Pilot Survey of Approaches to Integrated Care in Solo & Small Primary Care Practices

1. Pilot Survey of Approaches to Integrated Care in Solo & Small Primary Care Practices Collaborative Family Healthcare Association 16th Annual Conference October 16-18, 2014 Washington, DC Session 3b October 17, 2014

2. Co-Authors • Vasudha Narayanan, MA, MBA, MS. Associate Director Westat • Paul Weinfurter, MSPH Sr. Study Director Westat • Benjamin F. Miller, PsyD Department of Family Medicine University of Colorado School of Medicine • Garrett Moran, PhD Vice President Westat

3. Acknowledgements • National Integration Academy Council • Agency for Healthcare Research and Quality

4. Faculty Disclosure • We have not had any relevant financial relationships during the past 12 months.

5. Learning ObjectivesAt the conclusion of this session, the participant will be able to: • Identify potential barriers to behavioral health integration due to lack of access to behavioral health providers • Discuss what steps can be taken to overcome these barriers

6. Learning Assessment • We will hold a question and answer/ discussion at the end of this presentation.

7. What is Integrated Care Integrated behavioral health care is the care a patient experiences as a result of a team of primary care and behavioral health clinicians, working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population. This care may address mental health and substance abuse conditions, health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stress-related physical symptoms, and ineffective patterns of health care utilization

8. Goal Of This Study To understand how PCPs in solo and smaller practices manage behavioral health conditions

9. Why Is This Important • 72 percent of all Americans make an average of 6 office visits to an ambulatory primary care setting each year (Bernstein et al 2003) • Primary care is the logical basis of an effective health care system (IOM 1996) • Ultimately good care is “whole person” care

10. Study Methods • Qualitative methods to design a pilot survey • Mixed method data collection • Quantitative data from survey • Qualitative data from in-depth follow-up interviews

11. Who did we talk to? • Sample frame • National Plan and Provider Enumeration System • Providers with a National Provider Identifier (NPI) value • Subset to 10 states • Primary Care Practices • Restricted to Internal Medicine and Family Medicine Practitioners • Solo and Small • Defined a “small” practice as a practice with fewer than 10 total health care providers

12. Response • 33% response rate • 215 completed eligible surveys • 21 in-depth follow-up interviews • Data have been weighted • Results should not be used to make inferences about physicians across the country.

13. Profile of Responding Physicians Source: 2013 Survey of Behavioral Health Care in Solo and Smaller Primary Care Settings. Colorado, California, Maine, North Carolina, Texas, Maryland, Virginia, Louisiana, Illinois, Kansas

14. Physicians’ Practice Staffing • 87% of PCPs include other, non-physician health care providers • 21% share practice with behavioral health providers

15. Treatment • Nearly all PCPs • treat with medication • refer patient to a behavioral health provider • PCPs also treated patients by counseling them

16. Screening • 79% systematically screen for behavioral health conditions • 87% systematically screen for chronic physical conditions • 74% have a systematic process to screen for both chronic physical and behavioral health conditions • 8% have no systematic process for either conditions

17. Treatment: Adoption of evidence-based standards

18. Steps taken by PCPs during care of patients with behavioral health care needs

19. Treatment: Referral

20. Treatment: Care Coordination • 69% of PCPs require their patients to be responsible for their own coordination and follow-up • 11% have a care manager or social worker in place to coordinate needed care for patients • 20% coordinate the follow-up directly with the behavioral health provider • 53% of practices with an onsite behavioral provider have a process for care coordination • 25% practices with no onsite behavioral provider have a process for care coordination

21. Working in Care-Teams • A quarter of PCPs do not work in care teams • Of those who do work in care teams: • 88% agreed that collaboration within teams results in better decisions around patient care • 68 % disagreed that involvement of multiple team members increases the likelihood of medical errors • 66% disagreed that the team process creates a burden for the care team • Almost all PCPs agreed they are responsible for behavioral care of patients

22. Feedback loop– Referral and Care Coordination • An onsite behavioral care provider improves • frequency of feedback • 99% of the time vs. 70% of the time • frequency of verbal conversations • 64% vs. 28%

23. Providing Behavioral Care – Shared Decision Making • An onsite behavioral provider does not appear to change how PCPs share decisions with patient and/or patient’s families • 57 % vs. 54%

24. Conclusions • PCPs agreed they are responsible for behavioral care of patients • Co-location improves the ability of the PCP and behavioral care provider to communicate and collaborate • However, co-location alone does not equal integrated care • This pilot study will be able to guide the development of a national survey of PCPs

25. Limitations • The results are not generalizable to the entire United States • The small sample size prohibits analyzing subsets of the data and doing specific meaningful analyses

26. Q&A • When you refer patients to behavioral health providers what is the system for care coordination and follow-up? • How do you receive feedback from the psychiatrist or other behavioral health provider? • How often do you and the behavioral health provider work together to make decisions about the patient’s treatment plan? • There are a number of other standardized models for treating behavioral health conditions. Do you use any standardized model?

27. Contact information • Vasudha Narayanan email: VasudhaNarayanan@WESTAT.com; phone: 301-294-3808 • Paul Weinfurteremail: PaulWeinfurter@WESTAT.com; phone: 714-262-1856

28. Thank you for participating.