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Psychiatry in an ACO An Example from the Frontlines

Psychiatry in an ACO An Example from the Frontlines . Arthur E. Kelley, MD Medical Director, Partnership for Community Care (CCNC) Psychiatric Consultant, Cornerstone Healthcare, High Point, NC. The Context. Source: naviglinlp.blogspot.com.

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Psychiatry in an ACO An Example from the Frontlines

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  1. Psychiatry in an ACOAn Example from the Frontlines Arthur E. Kelley, MD Medical Director, Partnership for Community Care (CCNC) Psychiatric Consultant, Cornerstone Healthcare, High Point, NC

  2. The Context Source: naviglinlp.blogspot.com

  3. Primary Care: the De Facto Mental Health SystemNational Comorbidity Survey Replication Treated in Primary Care 23% Treated in MH System 18% Wang et al, Arch. Gen. Psychiatry, 63, June ,2005 Untreated 59%

  4. Co-Morbidity Percentages 2001-2003

  5. CANCER 10-20% DEPRESSION Chronic Pain 40-60% NEUROLOGIC DISORDERS 10-20 % GERIATRIC SYNDROMES 20-40 % DIABETES 10-20 % HEART DISEASE 20-40% University of Washington AIMS Center

  6. No Health Without Mental Health From: Center for Health Care Strategies, 2010

  7. LACK OF ACCESS Half of the Counties in US Have No Practicing Psychiatrist or Psychologist Source: Unutzer, Psychiatric News, November 1, 2013

  8. Changing Healthcare Environment Source: www.wcorha.org

  9. PCMH The main vehicle for the coming change. PCSP The medical “neighborhood”

  10. Impact Model for Collaborative Care of Depression in Primary Care Source: www.uwaims.org

  11. Core Components of Collaborative Depression Care Adapted from AIMS Center, Univ. of Washington

  12. Collaborative Care Improves Outcomes “ Comparative Effectiveness of Collaborative Care Models For Mental Health Conditions Across Primary, Specialty and Behavioral Health Settings: Systematic Review and Meta-Analysis” Am. J. Psych.,169(11), Aug 2012 Statistically Significant Effects Across All Mental Disorders For: • Clinical Symptoms • Mental Quality of Life • Physical Quality of Life • Social Role Functioning WITH: NO NET INCREASES IN TOTAL HEALTH CARE COSTS

  13. Lowers Healthcare Costs for Patients with Depression • Impact Study : $841 per annum/per patient over 4 years • Diamond Study: $1300 per annum/per patient over 4 years Unutzer, Harbin, Schoenbaum. and Druss, CMS Information Resource Center Brief,, 2013

  14. Lowers Costs for Other Disorders • Diabetes and Depression • Panic Disorder • SPMI Patients Katon et al, Diabetes Care. June 2008:31(6): 1155-1159 Katon et al, Archives of General Psychiatry. December 2002: 59(12): 1098-1104 Druss et al, American J. of Psychiatry. November 2011: 168(11): 1171-1178

  15. Cornerstone Care Outreach Clinic Our Team David Talbot, MD, Director Eileen Weston, NP, Clinician Mary Keever, LCSWA, Behavior Health Care Mgr. Art Kelley, MD, Consulting Psychiatrist Our Patients: Medicaid, Medicare, or Dually Eligible Current Enrollment: 360 (10/31/2013) Other Clinicians

  16. Our Experience • Importance of our tweaked EHR (Allscripts) • Screening Issues • The Registry • Triage Issues

  17. Our Statistics: Definitions • Positive PHQ-9 : score of > 10 • Response: 50% improvement in PHQ-9 score • Remission: PHQ-9 score of < 5 • Usual care: 20% of treated patients achieve a response. Source: Rush et. al.,Biological Psychiatry. 2004: 56(1): 46-53

  18. Our Results PROTOCOL PATIENTS (N=33) 48% achieved response or remission

  19. Non-Protocol Patients • 88 (73%) of patients with positive PHQ-9 did not enter the depression protocol • Reasons: 1. Depression comorbid with another disorder too complicated for primary care 2. Already under psychiatric care 3. Refused 4. Lost to follow-up

  20. Future Issues for CCOC • Is response/remission in 48% good enough? • How to improve medication/psychotherapy adherence. • What are the characteristics of good community partners in terms of referral? • Can we improve our numbers in regard to patients accepting Impact Model care? • Can we improve the medical numbers?

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