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Keynote: Proven Strategies to Advance Integrated Care in the Latino Community
The document discusses the 9th Annual Latino Health Forum, highlighting the importance of collaborative care in improving mental health treatment outcomes within Latino communities. It emphasizes the disparities in mental health care access and efficacy, presenting collaborative care as an effective model to enhance patient-centered treatment and accountability. The initiatives have shown significant improvements in depression management and patient satisfaction across diverse populations in Washington State.
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Keynote: Proven Strategies to Advance Integrated Care in the Latino Community
- 1. Sea Mar CommunityHealth Centers Presents 9th Annual Latino Health Forum Proven Strategies to Advance Integrated Care in the Latino Community Anna Ratzliff, MD, PhD Assistant Professor Associate Director for Education, Division of Integrated Care & Public Health Department of Psychiatry & Behavioral Sciences University of Washington
- 2. Disclosures • ConsultingPsychiatrist Contract, Community Health Plan of Washington • Supported from contracts and grants to the AIMS Center at the University of Washington
- 3.
- 4. Mental health disordersare common – who gets treatment?
- 5. The other 9patients. No Treatment Primary Care Provider Mental Health Provider Wang et al 2005
- 6. Disparities in DepressionCare for Minority Populations • Worse access to mental health treatment1 • Less likely to be identified2 • Less likely to receive antidepressant medications 3 • Have worse outcomes 4 1- Miranda et al. Am J Psychiatry. 2008 Sep;165(9):1102-8. 2- Borowsky et al J Gen Intern Med. 2000 Jun;15(6):381-8. 3- Miranda J, Cooper L. J Gen Intern Med 2004; 19: 120-6. 4- Van Voorhees et al Med Care Res Rev. 2007 Oct;64(5 Suppl):157S-94S.
- 7. Why not justrefer? ½ do not follow through 2 visit mean Grembowski, Martin et al. 2002 Simon, Ding et al. 2012
- 8. Why not justrefer? Thomas KC et al, 2009 1 in 5: unmet need for non-prescribers 96%: unmet need for prescribers
- 9. Is there abetter way? Yes - Collaborative Care! http://aims.uw.edu/daniels-story-introduction-collaborative-care
- 10. Principle 1: PatientCentered Team Care PCP Patient BH Care Manager Core Program Psychiatric Consultant New Roles
- 11. Principle 2: PopulationBased Treatment
- 12. Principle 3: MeasurementBased Treatment To Target
- 13. Principle 4: Evidence-BasedTreatment
- 14. STAR-D Summary Level1: Citalopram ~30% in remission Level 2: Switch or Augmentation ~50% in remission Level 3: Switch or Augmentation ~60% in remission Level 4: Stop meds and start new ~70% in remission Rush, 2007
- 15.
- 16. Pay-for-performance cuts mediantime to depression treatment response in half. 0.00 0.25 0.50 0.75 1.00 0 8 16 24 32 40 48 56 64 72 80 88 96 104 112 120 128 136 Weeks Before P4P After P4P Unützer et al. 2012.
- 17. Collaborative Care: TheResearch Evidence • Now over 80 Randomized Controlled Trials (RCTs) • Meta analysis of collaborative care (CC) for depression in primary care (US and Europe) Consistently more effective than usual care • Since 2006, several additional RCTs in new populations and for other common mental disorders • Including anxiety disorders, PTSD Archer, J. et al., 2012
- 18. Doubles Effectiveness ofCare for Depression % 50 % or greater improvement in depression at 12 months Usual Care IMPACT 1 2 3 4 5 6 7 8 Participating Organizations 70 60 50 40 30 20 10 0 Unützer et al., JAMA 2002; Psych Clin North America 2004
- 19. IMPACT Care Benefits Disadvantaged Populations 50 % or greater improvement in depression at 12 months 43% 54% 42% 19% 23% 14% 60% 50% 40% 30% 20% 10% 0% White Black Latino IMPACT Care Care as Usual Arean et al. Medical Care, 2005
- 20. IMPACT: Summary 1)Improved Outcomes: • Less depression • Less physical pain • Better functioning • Higher quality of life 2) Greater patient and provider satisfaction 3) More cost-effective “I got my life back” THE TRIPLE AIM
- 21. MHIP: > 30,000clients served across Washington State 2008 Pilot initiated in King & Pierce Counties 2009 Expanded state-wide to over 100 CHCs and 30 CMHCs •Funded by State of Washington and Public Health Seattle & King County (PHSKC) • Administered by Community Health Plan of Washington and PHSKC in partnership with the UW AIMS Center
- 22. MHIP High-Risk MothersProgram • Low income women who are pregnant or parenting • Community health clinics in King County • Identified by primary care provider with mental health care need • Enrolled in Collaborative Care
- 23. MHIP High-Risk MothersProgram Outcomes 70 60 50 40 30 20 10 0 % of Population with Depression Improvement All Latina White Black Asian Huang et al. Family Practice 2012 20:394-400.
