ATTC Messenger June 2014: Behavioral Health, System Transformation, and Team-based Care
Behavioral Health, System Transformation, and Team-Based Care
Traci Rieckmann, PhD
Oregon Health & Science University
The current, unprecedented innovations within the US healthcare system have also increased reporting, regulatory, and care delivery requirements. Addictions, mental health, and essentially all primary care providers are struggling to keep up with changes resulting from the Affordable Care Act (ACA) and other system transformation initiatives. One intervention that providers are employing to meet these challenges is through the creation of interdisciplinary care teams inclusive of behavioral health and primary care providers as well as support staff. Interdisciplinary care is an example of “reorganizing care so it is provided to patients by a team of professionals with diverse skills and talents,” which can “help to ensure patients get the education and support they need, reduce provider burn-out, and improve clinical quality as well” (Coleman and Reid, 2013).
Practicing alone, both isolating for the provider and less effective for the patient is rapidly being replaced by collaborative and integrated approaches, such as care teams. Notably, the ACA affirmatively supports team care as a means to systems transformation; the required Accountable Care Organizations (ACOs) create care delivery systems that encourage and support teams of physicians, hospitals, and other providers to collaboratively manage and coordinate care (Center for Medicaid and Medicare Services, 2010). In practice, the ACA should support care models that enable physicians, behavioral health providers, nurses, and staff to spend more effective and efficient time with their patients, while simultaneously reducing duplicative services.
As care delivery demands and documentation increase, the amount of time a provider needs to spend with a patient to attend to preventive, acute, and chronic conditions is more extensive than ever. An increase in evidence-based interventions recommended or required by bodies such as the United States Preventive Service Task Force (USPSTF) and through program requirements like those of the National Committee for Quality Assurance (NCQA) Patient-Centered Medical Home accreditation and Federally Qualified Health Centers (FQHC) has had an impact on provider time. Indeed, a recent study found that for practices with 2500 patients, more than 7 hours a day is needed to attend to that day’s patients with chronic conditions and more than 10 hours a day for acute and preventive services, demonstrating that a physician-centered, office-visit based care setting is no longer sufficient to meet patient or regulatory needs (Sevin, Moore, Shephard, Jacobs, & Hupke, 2009). At the same time that demands on provider time are increasing, Sevin and colleagues note that “continuity, patient-driven access to care, and being "known" by a provider or practice (particularly for patients with chronic diseases), have been shown to enhance patient satisfaction and health outcomes (Sevin, Moore, Shephard, Jacobs, & Hupke, 2009). Healthcare systems are challenged to effectively meet the wants and needs of patients by tailoring interventions based on each person's unique set of factors—his or her “strengths, preferences, and personal and social context” (Sevin et al., 2009).
So how does one achieve that balance between individualized care and increased demands on provider time? Creating and supporting multidisciplinary groups of healthcare professionals—care teams—enables system redesign and attention to patient needs more effectively. A team expands on the inherent limits in a 15-minute office visit during which demands for preventive care, chronic disease management, and new complaints compete. Team-based care models increase contact points between patient and health care teams, and decrease the likelihood that acute complaints will distract providers from making appropriate adjustments in the care of chronic conditions (Rosenthal, 2008).
If ever there were health care consumers whose chronic health conditions demanded integrated care, it is those who suffer from addictions and mental health conditions. With an estimated 40% of primary care involving psychiatric problems, primary care providers are ill-suited to treat, support, and manage the millions of patients presenting with mental health issues in primary care offices annually without support from psychiatrists and other mental health providers (Lieberman & Unutzer, 2013). Clinical trials have demonstrated that when someone has a substance abuse problem and one or more non substance-related disorders, integrated care can be more effective than traditional treatment delivery (i.e., separate, siloed primary care and substance abuse programs). Such integrated systems result in better health outcomes for individuals, in contrast to back-and-forth referrals between behavioral health and primary care offices that result in up to 80% of individuals not receiving care (Oslin et al., 2006).
What are care teams?
Care teams are a group of diverse clinicians who communicate with each other regularly about the care of a defined group of patients and participate in that care (Grumbach & Bodenheimer, 2004); care teams work to streamline care provision; provide whole-patient, integrated care; and reduce patient access barriers. There are different types of care teams: multidisciplinary teams include individuals from multiple disciplines that draw on knowledge from these different disciplines while also staying within the boundaries of those fields (Choi & Pak, 2006). An example of a multidisciplinary care team is seen in the IMPACT model (discussed later which includes a primary care physician, psychiatrist, and case manager who work together to facilitate streamlined patient care for a shared group of patients. Similarly, collaborative care organizes care around a patient, using a care-manager to give “less costly, qualitative good and effective care,” (Steenbergen-Weijenburg, et al., 2010).
Central to successful teams of any sort are five key elements highlighted in the conceptual work of several scholars: goals with measurable outcomes; clinical and administrative systems; division of labor; training; and communication (Grumback & Bodenheimer, 2004). How does this happen on a practical level? It isn’t easy, but there are lessons being learned, and shared, by those at the forefront. In the Safety Net Medical Home Initiative’s Implementation Guide on Improving Patient Care Through Teams the authors note: “Forming effective teams requires substantial and on-going effort. Making teams work for patients and staff is a tremendous undertaking—affecting practice culture and operations. Team structure, roles and responsibility definition, fostering team collaboration, and feedback affect daily operations, such as scheduling and visit planning. Changes in human resources policies, job descriptions, and performance expectations, as well as developing functional health information technology, are necessary for care team members to share care for an established patient panel. None of these changes are possible without senior leadership, staff buy-in, and tangible financial and personnel resources, such as protected time and space for teams to meet and problem-solve” (Coleman and Reid 2013). They go on to recommend practical ways to achieve specifics of team based care, such as empanelling patients, meeting regularly in team “huddles”, selecting the right team members, staff training and support, and much more.
Care teams and behavioral health
Care teams are particularly effective for complex patients and those suffering from chronic illness—certainly “complex” and “chronic” are accurate descriptors for individuals living with a substance abuse disorder, who often have one or more physical health problems such as lung disease, hepatitis, HIV/AIDS, cardiovascular disease, cancer, and/or mental disorders such as depression, anxiety, bipolar disorder, and schizophrenia (Mertens et al., 2003). In fact, persons with substance abuse disorders have: 9 times greater risk of congestive heart failure; 12 times greater risk of liver cirrhosis; 12 times the risk of developing pneumonia (Mertens et al., 2003). When persons with addictions have co-occurring physical illnesses, they may require medical care that is not traditionally available in, or linked to, specialty substance abuse care. The scope of treatment needed by individuals with addictions requires a team of different professionals that includes both specialty substance abuse providers and primary care providers.
Notably, the American Psychiatric Association (APA) issued a statement in support of integrated, multidisciplinary teams, referencing the enactment of the Affordable Care Act, Accountable Care Organizations, and patient-centered medical homes in addition to the increased national attention on mental health, as providing an unprecedented opportunity for psychiatrists and primary care providers to “join together and work collaboratively on increasing the overall health of millions of Americans” with the President of APA, Dr. Paul Summergrad, stating that he found the evidence of integrated care of mental health and substance abuse disorders compelling and necessary, and that without integrated care teams, not only is considerable pain and suffering caused, but there are also no ways of effectively addressing total health care costs unless “we reach out across the mental health and general medical care settings to ensure that we are all working together to provide that care” (Moran, 2014).
There are several models of behavioral health-inclusive teams that have delivered significant improvements. For example, the IMPACT model (Improving Mood-Promoting Access to Collaborative Treatment) care team consists of a depression care manager and supervising psychiatrist and primary care physician. In a randomized control trial of 1801 patients with depression in 8 health care organizations in 5 states, after 12 months, 45% of intervention patients had a reduction in depressive symptoms from baseline compared to 19% of usual care patients. (Unutzer, et al., 2002). Other models can be found at the SAMHSA/HRSA Center for Integrated Health Solutions website or the Millbank Memorial Fund’s “Evolving Models of Behavioral Health Integration in Primary Care” report.
Addiction treatment and behavioral health experts share many common beliefs/structures with medical providers, a strength for integrated care. Commonalities include: a professional norm emphasizing the use of evidence-based treatment practices, the use of a stepped care approach to treatment based on the severity of the presenting problem, using treatments that are based on diagnostic criteria clearly defined and developed by expert panels, creation of treatment plans as part of the clinical care process, ongoing documentation as part of quality treatment, and years of experience working with clients with complex chronic diseases.
Behavioral health providers have additional strengths and benefits to bring to the primary care setting, some of which may be unique or lacking without their inclusion in a treatment team:
- Expertise in treating addiction and mental health disorders, which often co-occur and need to be treated in a coordinated manner
- Significant experience in supporting family involvement in treatment
- Good connections to community support resources (housing, employment, social services, etc.)
- Significant experience dealing with clients who can be difficult and challenging to work with
- Connections to community-based prevention partners
- Deep understanding of and experience with recovery support as important aspect of successful chronic disease management including skills to help clients anticipate and manage relapse, how to develop and follow wellness plans, etc.
