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FRITS HUYSE Psychiater, Consulent Integrale Zorg Afdeling Algemene Interne Geneeskunde UMCG GRONINGEN Lid council Acade

Integrale zorg een blijvende ontwikkeling. FRITS HUYSE Psychiater, Consulent Integrale Zorg Afdeling Algemene Interne Geneeskunde UMCG GRONINGEN Lid council Academy of Psychosomatic Medicine USA. NFZP 9-6-2006 Universitair Medisch Centrum Utrecht. UMCG Groningen.

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FRITS HUYSE Psychiater, Consulent Integrale Zorg Afdeling Algemene Interne Geneeskunde UMCG GRONINGEN Lid council Acade

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  1. Integrale zorg een blijvende ontwikkeling FRITS HUYSE Psychiater, Consulent Integrale Zorg Afdeling Algemene Interne Geneeskunde UMCG GRONINGEN Lid council Academy of Psychosomatic Medicine USA NFZP 9-6-2006 Universitair Medisch Centrum Utrecht UMCG Groningen

  2. Hoofdstuk 6 Complexe patienten Huyse Slaets de Jonge

  3. Graeme C Smith Consultation-Liaison Psychiatry Research Unit Monash University Department of Psychological Medicine THE FUTURE OF CONSULTATION-LIAISON PSYCHIATRY Keynote speaker Anual meeting Dutch Psychiatric Association Maastricht The Netherlands 2005

  4. CONCLUSIONS • Patients with physical/psychiatric comorbidity and somatisation continue to be discriminated against in the public sector, despite the acknowledgement of this in the Second National Mental Health Plan • The implication for patients is both primary and secondary; the context in which psychiatrists are training is helping perpetuate the problem • Development of a seamless web of pre-admission/admission/post discharge functions is required if patients are to receive effective care and services are to be able to demonstrate efficacy

  5. Type patiënt % Verzekerden Kosten/ Verzekerde Beleid 100 90 80 70 60 50 40 30 20 10 Zorg coördinatie in relatie tot zorgbehoefte • Bezorgdheid • Voorbijgaande ziekte • Minder ernstige acute ziekte Vraag gestuurd Low • Chronische ziekte • Matig tot ernstige acute ziekte Ziekte gestuurd Medium Complexe medische patiënten Multi-morbiditeit, waaronder psychiatrische Meerder hulpverleners Psychologische, sociale en financiële ontregeling Zorg coördinatie Ambulant`/ Klinisch High Wie? Hoe? Cartesian Solutions Kathol 2002

  6. Results of ECLW Collaborative Study14470 patients 56 hospitals 11 countries CONSULTATION EMERGENCY equals PSYCHIATRY PSYCHIATRY • Consultation psychiatry • Rate 1% of all admissions • Reactive (wait and see) • Doctors and nurses needs driven • Liaison • Theorynot practice Huyse, Herzog, Lobo, Malt e.a. Gen Hosp Psychiatry 23(3):124-132, 2001

  7. General hospital population Consults; psychiatric, psychological, social work

  8. Graeme C Smith Consultation-Liaison Psychiatry Research Unit Monash University Department of Psychological Medicine THE FUTURE OF CONSULTATION-LIAISON PSYCHIATRY Keynote speaker Anual meeting Dutch Psychiatric Association Maastricht The Netherlands 2005

  9. CONCLUSIONS • Patients with physical/psychiatric comorbidity and somatisation continue to be discriminated against in the public sector, despite the acknowledgement of this in the Second National Mental Health Plan • The implication for patients is both primary and secondary; the context in which psychiatrists are training is helping perpetuate the problem • Development of a seamless web of pre-admission/admission/post discharge functions is required if patients are to receive effective care and services are to be able to demonstrate efficacy

  10. Graeme C Smith Consultation-Liaison Psychiatry Research Unit Monash University Department of Psychological Medicine THE FUTURE OF CONSULTATION-LIAISON PSYCHIATRY Keynote speaker VJC NVvP Maastricht 2005

