DHHS NORTH CAROLINA MEDICAID REFORM
North Carolina
National Alliance on Mental Illness
October 17, 2014
Courtney Cantrell, Ph.D.
Director, Division of Mental Health, Developmental Disability
and Substance Abuse Services
Understanding Integrated Care Options…
…and How YOU Can Benefit
NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES
“Every patient, every person, must have a
comprehensive personal care plan, that addresses the
whole person. That includes all of their problems and
concerns and resources and fears and experiences, and
essentially, incorporates into that those factors such
that you've got a coherent plan for health…that makes
use of all of that. So that if there are mental diagnoses,
if there are chronic diseases, if there are acute problems,
prevention needs, all of those are understood in the
context of each other; a whole person plan of care.”
These remarks by Frank DeGruy, MD, NIAC Chair, were part of the Mental Health Forum and Town Hall Meeting at the AHRQ
2011 Annual Conference. This Forum featured national experts on integrated healthcare, including several members of the
National Integration Academy Council (NIAC) who discussed policy, research, and the state of the field related to integrating
behavioral health and primary care.
NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES
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Integrated Care
• Integrated care model
Treating medical/physical and behavioral (mental
health/substance use) conditions in an integrated,
coordinated fashion in primary care, with the PCP
coordinator of the care team
• Collaborative Care
An integrated approach to health care delivery in
primary care, medical and behavioral health
providers work together to address the patients
medical and behavioral health needs.
NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES
System Integration and Transformation
Needed
Integrated Medical Team
PC Physicians
Usual Care
Fragmented (siloed)
Not coordinated
Patient
INTEGRATION and
Changing Payment
Models (ACOs)
Behavioral health care
- mental health
- substance abuse
Primary care
Specialist care
- Prevention
- Acute Care
Other care
- Chronic Care
NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES
BH Specialists
Specialists
Other licensed
health care providers
Coordination
Collaboration
Communication
Care is…
Integrated
Team-based
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TODAY’S CARE
Integrated Primary
Care
My main problem for the day is what
determines my care; BH problems
may or may not be discussed
All of my health needs are covered,
including BH, stress, housing, job…
factors necessary to plan care
Care is determined by today’s
problem and time available today
Care varies by scheduled time and
memory or skill of the doctor
Care is guided by patients goals
I am responsible for coordinating my
own care
Along with a team of professionals, I
help coordinate my care
I assume I’m getting quality care
because my doc is well-trained
Quality of my care is measured, and
continuously improved
I always have to make an
appointment or wait as walk-in; ED
If I need care today, I can walk-in or get
help without traveling to the clinic
I have to tell the doc what happened
to me
The doc knows all about my other
medical visits/tests/prescriptions
I have to go to another provider for
BH issues in another clinic
A team works with me, at the top of
their licenses to serve patients
Care is standardized according to
evidence-based guidelines
NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES
Modified Slide from Daniel Duffy MD School of Community Medicine Tulsa Oklahoma
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How the Team Works with Different Peoples’
Needs
Range of Need for Collaboration in the Patient Centered Medical Home (Kessler & Miller, 2009)
Severe Mental Health/ Identification and
Substance Use
Treatment of Mental
Health and Substance
Use
Primary Care Functions Manage pharmacology; Identification;
coordinate w/
motivational
community providers; interviewing; brief
crisis management
intervention;
pharmacology, refer to
mental
health/substance
abuse
Primary Care
Crisis intervention;
Treatment of
Behavioral Health
communication w/
depression/anxiety; coClinician
outside specialty care treatment w/ PCP;
providers
evidence based
treatment; medication
monitoring
NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES
Miller & Kessler, 2009
Medical and
Psychological
Presentations
Medical Presentations
Which Need
Behavioral Treatment
Identification; patient
education, cotreatment w/ mental
health, monitor
activation and
adherence (e.g. chronic
medical disorders, nonadherence)
Psychoeducation;
motivational
Interviewing;
behavioral activation
Identification;
education; referral for
consultation and cotreatment (e.g.,
primary insomnia,
Gastrointestinal,
headache)
Health behavior
change;
psychoeducation;
evidence based
treatment
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What it Looks and Feels Like in Primary
Care or a Beh Health Agency
You are at the center of your care
You work with a team as a member of the healthcare
team; brief interventions
All of your needs are addressed
…IF you have high blood pressure…
…if you MIGHT drink a little too much…
…IF you have schizophrenia…
…IF you have I/DD…
…IF you’re a caregiver…
NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES
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Six Reasons You Want Behavioral Health in Primary Care
Reason 1: We all go to Primary Care (or we should), including those with BH
needs
Reason 2: Many people don’t get BH needs met
Reason 3: High Cost of Unmet Behavioral Health Needs
Reason 4: Better Health Outcomes
Reason 5: Improved Satisfaction
Primary Care Behavioral Health
-Improves Access
-Reduces Costs
-Improves Patient
-Leads to Better Health
NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES
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Patient-Centered Medical Home