- 24.
- 25. Daniel’s Mom “Ibelieve it it’s made all the difference for him.”
- 26. Menu of InspirationOptions Patient Centered Team Population Based Care Measurement-Based Treatment to Target Evidence-Based Treatment Accountable Care •Use patient centered goals. •Communication with other providers. •Track patient outcomes. •Set a practice improvement goal. •Participate in continuing ed. •Form a learning collaborative. • Use screeners regularly. •Track patient goals regularly. •Use a registry. •Lead efforts for implementation.
- 27. Acknowledgments: Daniel andhis family Annie McGuire Angel Mathis Rebecca Sladek Jürgen Unützer AIMS Center Staff www.aims.uw.edu
Editor's Notes
- #4 Tales from the Collaborative side. Daniel is one of my patients and has given me permission to share his story. Daniel came into the clinic with depression and anxiety. He was struggling to make it through each day but he had dreams for a better life and came to get help. How many of you see patients? How many of you have had a patient like Daniel – coming into the clinic wanting to get better? Patients like Daniel are why I am so patient about my work as a consulting psychiatrist in a Collabotive care. This is the tale of my work in Collaborative Care and with it I hope to do two things:
- #5 2/10 see a psychiatrist or psychologist 4/10 receive treatment in primary care ~ 30 Million with an antidepressant Rx but only 20 % improve
- #6 2/10 see a psychiatrist or psychologist 4/10 receive treatment in primary care ~ 30 Million with an antidepressant Rx but only 20 % improve
- #8 When patients are referred to mental health specialists by a primary care provider, almost half do not follow through (Grembowski, Martin et al. 2002 ) Even when they do go, the mean number of appointments is 2 visits
- #9 County-Level Estimates of Mental Health Professional Shortage in the United States Kathleen C. Thomas, M.P.H., Ph.D.; Alan R. Ellis, M.S.W.; Thomas R. Konrad, Ph.D.; Charles E. Holzer, Ph.D.; Joseph P. Morrissey, Ph.D. Psychiatric Services 2009; doi: 10.1176/appi.ps.60.10.1323 1 in 5 - unmet need for non-prescribers 96% unmet need for prescribers Nearly one in five counties (18%) in the nation had unmet need for nonprescribers. Nearly every county (96%) had unmet need for prescribers and therefore some level of unmet need overall. Rural counties and those with low per capita income had higher levels of unmet need. Results Over three-quarters (77%) of U.S. counties had a severe shortage of mental health prescribers or nonprescribers, with over half their need unmet. Eight percent of U.S. counties had a severe shortage of nonprescribers, with over half of their need unmet. Almost one in five counties (18%) in the nation had at least some unmet need for nonprescribers. Seventy-seven percent of U.S. counties had a severe shortage of prescribers, with over half of their need unmet. Nearly every county (96%) had at least some unmet need for prescribers. Table 1 provides statistics on the percentage of need unmet at the county level. Ordinary least-squares regression of the percentage of county overall need unmet as a function of county characteristics indicated that rurality and per capita income were the best predictors of unmet need (R2=.34). A 1-point increase in rurality on the 9-point Rural-Urban Continuum Code corresponded to an increase in unmet need of 3.3 percentage points. A $1,000 increase in per capita income corresponded to a decrease in unmet need of 1.3 percentage points.