  11. CONCLUSIONS 1 Patients with physical/psychiatric comorbidity and somatisation continue to be discriminated against in the public sector, despite the acknowledgement of this in the Second National Mental Health Plan. Huyse NRC mei 2005: Geef psychiaters in ziekenhuizen de ruimte

  12. “De ziekenhuispsychiatrie kan mijns inziens een belangrijke rol vervullen. In dit opzicht sluit ik mij aan bij het standpunt van de heer Huyse. De stelselwijziging in de zorg die nu plaatsvindt, is mede bedoeld om de “ontschotting” van de lichamelijke en psychische zorg te verwezenlijken. …”

  13. CONCLUSIONS 2 The implication for patients is both primary and secondary; the context in which psychiatrists are training is helping perpetuate the problem. Huyse FJ, van der Mast RC, Boenink AD: De psychiater als medisch specialist: de psychiatrie een zorg? Tijdschrift voor Psychiatrie 44:795-802, 2002

  14. CONCLUSIONS 3 Development of a seamless web of pre-admission/admission/post discharge functions is required if patients are to receive effective care and services are to be able to demonstrate efficacy. Integrated care for the complex medically ill. Editors Huyse FJ, Stiefel FC Medical clinics of North America Elsevier Juli 2006

  15. Crossing the Quality Chasm “Quality problems occur typically not because of failure of goodwill, knowledge, effort or resources devoted to health care, but because of fundamental shortcomings in the ways care is organized” Trying harder will not work: changing systems of care will! a new HEALTH system for the 21st century (IOM, 2001)

  16. The Crossing the Quality Chasm Series To Err is Human (1999) Crossing the Quality Chasm - A New Health System for the 21st Century (2001) Leadership by Example (2002) Fostering Rapid Advances in Health Care (2002) Priority Areas for National Action (2003) Health Professions Education (2003) Keeping Patients Safe– Transforming the Work Environment of Nurses (2004) Patient Safety – Achieving a New Standard for Care (2004) Quality through Collaboration – the Future of Rural Health (2005) Improving the Quality of Health Care for Mental and Substance-use Conditions (2005) www.nap.edu

  17. Improving the Quality of Health Care for Mental and Substance-Use Conditions • Ensure that multiple providers’ care • of the same patient is coordinated • Plea for integration and removal of • dysfunctional barriers A Report in the Quality Chasm Series Commission of Quality of Care, Institute of Medicine, USA 2005 www.nap.edu

  18. Six Aims of Quality Health Care • Safe –avoids injuries from care bijvoorbeeld psychopharmaca en electieve chirurgie • Effective – provides care based on scientific knowledge and avoids services not likely to help bijvoorbeeld Pathway- (diabetes and depression) en IMPACT-studies (ouderen met somatische ziekten en depressies) 3.Patient-centered – respects and responds to patient preferences, needs, and values bijvoorbeeld algemeen ziekenhuis setting en geen RIAGG Crossing the Quality Chasm a new HEALTH system for the 21st century (IOM, 2001)

  19. De berg naar Mohammed of …………

  20. ……… of de psychiatrie naar de AGZ !

  21. Six Aims (cont.) • Timely – reduces waits and sometimes harmful delays for those receiving and giving care bijvoorbeeld geïntegreerde consulten bij onbegrepen klachten poli interne UMCG; gelijktijdig consult internist en psychiater 5.Efficient –avoids waste, including waste of equipment, supplies, ideas and energy bijvoorbeeld rechtstreekse verwijzing naar collega; “snuffel-consult” • Equitable – care does not vary in quality due to personal characteristics (gender, ethnicity, geographic location, or socio-economic status) bijvoorbeeld psychiatrische patient heeft gelijke toegang tot somatische zorg vv Crossing the Quality Chasm a new HEALTH system for the 21st century (IOM, 2001)

  22. Old Rules 1. Care is based on visits 2. Professional autonomy drives variability 3. Professionals control care 4. Information is a record 5. Decisions are based upon training and experience New Rules 1. Care is based upon continuous healing relationships 2. Care is customized to patient needs and values 3. The patient is the source of control 4. Knowledge is shared and information flows freely 5. Decision making is evidence-based Ten Rules for Achieving the Aims Crossing the Quality Chasm a new HEALTH system for the 21st century (IOM, 2001)

