Affordable Care Act &
Best Practices for Hispanics
Enhancing Quality and Improving Outcomes
for Latinos through
Integrated Health and
Behavioral Health Care
March 29, 2014
Learning Objectives
Participants will:
◦ Learn the basics of integrated primary care and behavioral
health care, and how the approach benefits Latinos.
◦ Review innovative practice-based examples in the
delivery of integrated care to reduce & eliminate health
disparities.
◦ Discuss the concrete recommendations related to the
delivery of integrated health care services to racial and
ethnic minority communities as outlined in the Hogg
Foundation - Office of Minority Health Consensus Report
that can be implemented in your setting.
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Eliminating Racial and Ethnic Disparities
through Integrated Health Care
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Literature review
Consensus Meeting
Consensus Statements
Recommendations
Innovations from the field
http://www.hogg.utexas.edu/
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Health Disparities Exist!
Factors affecting quality of health care for Latinos
including:
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Primary care does not have expertise in providing
behavioral health services and Behavioral Health clinics
do not have expertise in providing primary care.
Provider shortages/Network insufficiency
Lack of provider Spanish language capacity;
Few culturally competent services
Poor doctor patient communication (DPC)
Behavioral health conditions are among the most
expensive to treat.
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Primary Care Serves as the De Facto
Behavioral Health Care System
…are often the gateway to health
care for Latinos and other racial and
ethnic minority populations, including
individuals with limited English
proficiency (LEP) and, as such, have
become the portal for identifying
undiagnosed or untreated mental
health and substance use disorders.
Persons with serious mental illness (SMI) are now
dying 25 years earlier than the general population
Increased morbidity and
mortality are largely due to
treatable medical conditions
that are caused by modifiable
risk factors such as smoking,
obesity, substance abuse,
depression and inadequate
access to medical care (60%
of premature deaths in
persons w/SMI are due to
natural causes).
1. Overall health is essential to mental health.
2. Recovery includes wellness.
3. Recovery is possible!
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What is Integrated Care?
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The care that results from a practice team of
primary care and behavioral health clinicians,
working together with patients and families, using
a systematic and cost-effective approach to
provide patient-centered care.
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Addresses mental health and substance abuse
conditions, health behaviors (including their
contribution to chronic medical illnesses), life
stressors and crises, stress-related physical
symptoms, and ineffective patterns of health care
utilization.
Principles and Components of
Integrated Health Care
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Informed and activate patient
Team-based approach
Measurement/Evidence-based,
stepped treatment
Shared record/EMR
PCP supported by care manager
Patient registry to track progress
Psychiatric consultation and
caseload review
Training
Referral to specialty
providers/more intensive services
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Stages of Integrated Care
Why Integrate?
Silos of Care
Primary
Care
Psychiatry
Clinical
Social Work
&
Psychology
Social
Services
Community
Based
Services
Unutzer, 2009
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Patient-Centered Medical Home and
Integrated Care
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Pressure for transformation in health care has
intensified in response to unsustainable costs and
escalating concerns with quality and patient experience.
Thanks in large part to these pressures, interest in
successfully implementing the patient-centered medical
home (PCMH) has been exploding.
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In turn, this has led to widespread interest in
integration of behavioral health and primary care,
widely viewed as a critical component or function of
PCMH and required if primary care is to do its part in
achieving “The Triple Aim” of health, affordability, and
enhanced patient experience (IHI, 2010).
Role of Integrated Care in the ACA
Promote Integrated Behavioral Health & Health Care
through the Patient-Centered Medical Home:
Coordination of care for patients' total healthcare needs
in a timely, personal manner that achieves measurable
high-quality outcomes
 Improvement the quality of care
 Address the social determinants of health
 Establish functioning financial arrangements
 Recruitment and training of culturally and linguistically
competent workforce
 Utilization of information technology for optimal
communication among health professionals and patients
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Physical Health and Substance Abuse
Alcohol and drug abuse as a causal or contributing
factor to illness, injury, or the transmission of
infectious disease (e.g., cocaine-induced myocardial
infarction, substance-related cardio- and skeletal
myopathy, alcohol induced bone loss, intentional and
unintentional injury, poor fetal outcomes, tobaccorelated cancers, hepatitis and HIV transmission among
drug injectors).