- #10 Tales from the Collaborative side. Daniel is one of my patients and has given me permission to share his story. Daniel came into the clinic with depression and anxiety. He was struggling to make it through each day but he had dreams for a better life and came to get help. How many of you see patients? How many of you have had a patient like Daniel – coming into the clinic wanting to get better? Patients like Daniel are why I am so passionate about my work as a consulting psychiatrist in a Collaborative care. This is the tale of my work in Collaborative Care and with it I hope to do two things: give you a better sense of what this work is like and inspire you to consider using the principles of collaborative care in your work
- #11 Through Daniel’s story I will ntroduce you to 5 principles that define Collaborative care: Patient Centered Team Care - How many of you practice patient centered care ? Is your system provider centric or patient centric? This model is set up around where the patent is used to getting care. Daniel told me he never would have made it to get behavioral health treatment without it being right there in the clinic. We also focus on patient centered goals. Care team support each other to care for the patient. Two new roles: Care manager and psychiatric consultant – we will talk more about these roles in later slides
- #12 Annie entered Daniel information into a registry like this. This an important tool to define the population of patients being treated. Allows providers to quickly see who is improving and who might need treatment adjustment. Also make sure no one falls through the cracks. Each row is a single patient. If you look at the column that the blue arrow is pointing to, it shows the PHQ-9 score at the last follow-up contact. All of the columns are sortable by clicking on the column heading. This screen shot shows how I sorted by caseload by PHQ-9 score so that the highest score at last follow-up is shown at the top of the list and then in descending order. This allows me to quickly and easily see those patients who are not doing well. As with the reminders page we just looked at, when the measurement of clinical outcomes (in this case the PHQ-9) is not at least 50% lower than the score at the time treatment was initiated, the score shows up in red. You can see this with the top rows. If the score is at least 50% lower than baseline or under 10 it shows up in black, which you can see by looking in the middle.
- #13 Having Daniel complete a PHQ-9 and GAD7 were part of every visit. Daniel initial struggled with depression but as this improved he began to report more anxiety and difficulty concentrating. We were able to share his graphs with him to help identify interventions that were helpful as well as remind him of how much he had improved. This concept of picking a target and systematically working toward it is a core feature of Collaborative Care.
- #14 I serve as the mental health expert for the team providing information on both evidence based medications as well as brief behavioral interventions.
- #15 We use common treatment protocols, such as the information from Star-D to inform our care. Sequenced Treatment Alternatives to Relieve Depression The STAR-D trial provides evidence that measurement based care and systematic adjustment of treatment will lead to higher remission rates (70some % remit after several steps as opposed to 40 % with the initial trial of citalopram), but without systematic measurement and treatment adjustment, we miss too many opportunities to make the right kinds of treatment changes. 4,041 outpatients, ages 18-75 years, from 41 clinical sites around the country, which included both specialty care settings and primary medical care settings. Participants represented a broad range of ethnic and socioeconomic groups. All participants were diagnosed with MDD and were already seeking care at one of these sites. No media advertisements were used to recruit participants. Treatment Choices Throughout STAR*D LEVEL1 – All participants were treated with citalopram (Celexa) Those who went into remission (e.g., they became well) Those who did not get well, went on to Level 2 Went into follow-up LEVEL 2 – Switching treatments or adding to citalopram (Celexa) Those who chose to switch treatments were randomized to: • sertraline (Zoloft), • bupropion-SR (Wellbutrin), • venlafaxine-ZR (Effexor), or • cognitive behavioral therapy (CBT) Those who chose to add treatment were randomized to: • bupropion-SR (Wellbutrin), • buspirone (BuSpar), or • cognitive behavioral therapy (CBT) Those who did not get w e ll w ent on to Level 3 LEVEL 3 – Switching treatments or adding to existing medication LEVEL 4 – Switching treatments Those who became well w ent into follo w - up Those who chose to switch treatments were randomized to: • mirtazapine (Remeron) or • nortriptyline (Aventyl or Pamelor) Those who became well w ent into follo w - up Those who chose to add treatment were randomized to: • lithium or • triiodthyronine (T3) Those who did not get w e ll w ent on to Level 4 Participants were taken off all ot her medications and randomized to: • tranylcypromine, an MAOI (Parnate) or • venlafaxine XR (Effexor XR) + mirtazapine (Remeron) Another reason to learn about measurement is that increasingly, health plans will tie payment to achieving measurable improvements in outcomes. for example, one of the quality measures in the new ACO arrangements UW medicine is negotiating with payers is based on PHQ-9 measured remission rates ... and if we cannot demonstrate that, we will get paid less.
- #16 I think accountability is the principle that has shaped my practice the most. I now feel responsible to not only know how the population of patient I serve is doing but to commit to continuous quality improvement to deliver care
- #19 18
- #22 Funded by State of Washington and Public Health Seattle & King County (PHSKC) Administered by Community Health Plan of Washington and PHSKC in partnership with the UW AIMS Center Initiated in 2008 in King & Pierce Counties & expanded to over 100 CHCs and 30 CMHCs state-wide in 2009. Over 25,000 clients served.
- #25 One of the biggest challenges is that starting a Collaborative Care implementation is a huge undertaking requiring systematic change. After working in collaborative care, I returned to work in a more traditional co-located practice. This provided both a challenge an opportunity. I did not have access to many of the systems level support I had in Collaborative Care. This made me think more about what principles could I still practice. I am hoping that you can also think about thes ideas and how they may apply to your own practice?