  23. Old Rules “Do no harm” is an individual clinician responsibility Secrecy is necessary The system reacts to needs Cost reduction is sought Preference for professional roles over the system New Rule Safety is a system responsibility Transparency is necessary 8.Needs are anticipated 9.Waste continuously decreased Cooperation among clinicians is a priority Ten Rules for Achieving the Aims Crossing the Quality Chasm a new HEALTH system for the 21st century (IOM, 2001)

  24. Achieving Aims and Rules Requires • News ways of delivering care • Effective use of information technology (IT) • Managing the clinical knowledge, skills, and deployment of the workforce • Effective teams and coordination of care across patient conditions, services and settings • Improvements in how quality is measured • Payment methods conducive to good quality Crossing the Quality Chasm a new HEALTH system for the 21st century (IOM, 2001)

  25. Interdisciplinaire Opleidingen Een kans voor Interne Geneeskunde en Psychiatrie? ROB Gans Hoogleraar Interne UMCG VJC NVvP Amsterdam, April 4, 2003 Thisbee en ….

  26. Mental health services in the general hospital 1. Emergency services Attempted suicide Acute behavioral disturbances Deliria Withdrawal 2. Integrated services Screening and integrated assessment Patient tailored multidisciplinary care (horizontal integration) and care trajectories (vertical integration)

  27. Arie Querido (1901-1983) A Dutch psychiatrist: his views on integrated health care. Boenink AD, Huyse FJ. J Psychosom Res. 1997 Dec;43(6):551-7.

  28. Visie Querido 1935: Psychiatrie d’urgence • Naast gestichtspsychiatrie moet ambulante psychiatrie ontwikkeld worden tbv voor en nazorg • Dit is de motor achter de RIAGG vorming (70er jaren) en zorgcircuitgedachte (negentiger jaren) geweest 1955: Integrale geneeskunde • Populatie gebaseerde studie in Weesperplein ziekenhuis waarin hij als een van de eersten aantoonde dat PS-comorbiditeit leidt tot slechte uitkomsten van somatische zorg

  29. Ontwikkeling integrale geneeskunde Querido verliet de psychiatrie en werkte uiteindelijk in de sociale geneeskunde Rooijmans, voormalig voorzitter van de NVvP, zette de ziekenhuispsychiatrie op de kaart De huidige academische psychiatrie heeft geen visie op dit vakgebied

  30. Ontwikkeling integrale geneeskunde Querido verliet de psychiatrie en werkte uiteindelijk in de sociale geneeskunde Rooijmans, voormalig voorzitter van de NVvP, zette de ziekenhuispsychiatrie op de kaart De huidige academische psychiatrie heeft geen visie op dit vakgebied USA 1980: alle kernhoogleraren psychiatrie zijn psychoanalytici 1990: geen kernhoogleraar is psychoanalyticus

  31. Ontwikkeling integrale geneeskunde Querido verliet de psychiatrie en werkte uiteindelijk in de sociale geneeskunde Rooijmans, voormalig voorzitter van de NVvP, zette de ziekenhuispsychiatrie op de kaart De huidige academische psychiatrie heeft geen visie op dit vakgebied USA 1980: alle kernhoogleraren psychiatrie zijn psychoanalytici 1990: geen kernhoogleraar is psychoanalyticus 2004: Ziekenhuispsychiatrie subspecialisatie in USA

  32. Ontwikkeling integrale geneeskunde Querido verliet de psychiatrie en werkte uiteindelijk in de sociale geneeskunde Rooijmans, voormalig voorzitter van de NVvP, zette de ziekenhuispsychiatrie op de kaart De huidige academische psychiatrie heeft geen visie op dit vakgebied USA 1980: alle kernhoogleraren psychiatrie zijn psychoanalytici 1990: geen kernhoogleraar is psychoanalyticus 2004: Ziekenhuispsychiatrie subspecialisatie in USA Nederland 2006: Geen hoogleraren ziekenhuispsychiatrie 2010: Kernhoogleraren psychiatrie zijn ziekenhuispsychiaters