 Alcohol and drug abuse as an exacerbating factor to a
non-substance-related illness (e.g., abdominal pain,
diabetes, epilepsy, essential hypertension).
 Alcohol and drug abuse as a complicating factor in
treatment or patient compliance (e.g., asthma,
diabetes, depression, tuberculosis).
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Advantages of Integrating Substance Use &
Abuse Treatment into Primary Care
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Treatment goal is to end addiction and avoid relapse
Psychiatric co-morbidities such as anxiety and depression
are common in the substance abuse patient; must
aggressively managed by the team. If not, leads to increased
rates of addiction relapse.
Attention to health maintenance issues such as
hypertension, diabetes, obesity, tobacco use and lipids
essential.
Acute an chronic pain most safely managed in the SA
patient non-pharmacologically, and modalities such as
Physical Therapy, Chiropractic, Acupuncture and massage
can be safe and effective.
Treatment engagement and compliance.
SBIRT: Screening, Brief Intervention,
and Referral to Treatment
An evidence-based practice used to identify, reduce, and
prevent problematic use, abuse, and dependence on
alcohol and illicit drugs. Consists of 3 major components:
Screening: a healthcare professional assesses a patient for
risky substance use behaviors using standardized
screening tools. Screening can occur in any healthcare
setting.
 Brief Intervention: a healthcare professional engages a
patient showing risky substance use behaviors in a short
conversation, providing feedback and advice.
 Referral to Treatment: a healthcare professional provides
a referral to brief therapy or additional treatment to
patients who screen in need of additional services
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Chronic Disease May Lead to Depression
Chronic
disease
Increased
depression
and anxiety
Increased risk of
complications,
higher medical
costs
Additional
impairment
in
functioning
Poor
adherence
Increased
perception
of
symptoms
What is the PHQ-9?
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Is a nine item depression scale of the
Patient Health Questionnaire.
Is a powerful tool to assist clinicians
with diagnosing depression and
monitoring treatment response.
The nine items of the PHQ-9 are
based directly on the nine diagnostic
criteria for major depressive disorder
in the DSM IV.
Advantages to the PHQ 9
This tool :
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Is shorter than other depression rating scales,
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Can be administered in person, by telephone, or self-administered,
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Facilitates diagnosis of major depression,
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Provides assessment of symptom severity,
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Has proven effective in a geriatric population, (Löewe B,et al, 2004 Medical Care)
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Is well validated and documented in a variety of populations
FREE/PUBLIC DOMAIN: http://www.integration.samhsa.gov/images/res/PHQ%20%20Questions.pdf
Challenges to BH Treatment in
Primary Care
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Primary care providers may lack necessary
training and confidence, and even welltrained providers are limited in what they
can address in a 15 minute office visit.
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The time constraints of primary care
physicians have begun to force them to
redesign their practices and rely upon
ancillary providers in the management of
chronic disease.
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A Paradigm Shift-1
Imbed Cultural Competence
Administrative policies, job descriptions, performance
reviews, confidentiality agreements, and care
coordination practices should all reflect a culturally
competent integrated care practice.
◦ Establish a “change team” to influence culturally
competent integration.
◦ Consider a team composed of senior leaders, program
directors, and consumers from all of your organization’s
service areas.
◦ Develop organizational expectations, workflows, job
descriptions, performance review language, and quality
improvement benchmarks.
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A Paradigm Shift-2
Strategy: organization's strategic and business plans must
reflect culturally competent integrated health care goals as a
priority.
Technology: sharing information between primary care and
behavioral health providers is a core component to providing
culturally competent integrated health care services.
Source: SAMHSA-HRSA Center for Integrated Health Solutions; Hogg Foundation for Mental Health-OMH Consensus Report
(2012)
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A Paradigm Shift-3
Clinical Workflows: must be clear and consistent. Example: Are you
monitoring to ensure that your primary care and behavioral health staff
create person-centered culturally competent integrated health care plans
for each person served that includes all of the person’s behavioral health
and primary health goals?
Quality Improvement: CQI is a valuable way to make sure one is
meeting culturally competent integrated health care goals which improve
the overall health status of your clients.
