Opinion
VIEWPOINT
Lloyd I. Sederer, MD New York State Office of Mental Health, Albany, and Columbia University Mailman School of Public Health, New York, New York.
Corresponding Author: Lloyd I. Sederer, MD, New York State Office of Mental Health, Columbia University Mailman School of Public Health, 330 Fifth Ave, 9th Floor, New York, NY 10001 (lloyd.sederer @omh.ny.gov).
What Does It Take for Primary Care Practices to Truly Deliver Behavioral Health Care? In what may be the largest state government behavioral health endeavor nationally, New York State (NYS) is more than midway into a federally supported initiative to fully integrate behavioral health care into ambulatory, primary care resident training sites, beginning with selected academic medical centers (AMCs). This is not simply to detect and refer, nor to colocate medical and mental health services under the same roof or down the hall from each other; it is the integration of behavioral health care, starting with adults with depression, into the standard operations of the primary care practice—no different from how these practices serve people with diabetes mellitus, asthma, or cardiovascular diseases. The goal, over time, is statewide dissemination. In this Viewpoint, I describe the circumstances and the interagency partnership that permitted this initiative to be launched (ie, its essential elements, its tough implementation challenges, and what must be done for sustainability).
payment system, do not pay the indirect costs associated with collaborative care,1 which is the model that was selected). So was born the partnership between the DOH and the OMH, which is called the NYS Collaborative Care Initiative (CCI).2 In addition to Centers for Medicare & Medicaid Services Medicaid waiver funding, the OMH financed the technical assistance, contracting with the University of Washington AIMS (Advancing Integrated Mental Health Solutions) Center to assist the AMCs approved to deliver the CCI.3,4 The OMH would advise on their selection and assist in monitoring and supporting the practices throughout the grant period. In all, 19 (of 63 approved) AMCs selected the CCI (31 clinics)—a project integrating health care and behavioral health care. All practices, by design and requirement, were primary care residency training sites. The DOH-OMH partnership itself mirrors the integration expected at the delivery sites.
Background: Circumstances and Interagency Partnership
The Essential Elements of Collaborative Care
New York State, like other states, has been transforming primary care practices through service innovations such as patient-centered medical homes. When the state received a Medicaid waiver from the Centers for Medicare & Medicaid Services, including up to $250 million of support for more than 2.5 years, the NYS Department of Health (DOH) identified services and practices that it regarded as essential for improving primary care and strengthening resident training experiences. One critical aim was to amplify the number of training practices meeting the 2011 National Committee for Quality Assurance standards for patient-centered medical homes and, in so doing, to deliver on the triple aim of quality/outcomes, patient experience, and economically responsible services. The DOH would fund AMCs whose applications met a variety of specified quality, care integration, and safety goals for patient-centered medical homes. The DOH constructed its plan in close collaboration with the NYS Office of Mental Health (OMH) to ensure that evidencebased interventions for integrating behavioral health care within primary care would be implemented with sufficient fidelity to measurably improve outcomes. For the first time, on a large scale, the tumblers of a difficult safe to crack seemed to fall in place: full integration of medical and behavioral health care (essential to improving outcomes and reducing costs for a variety of chronic medical illnesses); a robust evidence-based service model for the treatment of adult depression in primary care; and the money to support such an initiative (procedure-based payments, which dominate our current
jamapsychiatry.com
Collaborative care is not just a collaboration among collegial primary care physicians working in any number of ways with their high numbers of patients with depression or with depression commonly co-occurring with highly comorbid and costly conditions (including diabetes, cardiovascular illnesses, asthma, cancers, inflammatory diseases, and Parkinson disease) and with lowincome populations served in training sites. Collaborative care is a highly prescriptive set of clinical activities. Its robust evidence base and varied experience made it suitable for NYS to adopt.1-4 The practice elements required for the CCI are as follows: a standardized depression screening (using the 2and 9-question Patient Health Questionnaires5); a medical diagnosis for patients who screen positive (screens detect, not diagnose); evidence-based, “stepped” depression care; care managers; patient/family education and activation; clinical and administrative staff training; ongoing tracking of patient status using 9-question Patient Health Questionnaire scores; a designated psychiatrist who consults with the care manager and the primary care physician; and continuous performance measurement and improvement. The CCI requires the reporting, quarterly, of specific metrics that show that primary care practices are delivering these elements because evidence demonstrates their association with results. Delivering collaborative care, as you may surmise, is hard to do—even when there is money to help.