  33. General hospital population Multidisciplinary care Physical: High acuity/intensity no artificial respiration Psychiatric: High acuity no severe behavioral dist MPU MPU = Medical- Psychiatric- Unit Screening for complexity Indicator-INTERMED Nurse specialist Multidisciplinary care Integrated assessment Psychiatrist/geriatrician Nurse specialist psychiatry Psychologist Social work

  34. Chronische ziekte en depressie • Verhoogde prevalentie • Versterkt de symptomen van de somatischeziekte • Vergroot de functionele beperkingen • Vermindert de compliance met somatische behandeling • Gaat gepaard met negatief gezondheidsgedrag (dieet, lichamelijke oefening, roken) • Gaat gepaard met een verhoogde mortaliteit

  35. Physical illness Adverse Bidirectional Interaction • Smoking • Sedentary lifestyle • Obesity • Lack of adherence to medical regimens • Medical illness at earlier age • Poor symptom control •  functional impairment •  complications of medical illness Major Depression After Katon

  36. DOES TREATMENT of the DEPRESSED MEDICALLY ILL HELP ? • SYSTEMATIC REVIEW OF ANTIDEPRESSANTS IN THE PHYSICALLY ILL • N of RCTs = 18 • Adverse reactions: • No differences of placebo • No difference between drugs • Number needed to treat 4 Gill and Hatcher Cochrane Review 2001

  37. Behavioral change can be considered according to a hierarchy of behavioral challenge, ranging from those that are least difficult (i.e., the initiation of new practices in which there is no preexisting habit that needs to be broken) to the most difficult (i.e., breaking addictive habits which satisfy physiological drives). Rozanski: Psychosom Med 2005; 67 [Suppl 1]: s67-s73

  38. MODELLEN VOOR INTEGRALE ZORG

  39. MODELLEN VOOR INTEGRALE ZORG • Depressie en somatische ziekte

  40. Multifactorial Interventions for Depression in Primary Care • Literature synthesis • 12 RCTs involving 6,274 patients • Most trials had 3-4 components • All 12 had care management; 7 had augmented mental health • 10 studies → improved outcomes Gerrity et al, J Gen Intern Med 2004 (abstract)

  41. Stepped Care • Patient self-management • Primary care provider • Care manager • Collaborative care • Indirect (TCM) – MHS supervises CM • Direct – MHS sees pt in consultation • Referral to Mental Health Specialist PC MH

  42. PHQ - 9 More than Nearly Not Several half the every at all days days day 0 1 2 3 Over the last 2 weeks, how often have you been bothered by the following problems? a. Little interest or pleasure in doing things b. Feeling down, depressed, or hopeless c. Trouble falling or staying asleep, or sleeping too much d. Feeling tired or having little energy e. Poor appetite or overeating f. Feeling bad about yourself, or that you are a failure . . . g. Trouble concentrating on things, such as reading . . . h. Moving or speaking so slowly . . . i. Thoughts that you would be better off dead . . . Subtotals: 0 3 4 9 TOTAL = 16

  43. PHQ-9 as Severity Measure • Cutpoints proposed on PHQ-9 for depression severity are:  5 = mild  10 = moderate  15 = moderately severe  20 = severe • Response to therapy = 5 point ↓ • Remission = score < 5

  44. Translating PHQ-9 Scores into Action

  45. The Pathway Study • RCT: depressie en diabetes mellitus • Verbetert diabetes door verbeterde depressie zorg? • Intervention: stepped care Tx depression • N=329 (int: 164; CAU 165) • 9 primary care klinieken • Outcomes: • Verbetering depressie 6 en 12 mnd • Verbetering algemeen gevoel na 6 en 12 mnd • Meer satisfactie met type zorg na 6 en 12 mnd • HBA-1C gelijk in interventie en controle groep Katon, Von Korff (2004) Arch Gen Psych 61:1042-1049

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