- Opportunity to capitalize on new advances in medicine, including the use of medications such as buprenorphine, acamprosate, and extended-release naltrexone to treat addictions; “in order for substance abuse treatment providers to take full advantage of these new medications, medical staff will need to be available and work closely with them to monitor medications and coordinate care” (CIHS 2013).
The big picture - care teams and the Triple Aim
The “Triple Aim” of health care reform includes: improving the experience of care, improving the health of populations, and reducing per capita costs of health care. Behavioral health has to be a key consideration because, according to the Institute for Health Care Improvement (www.ihi.org), “Organizations trying to achieve the Triple Aim for their population will struggle to succeed without an integrated behavioral health strategy.” An integrated strategy is best achieved through care teams, and such teams support the Triple Aim by improving:
- Access: The US Veteran’s Administration (VA) is the largest integrated health care system in the United States, caring for approximately 5.3 million Veterans in primary care settings. Over the past two years, VA has bolstered its support to all medical centers to expand established care teams, known as PACTs. Teams are comprised of a provider, a Registered Nurse care manager, a clinical associate, and an administrative associate. Clinical pharmacists, social workers, nutritionists, and behavioral health staff support PACTs. Since implementing PACTs, the number of primary care patients has increased 12 percent, and the number of encounters with Veterans has increased 50 percent mostly due to telehealth, telephone, and group encounters. Despite the increase of primary care patients, access to primary care has improved and continuity of care is better. Additionally, approximately 65 percent of Veterans requesting a same-day primary care appointment with their personal provider are accommodated and 78 percent of Veterans are able to see their own primary care provider for an appointment on the date they desire. Veteran access to primary care during extended hours (non-business hours) has increased 75 percent since January 2013.Over 72 percent of all Veterans discharged from VA are contacted within two days to ensure they are following discharge instructions and check in on their condition. These critical post-discharge follow-ups are important to reducing readmissions. Mental Health integration is also a critical component and, in just one year (FY12-FY13) using the PACTs model, mental health services offered in VA primary care clinics increased 18 percent. Overall, PACTs program implementation has been associated with important utilization changes—fewer primary care patients are receiving care in urgent care settings (decreased 33 percent) and acute hospital admissions have decreased 12 percent due to improved care management and coordination from PACTs (USDVA, 2014).
- Health Outcomes: Recent studies found that better team work and team climate were associated with improved: health outcomes for diabetic patients, continuity of care, access to care, and patient satisfaction. Kaiser Permanente‘s use of care teams has demonstrated superior patient outcomes, increased patient and provider satisfaction, and better control of diabetes and hyperlipidemia (Grumback & Bodenheimer, 2004). Additionally, patients who had received collaborative care showed greater improvements in the adequacy of dosage of anti-depressant medication, less depression severity, a higher rating of patient rated global improvement, and higher satisfaction with care (Katon et al., 2004). SAMHSA/HRSA’s Center for Integrated Health Strategies notes that providing primary care to individuals with addictions enhances their recovery from substance abuse (Holder, 1998).In fact, two or more primary care visits in a 6-month period has been shown to improve abstinence by 50% in individuals with substance abuse disorders (Saitz et al., 2005) and those with medical conditions related to substance abuse are three times more likely to achieve remission over 5 years (Mertens, et al., 2008).
- Cost: Given rising healthcare costs and increases in chronic illness, including mental and behavioral health disorders, integrated care delivery stands to have a significant impact on total cost of care. Indeed, in conjunction with the American Psychiatric Association study Economic Impact of Integrated Medical-Behavioral Healthcare: Implications for Psychiatry, the international actuarial firm, Milliman, Inc., found that effective integration of medical and behavioral health care could save $26-48 billion annually in healthcare costs, largely associated with a reduction in utilization of the Emergency Department by patients with mental health and substance use conditions (Moran, 2014). In a much earlier study, Laine (2001), found that regular health and addictions care for people with substance abuse disorders decreased hospitalizations by up to 30%.
Finally, team-based care can improve the overall satisfaction and functioning of the provider workforce, which contributes directly and indirectly to all of the triple aims. For example, following implementation of multidisciplinary care teams, provider job satisfaction improved, working with others improved and satisfaction with decision making also improved. Additionally, working in a team environment was very useful in dealing with complex primary care patients. (Dieleman, Farris, Feeny,Johnson, Tsuyuki, & Brilliant, 2004).
With the ACA and health care system transformation requiring and supporting innovative service delivery and quality improvement, integrated care teams inclusive of primary care and behavioral health stand to revolutionize service delivery and result in improved patient access and health outcomes while reducing total system cost.