Source: SAMHSA-HRSA Center for Integrated Health Solutions; Hogg Foundation for Mental Health-OMH Consensus Report (2012)
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Chronic Illness and Depression Care Management
Model: TEAMcare Variant
PCMH Primary Care Team
12 PCP, Nursing Staff
• Educate about benefits of treatment
• Initiate appropriate medication treatment
based on depression severity (PHQ-9 score)
and patient choice
• Screen for depression, confirm clinical
diagnosis
• Receive active feedback from Synergy Team
via EMR and/or telephone
Nurse Care Managers
3 experienced RNs, totaling 1 FTE effort
• Conducts comprehensive biopsychosocial
assessment
• Monitors PHQ-9 and medical indicators
• Chronic disease education
• Assists with appointments and concrete
services
• Uses patient-centered motivational strategies
to promote self management and wellness
Behavioral Health Manager (LCSW)
1 FTE
• Initiates screening, eligibility, assessment
• Conducts face-to-face behavioral health
treatment assessment and reviews treatment
plan with consulting psychiatrist
• Provides onsite and telephonic brief
psychotherapy tailored to patient’s needs
• Collaborates with nurse care manager,
Monitors PHQ-9, and medication effects,
including side effects
Consulting Psychiatrist
0.4 FTE
• Reviews cases with Synergy Team with
focus on patients not at target goals
• Reviews EMR and confirms/recommends
psychotropic medication adjustments or
additional workup to PCP
• Limited face-to-face treatment for complex
patients
• Available for telephone or email
collaboration
Care Manager
Essential to Integrated Care Team
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Provides patient-centered care
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Understands the person in their environment
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Coordinates care delivery systems
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Understands barriers and full and equal access
to care
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Communicates with the entire provider team
and family system
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Advocates for the patient’s rights
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Care Manager Role: Improving engagement,
treatment and follow-up
For Depression:
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Tracks outcomes (with quantitative
instruments)
Educates patients about depression
May offer a brief course of evidence based
counseling (billable service)
Monitors antidepressant therapy prescribed
by the patient's primary care provider
Monitors depression symptoms for treatment
response
Completes a relapse prevention plan patients
who have improved
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Enhancing the Delivery of Health Care: Eliminating Health Disparities through
a Culturally & Linguistically Centered Integrated Health Care Approach
Integrated Health Care:
National Movements
The Affordable Care Act
 Academy for Integrating Behavioral Health and
Primary Care, Agency for Healthcare Research
and Quality (AHRQ): Lexicon & Atlas
 Primary and Behavioral Health Care Integration
(PBHCI), Program, Substance Abuse and Mental
Health Administration.
 CMS Health Care Innovation Awards
 Behavioral Health and Integrated Care Initiative:
HHS Office of Minority Health
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Integrated Health Care
Organizational Level Example
The Connecticut Latino Behavioral Health System: a
collaborative of over a dozen organizations who have joined
with the Yale University School of Medicine/Department of
Psychiatry and the Connecticut Mental Health Center to build
a comprehensive system of care that integrates components of
behavioral health and primary care for the Latino population.
Provides qualitative and quantitative evaluation process
designed to assess the program at three levels: organizational,
staff and patient/consumer.
The Cultural Competency Index: designed to evaluate culturally
responsive clinical services and is being measured at three time
points. Evaluation at the staff level includes pre- and posttraining evaluations, satisfaction with trainings, and random tape
ratings to assess for language fluency and the integration of
Latino cultural values in treatment.
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If Not Now---------When?
The train is leaving has left the station!
 Health disparities persists.
 Affordable Care Act driving system change
 Increased demand for cost effectiveness &
outcomes.
 TRIPLE AIM! Improve outcomes, enhance the
patient experience of care, and decrease cost.
What does this mean for you?
Is your organization on the train?
What are you doing to strengthen/expand cultural
and linguistic competent integrated health care
services?
Opportunity to be a part of a “new”
system of care to address the “whole
health” needs of patients/consumers.
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Panel Contact Information
Katherine Sanchez, LCSW, PhD
Assistant Professor
Octavio N. Martinez, Jr., MD,
MPH
University of Texas, Arlington
ksanchez@uta.edu
Hogg Foundation for Mental Health
Pierluigi Mancini, Ph.D.
Teresa Chapa, Ph.D., MPA
Chief Executive Officer
Senior Policy Advisor, Mental Health
CETPA, Inc.
US DHHS, Office of Minority Health
www.cetpa.org
http://minorityhealth.hhs.gov/
Hogg-ED@austin.utexas.edu