RWJ Depression in Primary Care

1. RWJ Depression in Primary Care State Medicaid Strategies for Integrated Care Health Plan Experience Marshall R. Thomas M.D. V.P. of Medical Services/CMO Colorado Access Vice Chair Department of Psychiatry UCH/UCHSC

2. Colorado Access • Non-profit Medicaid/Medicare Health Plan • Product Lines • Access Health Plan • Access Behavioral Care • Access CHP+ • Access Advantage • Medicaid/Medicare Duals • Mental Health Co-morbidities • 40% of adult Medicaid recipient • Depression, anxiety, SA (15% each) • High cost to the medical plan • Bipolar, schizophrenia (5% each) • High cost to BH, Medical/Pharmacy • 1/3 seen by MH specialists • Overall increase costs 2.3 fold

3. Depression and Primary Care Initiative • MacArthur Grant • Dissemination of Three Component Model (TCM) • Remission in severe depression • TCM- 58.8% • Usual Care- 0% • Lessons learned • PCPs appreciated the help • Practice patterns difficult to change • Providers referred patients they wanted help with; not the patients who qualified for the studies • Help with medical and psychiatric co-morbidities • Patients liked the care managers

4. How Are Medicaid Populations and Providers Different? • Incentive Misalignment • As in commercial world • Medicaid Populations • Higher prevalence of mental health issues • Higher rates of poverty and other psychosocial stressors • Diverse • Pregnant moms and babies, TANF moms and kids, and Disabled • Culturally and ethnically diverse • Hispanic, African-American, Asian-Pacific, Eastern European.... • Harder to reach • ? Multiple co-morbidities • ? More likely to be helped by care management • Medicaid Providers • Diverse • FQHCs, University (resident) clinics, and private FM and Pediatric practices • Too much work, too few resources • Mission driven; philosophically dedicated to underserved; • ? More economically and technologically challenged • Decision-making mosaic

5. Robert Wood Johnson Foundation: Depression in Primary Care • RWJ: Linking Clinical and System Strategies • Develop an economically sustainable model for implementing depression care management • Build into already prioritized disease management programs • 50% rates of depression in asthma/COPD, CHF, diabetes, and high Kronick scores (90 percentile). • Depression associated with 2-4 fold increase in costs • Initial target of diabetes, CHF etc with co-morbid depression. • Diabetes depression pilot • 10.6/14 diagnostic categories • 26.5 diagnoses • 66% mental health diagnoses • 75% narcotic use

6. The Current System is Not Working • Usual care for complex Medicaid patients • Ineffective, inefficient, costly, and frustrating for all involved • “System overload” • Multiple medical comorbidities, psychosocial issue, psychiatric and substance use disorders • Multiple providers • Inadequate communication/coordination • Lack of a “medical home” • Lack of communication between PH and mental health providers • Polypharmacy • Use of expensive and addictive meds • Ineffective doses and strategies

7. Patient-focused Intensive Care Management Program • Focus on top 2-3 % of population • Risk stratification • High Kronick/Health Risk Assessment • Integrated general medical/behavioral health focus • Medical, behavioral, psychosocial domains • Basic needs • Food, shelter, transportation, benefits • Patient engagement/self-management goals • Mental health/cognitive barriers to engagement • Coordination of care among providers • Poly-pharmacy and medication adherence issues • Help navigating the medical and social service systems • Care management team • Nurses, social workers and resource coordinators • Consumer navigators and family resource coordinators • Home-grown care management software

8. Enrollee Demographics

9. PHQ-9 Trends

10. ER and Office Visit Trends

11. Admit and Days/1,000 Trends

12. Medical Cost Trends • Savings of $170 per enrollee per month • 12.9% reduction in costs in high-cost, high risk patients • $2040/year per patient • 370 patients x $2040 = $754,800 annual medical cost savings • Need Comparative Cohort analysis

13. Colorado Access’ Depression Integration Initiative (RE-AIM) • Reach • Directly reaches a relatively small but important subset of Medicaid patients • Directly reaches all health plan care management staff • Indirectly reaches many more providers and patients • Efficacy • Appears good (see proceeding data) • Adoption • High within the health plan staff • Implementation • Challenged to obtain model fidelity across staff • Competing demands • Decision support tools • Maintenance • High- depression and MH co-morbidity screening/monitoring part of all ICM assessments • New initiatives • FQHC clinic-based depression and diabetes CM • Bipolar (and SMI) CM • Enhanced MH screening for perinatal moms • AFFIRM- SED kids and families

14. Ingredients for Success • Support of senior management • Effective clinical leadership • Clear focus that supports both clinical and business priorities • Sphere of influence versus sphere of concern • Credible datato support start-up, implementation, and ongoing evaluation • Titrate degree to which innovation requires organizational change • Plan for program sustainability from the start; create a specific infrastructure with resources and expertise devoted to diffusion • Close relationship between the disseminating infrastructure and the adopting organization. • Perceived ability of the innovation to reduce external threats Bradley, et al., Commonwealth Foundation Fund: Issues Brief, 7/04