Reason One: Most of Us Get Primary Care
• 84% of the time, the 14 most common physical
complaints have no identifiable cause1
• 80% with a behavioral health disorder will visit primary
care at least 1 time in a year2
• HALF of all behavioral health disorders are treated in
primary care3
• Almost half of the appointments for all psychiatric
medications are with a non-psychiatric primary care
provider4
NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES
1. Kroenke & Mangelsdorf, Am J Med. 1989;86:262-266.
2. Narrow et al., Arch Gen Psychiatry. 1993;50:5-107.
3. Kessler et al., NEJM. 2006;353:2515-23.
4. Pincus et al., JAMA. 1998;279:526-531.
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Patient-Centered Medical Home
Reason Two: Unmet Behavioral Health Needs
• More than half of people with a behavioral health disorder do
not get behavioral health treatment1
• 30-50% of referrals from primary care to an outpatient
behavioral health clinic don’t make first appt2,3
• Two-thirds of primary care physicians reported not being
able to access outpatient behavioral health for their
patients…due to shortages of mental health care providers,
health plan barriers, and lack of coverage or inadequate
coverage
NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES
1. Kessler et al., NEJM. 2005;352:515-23.
2. Fisher & Ransom, Arch Intern Med. 1997;6:324-333.
3. Hoge et al., JAMA. 2006;95:1023-1032.
4. Cunningham, Health Affairs. 2009; 3:w490-w501.
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Unmet Needs: Reasons People Die
1. McGinnis JM, Foege WH. Actual Causes of Death in the United States. JAMA 1993;270:2207-12.
.
2. Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual Causes of Death in the United States, 2000. JAMA 2004;291:1230-1245
NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES
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Cost of Unmet Needs Continued
• Healthcare use/costs twice as high in diabetes and heart disease patients with
depression1
Annual Cost – those
without MH condition
Annual Cost – those
with MH condition
Heart Condition
$4,697
$6,919
High Blood Pressure
$3,481
$5,492
Asthma
$2,908
$4,028
Diabetes
$4,172
$5,559
• Approximately 217 million days of work are lost annually to related mental
illness and substance use disorders (costing employers $17 billion/year)2
1. Original source data is the U.S. Dept of HHS the 2002 and 2003 MEPS. AHRQ as cited in Petterson et al. “Why there must be room for mental
health in the medical home (Graham Center One-Pager)
NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES
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Patient-Centered Medical Home
Reason Four: Better Outcomes
Depression1-4
Panic Disorder1-2
Tobacco
Alcohol Misuse
Diabetes
IBS
GAD
Chronic Pain
Primary Insomnia
Somatic Complaints
NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES
1. Butler et al., AHRQ Publication No. 09- E003. Rockville, MD.
AHRQ. 2008.
2. Craven et al., Canadian Journal of Psychiatry. 2006;51:1S-72S.
3. Gilbody et al., British Journal of Psychiatry, 2006;189:484-493.
4. Williams et al., General Hospital Psychiatry, 2007; 29:91-116.
5. Hunter et al., Integrated Behavioral Health in Primary Care:
American Psychological Association, 2009
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Patient Centered Medical Home
Reason Six: Improved Satisfaction
Improved Patient Satisfaction 1-5
Improved Primary Care Provider
Satisfaction 6,7
1.
2.
3.
4.
5.
6.
7.
Chen et al., American Journal of Geriatric Psychiatry. 2006; 14:371-379.
Unutzer et al., JAMA. 2002; 288:2836-2845.
Katon et al., JAMA. 1995; 273:1026-1031.
Katon et al., Archives of General Psychiatry. 1999; 56:1109-1115.
Katon et al., Archives of General Psychiatry. 1996; 53:924-932.
Gallo et al., Annals of Family Medicine. 2004; 2:305-309.
Levine et al., General Hospital Psychiatry. 2005; 27:383-391.
NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES
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Sounds GREAT…How do I get it?
NOT Paid for in current fee for service
system
Some FQHCs and a few primary care
practices funded by grants
Some BH agencies offer primary care
in their agencies as well
NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES
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THE ANSWER: Medicaid Reform
Accountable Care Organizations are integrated
groups of health care providers who:
• Deliver coordinated care across health care
settings
• Agree to be held accountable for achieving:
– measured quality improvements and
– reductions in the rate of spending growth.
• Keep and Improve the LME-MCO System
NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES
Sounds GREAT…How do I get it?
Talk to your general assembly members about what
YOU want, because where the state system goes, others
usually follow!
www.nhmh.org: No Health without Mental Health;
Consumer/Patient Guide to Integrated Care
http://integrationacademy.ahrq.gov/
Federal site all about Integrating Behavioral Health and
Primary Care
NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES
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THANK YOU!
Courtney Cantrell
Courtney.m.Cantrell@dhhs.nc.gov
919-733-7011
NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES