Session #A1
October 5, 2012
Uniting the Field:
The AHRQ Academy for Integrating
Behavioral Health and Primary Care
Alexander Blount, EdD; Director, Center for Integrated Primary Care,
Univ. of Massachusetts Medical School
Deborah Cohen, PhD; Associate Professor, Oregon Health and Science
University
Neil Korsen, MD; Medical Director, Program to Integrate Medical and
Behavioral Healthcare, MaineHealth
Benjamin Miller, PsyD; Assistant Professor, Dept. of Family Medicine,
University of Colorado School of Medicine
C.J. Peek, PhD; Associate Professor, University of Minnesota
Collaborative Family Healthcare Association 14th Annual Conference
October 4-6, 2012 Austin, Texas U.S.A.
Faculty Disclosure
I/We have not had any relevant financial relationships
during the past 12 months.
Objectives
• At the conclusion of this presentation,
participants will be able to:
– List three ways the Academy website can be a
resource for the integration community
– Describe three projects funded by the federal
government addressing integration, and
– Explain two ways the larger integration
community can become involved in these national
efforts
Learning Assessment
A learning assessment is required for CE credit.
Attention Presenters:
Please incorporate audience interaction through a
brief Question & Answer period during or at the
conclusion of your presentation.
This component MUST be done in lieu of a written
pre- or post-test based on your learning objectives to satisfy
accreditation requirements.
Funded under contract #HHSA290-2010-00002i by the Agency for Healthcare Research and Quality
Uniting the Field:
The AHRQ Academy
CFHA Annual Conference
October 5, 2012
Brilliance
Brilliance
Brilliance
Brilliance
Brilliance
• Lexicon (language
critical)
• First and second
steps for the field in
research
• Metrics for
evaluating
integration
• Unite the field and
move it forward
But wait….
A RESOURCE
Homepage
Literature repository
NIAC
http://integrationacademy.ahrq.gov/
The organized thinking
•
Academy
–
Workforce
–
Survey
•
IQM
•
Lexicon
•
Research agenda
Survey
•
Survey small and solo primary care providers to
learn what they are doing for mental health
–
National survey
–
Currently through OMB process
–
Important group not often included within integration
efforts
Uniting the Field—The AHRQ Academy
for Integrating Behavioral Health and Primary Care:
Developing and Applying a Consensus Lexicon
AHRQ Annual Meeting
September 10, 2012
Bethesda, MD
C.J. Peek, PhD
Associate Professor
Dept of Family Medicine and Community Health
University of Minnesota Medical School
15
“Is there a Lexicon in the House?”
2012 CFHA Annual Meeting
C.J. Peek, PhD; University of Minnesota
Normal confusion in a new field
•
“Are you saying integrated behavioral health and collaborative care are the same?”
•
“Is that the same as co-located mental health or primary care behavioral health?”
•
“What functions define the genuine article? What can be different from practice to
practice?”
•
“How can we implement, ask research questions (or write a book) if we can’t even get
through a phone call without stumbling over the basic concepts in our field?
The archetypal experience:
“We already do that. . .”
“. . . No you don’t”
16
Communities this lexicon intends to unite:
Patients & families:
• What do I want and expect as a standard of practice?
• How would I recognize it if I saw it?
• How would I know if what I see is up to standard?
Clinician & system implementers:
• What exactly do I implement?
• What are the core functions and what
do I locally adapt?
Purchasers/plans:
• What exactly am I buying?
• What do I tell employees or members
what to expect for the cost?
Policymakers & business modelers:
• If asked to change rules of the game or business models, what
functions need to be supported?
• Says who?
Researchers:
• What comparisons of effectiveness?
• What terms for asking consistently understood
questions across PBRN’s?
17
Requirements for lexicon development method:
A.Consensual
but analytic
(a disciplined process--not a political campaign)
B.Involving “native
speakers” (in this case, 24
diverse)
(implementers and users)
C.Focused
practice
on what functionalities look like in
(not just principles, values, abstractions)
D.Amenable
to gathering an expanding circle of
“owners” and contributors
(not just an elite group coming with a declaration)
Method: Paradigm Case Formulation and Parametric Analysis
Ossorio (2006); The Behavior of Persons. Descriptive Psychology Press, Ann Arbor
18
Defining clauses for genuine integrated BH:
A. The “What”—a two-sentence definition; a glossary at the end
B. The “How”:
1. A practice team tailored to the needs of each patient and situation
(spelled out in 3 sub-clauses)
2. With a shared population and mission—with responsibility for total
health outcomes
3. Using a systematic clinical approach (spelled out in 5 sub-clauses)
C. “Supported by”:
4. A community or population expecting that BH and PC will be appropriately
integrated as a standard of care
5. Supported by office practice, leadership alignment, and business model
(spelled out in 3 sub-clauses)
6. And ongoing QI and measurement of effectiveness
(spelled out in 2 sub-clauses)
Based on Peek, C.J. and the National Integration Academy Council (AHRQ—in press). A consensus lexicon or operational definition:
Integrated behavioral health and primary care. 2011 version available at:http://www.ahrq.gov/research/collaborativecare/
19
19
Parameters—how practices might differ (examples)
1. Range of team
functions available
Foundational:
Extended functions
(9 functions)
2. Type of spatial
arrangement
3. Type of
collaboration
Foundational plus
Mostly separate
space
Co-located space
Fully shared
space
Referral-triggered
exchange
Regular commun.
& coordination
Full collaboration /
integration
5. Level shared workflows
& protocols are followed
7. Level of systematic
followup & tx adjust.
Less than 50%
(Not acceptable)
Less than 40%
More than 50%
(not acceptable)
8. Community expectation
for integrated BH / PC
Little or
none
9. Level of office practice
design & reliability
Non-systematic
11. Level of leadership
alignment
More than 50%,
less than 100%
(not acceptable)
Misaligned
(not acceptable)
Nearly 100%
(standard work)
Nearly 100%
(standard work)
Expected in
pockets
Partially
routinized
Partially aligned
Widely understood
and expected
Standard work
Fully aligned
Implementation: Lexicon Applications
(Behavioral health integrated in primary care)
Implementation Application
“What functions do I need to build?”
(“What is required, what can vary?”)
User or product
Full operational description plus
derivative summaries
Practice “checklists”
AHRQ practice surveys and
(to describe and compare practices over time) multiple others
Workflows and team functions
(Like “specifications” for shared workflows)
Implementers such as U of MN
family medicine clinics
Project milestones
implementers
(“X functions at Y levels by Z date”)
Patient engagement & demand
(what functions should I expect and demand
as a standard of practice?)
AHRQ Academy; Institute for
Clinical Systems Improvement
21
21
Lexicon Applications
(Behavioral health integrated in primary care)
Application
Sponsor or product
Measures: Quality of integration
AHRQ Atlas of Measures
(Integration of behavioral health & prim care)
(Academy for Integration of BH & PC)
Workforce competencies
AHRQ
(For practices and individuals)
(Academy for Integration of BH & PC)
Research: Asking consistently understood Collaborative Care Research
research questions, esp in PBRN’s
Network (AAFP NRN)
Patients and citizen representatives
AHRQ, Institute for Clinical
(what should I expect? How do I recognize it?) Systems Improvement (MN)
Publications and training
(A unified field with consistent language)
Policy and business model development
(What functions do new rules and business
models need to support?)
Edited book (Talen & Valeras)
AHRQ Academy web portal, other
AHRQ Academy, Milliman, others
interested in policy and business
models
22
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Question
•
What areas of the field (or your own work) could
most benefit from more common language and
definition?
Funded under contract #HHSA290-2010-00002i by the Agency for Healthcare Research and Quality
Workforce
Alexander Blount, EdD
Workforce
•
Develop competencies for both behavioral health
and primary care providers
–
Different method, different approach
–
Studying the exemplars
–
National team of experts
–
Develop plan for technical assistance
Workforce
•
•
What counts as an exemplar?
–
Do we go with the ones we know and love?
–
Do we use the definitions of the Lexicon?
–
Is the Lexicon definition somewhat aspirational?
Aren’t competencies a moving target based on the
maturity of the setting?
–
Mature settings have more of the competencies represented as
regular practices and protocols.
–
Competencies move from the skills of the provider to the
standard practice of the team.
Question
•
How would you define an exemplar?
Integration Quality
Measurement Atlas
Neil Korsen, MD
AHRQ Annual Meeting
September 10, 2012
Purpose of Atlas Project
•
To create a resource for those doing research,
evaluation, or quality improvement related to
behavioral health integration in primary care
•
To collect quality measures related to integration in
one convenient website
•
To identify domains related to integration for which
new measure development would be desired
Atlas Development Process
LEXICON
PERFORMANCE
DOMAINS
MEASUREMENT
CONSTRUCTS
MEASURES
Environmental Scan
•
•
Search strategy was guided by the following:
–
Lexicon definition
–
Measures in the public domain; and
–
Measures published since 2001
28 measures identified
Challenges
•
Why behavioral health and not mental health?
•
Isn’t this just measuring ‘good health care’?
•
Why aren’t we listing all the behavioral health
outcome measures?
Question
•
What help do you need with measurement of the
impact of integration?
Funded under contract #HHSA290-2010-00002i by the Agency for Healthcare Research and Quality
Evaluation and Measurement
Deborah Cohen, PhD
Oregon Health & Science University
Overview
•
•
•
Observations from the field
–
Integrating care takes time, energy and passion
–
Most practices do not track or measure important data
–
Learning how to do integration is a process
Implications for Assessment
–
The process is more important than what you measure
–
Measurement requires engagement
How can the Academy help
Observations from the field
What are the challenges in changing to an integrated
practice?
–
Core team resilience and adaptability
–
Creating space for teamwork
–
Culture and identity change
–
Creating a sustainable business model
–
Information technology
–
Tracking and measuring care
How do practices learn how to do this
work?
–
Try something
–
Have an experience
–
Observe what happens (data)
–
Reflect on experience
–
Try out something new
How can tracking and
measurement support this learning process?
Where to start?
•
What does your organization and its members want to accomplish? Passion for change?
•
What patients do you want to impact?
•
How are we going to have an impact on those patients?
•
–
How will we identify these patients?
–
What treatment will patients receive (type, length)?
–
What will have to change in the practice to make this happen?
How will I know if the practice is changing?
–
How will I know if I am reaching all of the patients with this need?
–
How will I know if they’re improving?
A Framework for Assessment - REAIM
•
Reach
•
Effectiveness
•
Adoption
•
Implementation
•
Maintenance
RE-AIM. (Reach, Effectiveness, Adoption, Implementation,
Maintenance). See http://www.re-aim.org/
Reach – some questions to answer
•
Most practices struggle with answering the
following questions:
–
How many people are served by my practice?
–
What proportion of my patients have behavioral health (or
physical health needs)?
–
What percentage of these patients do we screen for
physical or behavioral health needs?
–
What % of patients receive the need behavioral health (or
physical health) services?
Effectiveness - Possible Measures
Physical health domain
Process measures
General

Annual cholesterol screening

Annual influenza vaccination

Height and Weight for BMI
Diabetes Follow-up Care

Hemoglobin A1c testing every 6 months

Retinal examination

Foot examination

LDL-C everry 12 months
Outcome measures
General

BMI – outside normal range
Diabetes
•
Hemoglobin A1c > 9%
•
LCL-C < 100 mg/dl
•
BP > 130/85 mmHg
Mental health domain
Process measures
Depression

PHQ 9 screening / monitoring

On medication – for moderate / severe depression

Referral for counseling – 6-8 sessions

Follow-up visits for monitoring
Anxiety

GAD7 screening / monitoring

On medication – for moderate / severe depression

Referral for counseling – 6-8 sessions

Follow-up visits for monitoring
Alcohol Use

AUDIT screening / monitoring

Referral for counseling – 6-8 sessions

Follow-up visits for monitoring
Outcome measures

Measure improvement in above scores
Implementation
Observe
–
Physically watch how things are done
–
Look at patterns unobtrusively
Talk
–
Talk to people about what’s working and what’s not
The value of answering these questions
•
Answering these questions is important.
–
Diagnose strengths / weakness of care processes
–
Foster learning and innovation
–
Engage patients and the practice
–
Collect data that helps you evaluate what works and what
doesn’t
Nelson, EC. et al. Using Data to Improve Medical Practice by Measuring Processes and
Outcomes of Care. Journal on Quality Improvement. 26(12) 667.
How the Academy website can help
•
Literature
•
Measures
•
Examples
Resources available via The Academy
•
What else could be included on the the Academy
website to help me do quality improvement and
measurement?
Questions
•
What else could be included on the Academy
website to help me do quality improvement and
measurement?
•
What help do you need with measurement of the
impact of integration?
•
How would you define an exemplar?
•
What areas of the field (or your own work) could
most benefit from more common language and
definition?
Session Evaluation
Please complete and return the
evaluation form to the classroom monitor
before leaving this session.
Thank you!