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San Diego Long Term Care Integration Project (LTCIP)

San Diego Long Term Care Integration Project (LTCIP). Mental Health & Substance Abuse Workgroup September 23, 2003. Community Planning Process. Grass-roots effort to improve system of care for long term care consumers and providers

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San Diego Long Term Care Integration Project (LTCIP)

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  1. San Diego Long Term Care Integration Project (LTCIP) Mental Health & Substance Abuse Workgroup September 23, 2003

  2. Community Planning Process • Grass-roots effort to improve system of care for long term care consumers and providers • From 50 to 550+ key stakeholders over past 4 years: 10,000+ hours • Agreement to use existing providers, assure fair compensation • Planning within state LTCIP authorization, AB 1040 (form follows funding)

  3. Long Term Care Integration Project Organizational Chart & Decision Tree San Diego County Board of Supervisors & State Office of Long Term Care Rodger G. Lum, Ph.D,Director County of San Diego, Health & Human Services Agency, (HHSA) • Internet • Facilitates communication • Provides broad public education Pamela B. Smith, Project Director Evalyn Greb, Project Manager Aging & Independence Services Lead County Agency Advisory Group: Goal: Make final decisions and recommendations for inclusion in the plan. Planning Committee: Goal: Guide the LTCIP planning process. Suspended Workgroups pending service delivery model decision Health Plan Workgroup Finance/Data Workgroup Options Workgroup Mental Health Workgroup Developmental Disabilities Workgroup Incremental LTCI Strategies: 1) Network of Care 2) Physician Strategy 3) Health Plan Pilots Make recommendation to PC re: inclusion of persons with developmental disabilities in LTCIP. Determine the financial feasibility of the proposed LTCIP for San Diego County. Make recommendation to Planning Committee re: inclusion of mental health and substance abuse services in LTCIP. Explore use of the Healthy San Diego model for potential Service delivery system for LTCIP. Governance -Case Management -Info/Technology -Quality Assurance -Scope of Services -Workforce Issues -Community Network Development 8/2003 www.sdcounty.ca.gov/cnty/cntydepts/health/ais/ltc/

  4. Legislative Authority • AB 1040 in 1995 (revised in 1998) • State Office of LTC: • provides planning $$ • provides “Center” resources • provides liaison with other state programs • approves local activity toward LTCI • will assist in procuring federal waivers

  5. San Diego LTCIP Stakeholder Vision for Elderly & Disabled • Develop “system” that: • provides continuum of all health, social and support services that “wrap around consumer” w/prevention & early intervention focus • pools associated (categorical) funding • is consumer driven and responsive • expands access to/options for care

  6. Stakeholder Vision (continued) • Fairly compensates all providers w/rate structure developed locally • Engages MD as pivotal team member • Decreases fragmentation/duplication w/single point of entry, single plan of care • Improves quality & is budget neutral • Implements Olmstead Decision locally • Maximizes federal and state funding

  7. Why change? • Impact of demographics • Cost containment vs. care management • Consumer/outcomes not current focus • Incentives for optimum care not aligned • Health & support service fragmentation

  8. From Vision to Service Delivery Model…

  9. From Vision to Service Delivery Model… • Explore Healthy San Diego due to: • Access, education, prevention • Advocacy • Cost-effectiveness • Population-based • Existing infrastructure • Stakeholder-designed, BUT

  10. HSD Currently Does NOT… • Tailor the program for chronic care or aged and disabled persons • Provide “wraparound” services • Provide chronic care management on a population basis • Receive adequate reimbursement for chronic care • Have much info on “duals”

  11. Where are we now? • BOS: “come back with 3 options” • Dr. Mark Meiners strategies/looking for “consortium of funding”: • Network of Care • Physician Strategy • HSD Health Plan/Pilot Projects • Administrative Action Plan for FY 2003-04 State Development Grant • Establishment of Mental Health Workgroup

  12. Why should mental health stakeholders get involved? • To influence planning and decisions • To impact delivery of acute & LTC needs of individuals (support+services) • To recommend to include mental health and substance abuse service integrated with primary, acute, and social support

  13. Mental Health Today • Current Medi-Cal carve-out (UBH) • Limited Medicare reimbursement • LTCIP stakeholders want no carve-outs • Mental health problems under-diagnosed & under-treated • Quality of life and cost impact of untreated mental illness/substance abuse is huge • Most state integration projects do not enroll disabled w/primary MH diagnosis • Seniors do not self-identify as having MH need; don’t use MH Centers

  14. Mental Health and LTCIP • Establishment of Mental Health Workgroup to: • hear from broad array of stakeholders (132 invited!) • focus on consumer as “whole” in system • develop plan specific to San Diego and LTCIP • How do we “mainstream” mental health services for aged and disabled? • parity w/physical health for treatment • age-, disease-specific treatment • delivered as “part of the whole” • viewed within greater context of health

  15. LTCIP Mental Health Workgroup Goal • Process… • Make recommendation to Planning Committee on inclusion of mental health programs, populations, and services • Importance of consensus on a recommendation • Forward to Planning Committee by February 2004

  16. Why do we even talk about Integrating primary medical care and mental health care? Margaret E. McCahill, M.D. Clinical Professor, UCSD School of Medicine Director of Clinical Services, St. Vincent de Paul Village Diplomate, American Board of Family Practice Diplomate, American Board of Psychiatry and Neurology

  17. How do we think about diagnoses? • Axis-I: what major mental illness does the patient have? • Axis-II: what kind of patient has the illness? (P.D.’s, developmental disorders, etc.) • Axis-III: what general medical conditions does the patient have? • Axis-IV and Axis-V: interesting, and have some prognostic value, but not generally used by primary care practitioners

  18. It takes awareness of the proper treatment of all THREE axes to treat the patient effectively • The personality-disordered patient will act out more if the major depression is not treated • The diabetic will be out of control if the personality disorder or psychosis is not managed • The psychosis will be worse if the asthma, diabetes, pneumonia, etc., is not treated

  19. Multidisciplinary teams • Bring a wealth of comprehensive skills and service to the patient • are essential in many settings to be sure that the patient is receiving the correct treatment that he/she needs • However…they need to be well coordinated, and someone needs to be aware of the big picture…the overall view of the patient’s health care needs--all 3 axes.

  20. Integration is not new:From the AAFP, 11/94: • “White Paper on the Provision of Mental Health Care Services by Family Physicians” AAFP Reprint no. 714 • “After replacing its managed care firm (i.e., a “carve-out” model) with a collaborative mental health care model, a large health care delivery system reduced by 33% its overall medical and mental health costs, while retaining high consumer and provider satisfaction.”

  21. Expertise in psychiatric diagnosis • Most primary care physicians can recognize most mood disorders, anxiety disorders, psychoses • personality disorders and substance use disorders can be more difficult to recognize at first • but remember...

  22. Even for the “experts:” Psychiatric diagnosis is always a work in progress • For example, major depression is only major depression until the first episode of mania, and now its bipolar disorder • “Schizophrenia” may be an initial impression until the UDS comes back positive for amphetamines… • The challenge: how to treat the patient when the diagnosis might change…

  23. general and family physicians ? % internists ? % other specialists ? % psychiatrists ? % Is this our field of expertise? Who treats patients for depression? (Rx only)

  24. general and family physicians 56% internists 11% other specialists 10% psychiatrists 23% Is this our field of expertise? Who treats patients for depression? (Rx only)

  25. Physical Symptoms often attributed to Psychiatric illness Kroenke and Price. Arch Intern Med. 1993;153:2474.

  26. Somatic Symptoms In Mood And Anxiety Disorders Kroenke et al. Arch Fam Med. 1994;3:774.

  27. Physical Symptoms & Risk of Psychiatric Disorder % Physical Symptoms (#) Kroenke et al. Arch Fam Med. 1994;3:774.

  28. Psychiatric Disorders In Rheumatology Referrals * Prev. (%) * Psychiatric Disorder Connective Articular or Periarticular Nonarticular or Other *P<.05 O’Malley et al. Arch Intern Med. 1998;158:2357.

  29. Cumulative Mortality For Depressed And Non-depressed Patients Following Heart Attack Frasure-Smith et al. JAMA. 1993;270:1819.

  30. Cancer Site Pancreas Oropharynx Breast Colon Gynecological Reported Rates 50% 22% - 40% 10% - 32% 13% - 25% 23% Prevalence Of Depression In Patients With Cancer McDaniel et al. Arch Gen Psychiatry. 1995;52:89.

  31. Anticancer Drugs Associated With Depression • Corticosteroids • Interferon • Asparaginase • Cyproterone • Vinblastine • Vincristine • Procarbazine • Tamoxifen Massie et al. J Pain Symptom Manage. 1994;9:325.

  32. HIV Disease • Initial presentation of illness may be psychiatric symptoms • Untreated mental disorders worsen the primary illness • The medications used in treatment of HIV disease may exacerbate/cause mental illness • A presentation unto itself

  33. Psychiatric Disorders &High Medical Utilizers (n=119) Patients (%) Katon et al. Gen Hosp Psychiatry. 1990;12:355.

  34. Special problems: • Drug interactions • abuse potential of medications • compliance issues • diversion of medications • follow-up issues • interaction between mental illness and general medical conditions—both current and those that develop with time…..others…

  35. Next Steps • Sign-up to be considered for smaller stakeholder work committee • 15 stakeholders will be selected by LTCIP staff and Dr. McCahill • Formal invitation to participate in working committee by October 10 • First meeting: Oct. 21, 2003 from 2:30-4:00 at Aging & Independence Services

  36. November 2003 Mental Health Workgroup Meeting • Staff and committee work to-date presented • Option discussion by full group • Ideas for further option development • Refer back to staff and committee • Consensus development at January MH Workgroup meeting • Forward recommendation to LTCIP Planning Committee

  37. How can you influence planning? • Get on LTCIP mailing list for updates • Participate in Planning Committee and Mental Health Workgroup meetings • Log onto website for background & info: www.sdcounty.ca.gov/cnty/cntydepts/health/ais/ltc/ • Call 858-495-5428 or e-mail on-going input/ideas: evalyn.greb@sdcounty.ca.gov

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