1. Health Homes and
Behavioral Health/General
Medical Care Integration
On the Banks or in the Mainstream?
Harold Alan Pincus, MD
Professor and Vice Chair, Department of Psychiatry
Co-Director, Irving Institute for Clinical and Translational Research
Columbia University
Director of Quality and Outcomes Research
New York-Presbyterian Hospital
Senior Scientist, RAND Corporation
HHS Health Homes Webinar
February 25, 2011 1

2. The Bottom Line
• Co-morbidity of behavioral disorders and general medical conditions is highly
prevalent (especially in Medicaid populations
• This pattern of co-morbidity is especially concentrated among those who have
high costs and frequent hospital admissions
• These individuals die at younger ages
• Impacts and solutions go both ways across the GM/BH divide
– Primary Care patients needing Mental Health care, and
Mental Health patients needing Primary /Specialty Medical Care
• Evidence-based models for integrating care have been well documented
• These models have not been widely implemented due to structural barriers and
financial disincentives
• Health Home option provides flexibility and incentives and opportunity
HHS Health Homes Webinar
February 25, 2011 2

3. BH/GMC Clinical Examples
• 35 year old male with schizophrenia, diabetes, and
tobacco dependence
– Can expect up to 25 year shortened life span,
increased medical costs
• 25 year old HIV+ female IV drug user with PTSD
– Frequent ED visits, non adherence to meds,
increased medical costs
• 60 year old female with diabetes, CHF and
depression
– Frequent (re-) hospitalizations, poor self management
and adherence, early candidate for LTC
HHS Health Homes Webinar
February 25, 2011 3

4. Currently, Poor Quality and Care
Coordination for All Populations
• Patients primarily in contact with the general
medical sector with co-morbid BH conditions
(e.g., depression)
– Not treated or treated as acute problems with little follow-up
• Patients with severe and persistent BH
conditions (e.g., schizophrenia) and treated in
BH specialty settings
– Poor self-care, medications worsen general medical conditions
– Limited provider capacity and incentives for
• Accessing treatment of co-morbid medical conditions
• Preventive and wellness care
• Medical and BH providers operate in silos
HHS Health Homes Webinar
February 25, 2011

5. HHS Health Homes Webinar
LPHI/CIBHA Conference
February3-4, 2011
February 25, 5

6. HHS Health Homes Webinar
LPHI/CIBHA Conference
February3-4, 2011
February 25, 6

7. HHS Health Homes Webinar
LPHI/CIBHA Conference
February3-4, 2011
February 25, 2011 7

8. HHS Health Homes Webinar
February 25, 2011 8

9. Crossing the Quality Chasm
9

10. Crossing the Quality Chasm
Quality problems occur typically
not because of failure of goodwill,
knowledge, effort or resources
devoted to health care, but
because of fundamental
shortcomings in the ways care is
organized
The American health care delivery
system is in need of fundamental
change. The current care
systems cannot do the job.
Trying harder will not work:
Changing systems of care will!
LPHI/CIBHA Conference
February3-4, 2011 10

11. HHS Health Homes Webinar
February 25, 2011 11

12. Overarching Recommendation 1
The aims, rules, and strategies for redesign
set forth in Crossing the Quality Chasm
should be applied throughout M/SU health
care on a day-to-day operational basis but
tailored to reflect the characteristics that
distinguish care for these problems and
illnesses from general health care.
HHS Health Homes Webinar
February 25, 2011 12

13. Overarching Recommendation 2
Health care for general, mental, and
substance-use problems and illnesses must
be delivered with an understanding of the
inherent interactions between the mind /
brain and the rest of the body.
HHS Health Homes Webinar
February 25, 2011 13

14. René Descartes
HHS Health Homes Webinar
February 25, 2011 14

15. Don t Split Mind and Body
HHS Health Homes Webinar
February 25, 2011 15

16. GM/BH Integration Questions
• Why not?
• Who?
• When?
• Where?
• How?
• For whom?
• Why?
HHS Health Homes Webinar
February 25, 2011 16

17. Who? Responsibility for Care
Primary
Care
Provider
(PCP) Behavioral
Health
Specialist
(BHS)
HHS Health Homes Webinar
February 25, 2011 17

18. When?
Risk Factor Diagnosis/ Short-term Continuing
Identification/ Assessment Management Care
Prevention
HHS Health Homes Webinar
February 25, 2011 18

19. How?
Integrated Team
Collaborative Care
Consultative Care
Referral
Independent
Autonomous (PCP)
Autonomous (MHS)
HHS Health Homes Webinar
February 25, 2011 19

20. Evidence-Based Chronic (Planned) Care Approaches
for Treating Depression
Are Effective
Community Health System
Resources and Policies Health Care Organization
Self- Delivery Clinical
Decision Information
Management System Support Systems
Support Design
Productive Interactions
Patient-Centered Coordinated
Informed, Empowered Prepared, Proactive
Patient and Family Timely and Evidence- Practice Team
Efficient Based and Safe
Improved Outcomes
HHS Health Homes Webinar
February 25, 2011 20

21. Where?
Models of Linkage / Integration
Embedded PCP in BHS Co-location of BHS in PCP
B P
P B
Unified Coordination / Collaboration
B B P
HHS Health Homes Webinar
February 25, 2011 21

22. For Whom?
• Two Populations
– General/Primary Care with mild to moderate
BH conditions (e.g., anxiety, depression)
– Severe/Persistent Behavioral Health
Conditions (e.g., schizophrenia, drug
dependence)
• Two Strategies
– Mainstream
– Separate BH Specialty Adaptations
HHS Health Homes Webinar
February 25, 2011 22

23. Two Overall Strategies
Strategy 1: Primary Care Health Home
For patients primarily in contact with
general medical sector
(and mild to moderate BH conditions):
• Organize around primary care/general medical setting
• Apply evidence-based clinical and organizational
strategies
• Design specific policy tools to hold medical providers
accountable for meeting the BH care needs of patients.
HHS Health Homes Webinar
February 25, 2011

24. Two Overall Strategies
Strategy 2: BH Health Home
For patients with severe and persistent BH
conditions and primarily treated in a BH
specialty setting:
• Organize health home around BH setting
• Apply evidence-based clinical and organizational
strategies
• Develop specific policy tools to assure access to high-
quality primary care and non-BH specialty care
HHS Health Homes Webinar
February 25, 2011

25. Evidence-Based
Integration Mechanisms
• Clinical integration of services, or
• Co-location of services
• Formal agreements with external providers
• Shared patient records
• Screening and longitudinal monitoring
• Clinical registry
• Care management
• Evidence-based guideline support/training
• Measurement-based / Stepped care
• Close collaboration with other specialty, substance abuse
care and human services providers
HHS Health Homes Webinar
February 25, 2011 25

26. Policy Strategies
• Medical/ Health Home Models
• Accreditation
– New NCQA criteria expand BH expectations
• Quality Incentives
• Mutual Accountability Across BH and GM Providers
– For Quality and Costs
• Payment Related to Complexity
– Tiers/Risk Adjustment
• Support Improved Communication
– EMRs, Health Information Exchanges (with protections)
• Training and Technical Assistance
• Flexibility
HHS Health Homes Webinar
February 25, 2011 26

27. BH/GMC Programmatic Examples
• SAMHSA Primary and Behavioral Health Care
Integration Program
• Minnesota DIAMOND Project
• Community Care of North Carolina
• IMPACT Model
• PCARE Model
• SAMHSA/HRSA-funded Technical Assistance
Center (NCCBH)
HHS Health Homes Webinar
February 25, 2011