The Tough Implementation Challenges The technical assistance team established in NYS by the AIMS Center provides on-site support at 6 AMCs JAMA Psychiatry May 2014 Volume 71, Number 5
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archpsyc.jamanetwork.com/ by a Columbia University User on 07/30/2017
485
Opinion Viewpoint
(1 in Buffalo, 1 in Rochester, and 4 in New York City). The other remaining sites are provided with virtual support through webinars and online tools. We will determine if these 2 levels of support produce different results. The OMH oversight is provided by Marisa Derman, MD, MSc, a Columbia University Public Psychiatry Fellow working with me. Changing medical practices gives new meaning to the word difficult. At first, there were many understandable reasons why clinics could not, for example, have a care manager in place, or a consulting psychiatrist, or a way of registering and following up with patients (like with a diabetes registry). Because the funding went centrally to the AMCs, some practices encountered hurdles receiving the money they needed. Even Hurricane Sandy slowed things down in New York City. But explanations were not conditions for exception. The DOH and the OMH held the AMCs to their agreed on deliverables, or their funding would be affected. Perhaps the greatest challenges have been cultural— attitudinal, if you will. Some primary care practices believed in what they were doing, even though there was little evidence for it. Others did not regard depression amenable to detection and care paths, as they did hypertension or diabetes. Others needed to move beyond an ethos of “don’t ask, don’t tell” (quoting Michael Hogan, PhD) about mental and addictive conditions. There is wisdom in recognizing that behavior change precedes attitudinal and cultural change. We focused on behavior change. The reported metrics ensured that it was happening. ARTICLE INFORMATION Published Online: March 3, 2014. doi:10.1001/jamapsychiatry.2014.26. Conflict of Interest Disclosures: None reported. Additional Information: I would like to acknowledge Marisa Derman, MD, MSc, Foster Gesten, MD, Nirav Shah, MD, MPH, Michael Hogan, PhD, Jürgen Unützer, MD, MPH, MA, Virna Little, PhD, and Gregory Burke, MPA, for their invaluable contributions to this project. REFERENCES 1. Unützer J, Harbin H, Schoenbaum M, Druss B; Center for Health Care Strategies and Mathematical
486
Ensuring Continuation of Collaborative Care The financial support for the CCI that comes from the Centers for Medicare & Medicaid Services, the DOH, and the OMH concludes December 31, 2014. We have identified (from meeting with providers, payers, and advocates) what must be done, at a minimum, for collaborative care to endure after funding ceases (evidence indicates that, after several years, integrated care can be self-funding6). The following issues are central to sustainability: (1) financing to pay for the indirect costs of care managers, consulting psychiatrists, and information technology and administrative infrastructure; (2) regulatory and licensing relief that reduces unnecessary burdens from multiple licenses and surveys, as well as antiquated facility requirements; and (3) special attention to recruiting, training, and supervising the care managers and psychiatrists integral to collaborative care and their career development. The clock is ticking. New York State Medicaid has expressed support for some ongoing support for practices showing measurable improvements and model fidelity. Some ground is being gained, and some surely will remain after 2014 concludes. Can-do optimism fuels many programs and dedicated professionals—if there is just enough to keep them going. New York State is on a path to fully integrate health and behavioral health for its citizens, primary care practices, and budget requirements and to take pride in its medical services. Primary care integration of behavioral health is no luxury: it is fundamental to improving patient outcomes. Ask us next year just how far we have gotten.
Policy Research for Centers for Medicare & Medicaid Services. The collaborative care model: an approach for integrating physical and mental health care in Medicaid health homes. http://medicaid.gov /State-Resource-Center/Medicaid-State-Technical -Assistance/Health-Homes-Technical-Assistance /Downloads/HH-IRC-Collaborative-5-13.pdf. Published May 2013. Accessed January 29, 2014. 2. Thota AB, Sipe TA, Byard GJ, et al; Community Preventive Services Task Force. Collaborative care to improve the management of depressive disorders: a community guide systematic review and meta-analysis. Am J Prev Med. 2012;42(5):525-538.
3. Hospital-Medical Home (H-MH) Demonstration. New York State Department of Health website. https://hospitalmedicalhome.ipro.org/. Accessed January 29, 2014. 4. University of Washington AIMS Center website: http://uwaims.org/. Accessed January 30, 2014 5. Arroll B, Goodyear-Smith F, Crengle S, et al. Validation of PHQ-2 and PHQ-9 to screen for major depression in the primary care population. Ann Fam Med. 2010;8(4):348-353. 6. Unützer J, Katon WJ, Fan MY, et al. Long-term cost effects of collaborative care for late-life depression. Am J Manag Care. 2008;14(2):95-100.
JAMA Psychiatry May 2014 Volume 71, Number 5
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archpsyc.jamanetwork.com/ by a Columbia University User on 07/30/2017
jamapsychiatry.com
VIEWPOINT
Lloyd I. Sederer, MD New York State Office of Mental Health, Albany, and Columbia University Mailman School of Public Health, New York, New York.
Corresponding Author: Lloyd I. Sederer, MD, New York State Office of Mental Health, Columbia University Mailman School of Public Health, 330 Fifth Ave, 9th Floor, New York, NY 10001 (lloyd.sederer @omh.ny.gov).
What Does It Take for Primary Care Practices to Truly Deliver Behavioral Health Care? In what may be the largest state government behavioral health endeavor nationally, New York State (NYS) is more than midway into a federally supported initiative to fully integrate behavioral health care into ambulatory, primary care resident training sites, beginning with selected academic medical centers (AMCs). This is not simply to detect and refer, nor to colocate medical and mental health services under the same roof or down the hall from each other; it is the integration of behavioral health care, starting with adults with depression, into the standard operations of the primary care practice—no different from how these practices serve people with diabetes mellitus, asthma, or cardiovascular diseases. The goal, over time, is statewide dissemination. In this Viewpoint, I describe the circumstances and the interagency partnership that permitted this initiative to be launched (ie, its essential elements, its tough implementation challenges, and what must be done for sustainability).
payment system, do not pay the indirect costs associated with collaborative care,1 which is the model that was selected). So was born the partnership between the DOH and the OMH, which is called the NYS Collaborative Care Initiative (CCI).2 In addition to Centers for Medicare & Medicaid Services Medicaid waiver funding, the OMH financed the technical assistance, contracting with the University of Washington AIMS (Advancing Integrated Mental Health Solutions) Center to assist the AMCs approved to deliver the CCI.3,4 The OMH would advise on their selection and assist in monitoring and supporting the practices throughout the grant period. In all, 19 (of 63 approved) AMCs selected the CCI (31 clinics)—a project integrating health care and behavioral health care. All practices, by design and requirement, were primary care residency training sites. The DOH-OMH partnership itself mirrors the integration expected at the delivery sites.
Background: Circumstances and Interagency Partnership
The Essential Elements of Collaborative Care
New York State, like other states, has been transforming primary care practices through service innovations such as patient-centered medical homes. When the state received a Medicaid waiver from the Centers for Medicare & Medicaid Services, including up to $250 million of support for more than 2.5 years, the NYS Department of Health (DOH) identified services and practices that it regarded as essential for improving primary care and strengthening resident training experiences. One critical aim was to amplify the number of training practices meeting the 2011 National Committee for Quality Assurance standards for patient-centered medical homes and, in so doing, to deliver on the triple aim of quality/outcomes, patient experience, and economically responsible services. The DOH would fund AMCs whose applications met a variety of specified quality, care integration, and safety goals for patient-centered medical homes. The DOH constructed its plan in close collaboration with the NYS Office of Mental Health (OMH) to ensure that evidencebased interventions for integrating behavioral health care within primary care would be implemented with sufficient fidelity to measurably improve outcomes. For the first time, on a large scale, the tumblers of a difficult safe to crack seemed to fall in place: full integration of medical and behavioral health care (essential to improving outcomes and reducing costs for a variety of chronic medical illnesses); a robust evidence-based service model for the treatment of adult depression in primary care; and the money to support such an initiative (procedure-based payments, which dominate our current
jamapsychiatry.com
Collaborative care is not just a collaboration among collegial primary care physicians working in any number of ways with their high numbers of patients with depression or with depression commonly co-occurring with highly comorbid and costly conditions (including diabetes, cardiovascular illnesses, asthma, cancers, inflammatory diseases, and Parkinson disease) and with lowincome populations served in training sites. Collaborative care is a highly prescriptive set of clinical activities. Its robust evidence base and varied experience made it suitable for NYS to adopt.1-4 The practice elements required for the CCI are as follows: a standardized depression screening (using the 2and 9-question Patient Health Questionnaires5); a medical diagnosis for patients who screen positive (screens detect, not diagnose); evidence-based, “stepped” depression care; care managers; patient/family education and activation; clinical and administrative staff training; ongoing tracking of patient status using 9-question Patient Health Questionnaire scores; a designated psychiatrist who consults with the care manager and the primary care physician; and continuous performance measurement and improvement. The CCI requires the reporting, quarterly, of specific metrics that show that primary care practices are delivering these elements because evidence demonstrates their association with results. Delivering collaborative care, as you may surmise, is hard to do—even when there is money to help.
