCQA Benjamin Littenberg M.D., Amanda Kennedy Pharm.D.,Charles Maclean M.D. University of Vermont

3. Background Primary care practices are increasingly integrating mental health, substance abuse, and health behavior services. The American Academy of Family Practice recently adopted principles for integrating behavioral health care into the patient-centered medical home (PCMH). We currently know very little about how PCMHs integrate behavioral health care.

4. Research Questions Do Patient Centered Medical Homes have organizational and clinical systems to provide behavioral and health behavior care? How does this compare to practice systems for other health care and health care providers? What are the key identified barriers? Is level of NCQA certification associated with organizational or clinical systems?

5. Method NCQA and CCRN developed a 20 item survey of clinical leaders concerning organizational and clinical activities related to Behavioral Health in PCMH. Sampling frame: All 447 NCQA certified practices as of March 2010 were identified. One practice per multi site organization was selected leaving a sample of 238 surveyed. The survey was administered via email then mail with phone follow-up. Approved by AAFP IRB

6. Sample • N= 123 (52%)* • PCMH level • 1 =37% • 2 =07% • 3 =56% Location East =67% Midwest =20% South =06% West =06% *No significant differences between responders and non responders • <5 providers =55% • Multi site =17% • FQHC =06% • Practice Specialty Category • IM =22% • FM =41% • Peds =06% • Adult Peds =14% • FP & Peds =12% • Other =05%

7. 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% • Evidence Based protocols for Mental Health, Substance Abuse 20% • EB protocols for Health Behavior rated as working well Headaches 11% Insomnia 13% Obesity 23% Smoking 37% • MH,SA, HB results inEHR rated as working well 35%

8. Results - How Processes Compare with Other Specialties Standard process for referrals that works well • Cardiology 73% • Endocrinology 69% • MH SA 50% Standard process to track referrals that works well • Cardiology 50% • Endocrinology 45% • MH SA 33% Standard process to share information that works well • Cardiology 72% • Endocrinology 71% • MH SA 56%

9. Results - How Processes Compare with Other Specialties Standard process for receiving consultation reports that works well • Cardiology 71% • Endocrinology 60% • MH SA 34% Standard process to schedule appointments that works well • Cardiology 69% • Endocrinology 66% • MH SA 40%

10. Results - Identified Barriers • 92% Lack of Time • 91% Reimbursement Issues • 74% Lacked Expertise

11. Results - Does NCQA certification level Affect Behavioral Health Clinical and Organizational Improvements? MH organizational index Mean=12.3 Level 3=12.4 Level 1/2 =12.2 p= .086 MH clinical index Mean=07.6 Level 3=08.2 Level 1/2 =06.7 p= .11

12. Discussion Key findings and observations having nothing to do with data (in Vermont, opinions carry more weight than data) • There is no level playing field • There has not been structural carrot to attend to behavior • Behavioral health and medicine are still separate • Barriers, barriers, barriers • Behavioral issues in primary care recent phenomena

13. Bothersome Key Findings That Need To Be Addressed In Addition To The Other Findings That Need To Be Addressed • Within the field(s) we have silos • Behavioral Health and Health Behavior are functionally two different universes • Substance Abuse and Mental Health are two different planets • Silos

14. Mental Health Health Behavior Substance Abuse

15. Bothersome Key Findings That Need To Be Addressed In Addition To The Other Findings That Need To Be Addressed • Within the field(s) we have silos • Behavioral Health and Health Behavior are functionally two different universes • Substance Abuse and Mental Health are two different planets • Silos • Survey findings suggest these divisions exist in primary care behavioral health • Right now NIH is equally stuck

16. Limitations and Future Directions Limitations • Sample constraints • Survey instrument • Variation in who filled out survey • PCMHs are not necessarily representative Future Directions • NCQA engagement survey • Further Analysis • Robust Resurvey

17. Thank You PCPCC for Funding Support

18. We approve of this presentation And don’t forget to drink milk!...