The Tough Implementation Challenges The technical assistance team established in NYS by the AIMS Center provides on-site support at 6 AMCs JAMA Psychiatry May 2014 Volume 71, Number 5
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archpsyc.jamanetwork.com/ by a Columbia University User on 07/30/2017
485
Opinion Viewpoint
(1 in Buffalo, 1 in Rochester, and 4 in New York City). The other remaining sites are provided with virtual support through webinars and online tools. We will determine if these 2 levels of support produce different results. The OMH oversight is provided by Marisa Derman, MD, MSc, a Columbia University Public Psychiatry Fellow working with me. Changing medical practices gives new meaning to the word difficult. At first, there were many understandable reasons why clinics could not, for example, have a care manager in place, or a consulting psychiatrist, or a way of registering and following up with patients (like with a diabetes registry). Because the funding went centrally to the AMCs, some practices encountered hurdles receiving the money they needed. Even Hurricane Sandy slowed things down in New York City. But explanations were not conditions for exception. The DOH and the OMH held the AMCs to their agreed on deliverables, or their funding would be affected. Perhaps the greatest challenges have been cultural— attitudinal, if you will. Some primary care practices believed in what they were doing, even though there was little evidence for it. Others did not regard depression amenable to detection and care paths, as they did hypertension or diabetes. Others needed to move beyond an ethos of “don’t ask, don’t tell” (quoting Michael Hogan, PhD) about mental and addictive conditions. There is wisdom in recognizing that behavior change precedes attitudinal and cultural change. We focused on behavior change. The reported metrics ensured that it was happening. ARTICLE INFORMATION Published Online: March 3, 2014. doi:10.1001/jamapsychiatry.2014.26. Conflict of Interest Disclosures: None reported. Additional Information: I would like to acknowledge Marisa Derman, MD, MSc, Foster Gesten, MD, Nirav Shah, MD, MPH, Michael Hogan, PhD, Jürgen Unützer, MD, MPH, MA, Virna Little, PhD, and Gregory Burke, MPA, for their invaluable contributions to this project. REFERENCES 1. Unützer J, Harbin H, Schoenbaum M, Druss B; Center for Health Care Strategies and Mathematical
486
Ensuring Continuation of Collaborative Care The financial support for the CCI that comes from the Centers for Medicare & Medicaid Services, the DOH, and the OMH concludes December 31, 2014. We have identified (from meeting with providers, payers, and advocates) what must be done, at a minimum, for collaborative care to endure after funding ceases (evidence indicates that, after several years, integrated care can be self-funding6). The following issues are central to sustainability: (1) financing to pay for the indirect costs of care managers, consulting psychiatrists, and information technology and administrative infrastructure; (2) regulatory and licensing relief that reduces unnecessary burdens from multiple licenses and surveys, as well as antiquated facility requirements; and (3) special attention to recruiting, training, and supervising the care managers and psychiatrists integral to collaborative care and their career development. The clock is ticking. New York State Medicaid has expressed support for some ongoing support for practices showing measurable improvements and model fidelity. Some ground is being gained, and some surely will remain after 2014 concludes. Can-do optimism fuels many programs and dedicated professionals—if there is just enough to keep them going. New York State is on a path to fully integrate health and behavioral health for its citizens, primary care practices, and budget requirements and to take pride in its medical services. Primary care integration of behavioral health is no luxury: it is fundamental to improving patient outcomes. Ask us next year just how far we have gotten.
Policy Research for Centers for Medicare & Medicaid Services. The collaborative care model: an approach for integrating physical and mental health care in Medicaid health homes. http://medicaid.gov /State-Resource-Center/Medicaid-State-Technical -Assistance/Health-Homes-Technical-Assistance /Downloads/HH-IRC-Collaborative-5-13.pdf. Published May 2013. Accessed January 29, 2014. 2. Thota AB, Sipe TA, Byard GJ, et al; Community Preventive Services Task Force. Collaborative care to improve the management of depressive disorders: a community guide systematic review and meta-analysis. Am J Prev Med. 2012;42(5):525-538.
3. Hospital-Medical Home (H-MH) Demonstration. New York State Department of Health website. https://hospitalmedicalhome.ipro.org/. Accessed January 29, 2014. 4. University of Washington AIMS Center website: http://uwaims.org/. Accessed January 30, 2014 5. Arroll B, Goodyear-Smith F, Crengle S, et al. Validation of PHQ-2 and PHQ-9 to screen for major depression in the primary care population. Ann Fam Med. 2010;8(4):348-353. 6. Unützer J, Katon WJ, Fan MY, et al. Long-term cost effects of collaborative care for late-life depression. Am J Manag Care. 2008;14(2):95-100.
JAMA Psychiatry May 2014 Volume 71, Number 5
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archpsyc.jamanetwork.com/ by a Columbia University User on 07/30/2017
jamapsychiatry.com
