Caring for Our Aging
Population:
An Integrated Care Approach
Presentation by:
Eric Christian, MAEd, LPC, NCC, Director of Behavioral Health Integration, CCWNC
Mary Buttitta, MS, LPC, IMPACT Program Coordinator, CCWNC
Some slides curtesy of:
Courtney Cantrell, Ph.D.
Cathy M. Hudgins, Ph.D., LPC, LMFT
Learning Objectives
Identify the basic concepts of Integrated Care
and the rationale for team-based treatment
Describe the unique health, mental health, and
substance abuse treatment needs of older adults
Describe collaborative care approaches to
depression care
Integrated Care –
What is it?
Mental health and medical care providers working together
to address both the physical and mental health needs of
their patients.
Evidence-based, strategic framework that addresses the
whole person, no matter which “door” the person enters.
Assumes that health is a shared community responsibility
and can be achieved through the dissolution of barriers that
result in silo-style service provision (Mauer & Jarvis, 2010).
The “Graying” of America
By the year 2025, the world’s older
population (60 and older) will
approach 1.2 billion.
By the year 2030, 1 of every 5
people in the U.S. will be 65 or older.
Older Americans will number more
than 65 million
Integrated Care –
Why do it?
Older adults CAN have at least two chronic health conditions, including heart
disease, cancer, and stroke and these CAN be exacerbated by MODIFIABLE
health behaviors:
Smoking
Poor diet
Physical inactivity (Mokdad et al., 2004)
Older adults have high levels of depression and anxiety with:
Obstructive pulmonary disease (Maurer et al., 2008)
Rheumatoid arthritis (Isik et al., 2007)
Type II diabetes (Grigsby et al., 2002)
The highest rates of depression are found in those with strokes (30% to 60%),
coronary artery disease (up to 44%), cancer (up to 40%), Parkinson's disease (40%),
and Alzheimer's disease (20% to 40%)
(Birrer et al., 2004)
Older Adults Have More
Chronic Health Problems
Even small amounts of alcohol can:
Cause or create medical conditions;
Produce unsafe medication interactions;
Increase falls, confusion, depression, and insomnia; and
Cause premature mortality.
Alcohol abuse is often undetected and untreated in older adults.
(TIP #26)
Older Adults and Alcohol
Older adults
purchase over ¾ of all OTC medications, and often misuse them.
consume more prescribed and OTC medications than any other age group
in the United States.
Prescription drug misuse and abuse is prevalent among older
adults not only because more drugs are prescribed to them but
because, as with alcohol, aging makes the body more vulnerable
to drugs’ effects.
Antipsychotic drugs, which are commonly and often
inappropriately prescribed to older adults with behavioral
problems, leads to problematic, potentially dangerous symptoms
and side effects.
(Steinhagen, 2008)
Prescription Drugs and
Medications
Social isolation
Loss of capacity
Grief and loss
Unmarried due to death of partner or divorce
Medical illness of partner or self
Caregiving responsibilities
Depression at an earlier stage of life
(Unutzer et al., 1999)
Our Older Adults have more
RISKS after the age of 65
AND…Let’s not forget about
COST!
The US Health System is the MOST costly in the WORLD!
17% of the gross domestic product (GDP) is spent on
HEALTH CARE
with estimates that this percentage will grow to nearly
20% by 2020!
Compare this to other developed
countries that spend between
9 – 11 % GDP
Source: National Healthcare Expenditure Projections, 2010-2020. Centers
for Medicare and Medicaid Services, Office of the Act
How does Integrated
Care work?
Medical and behavioral health providers partner to
Screen,
treat,
and follow patient’s behavioral and physical conditions.
The patients’ entry into services drives the model:
Behavioral health into the healthcare setting,
Healthcare into the behavioral healthcare setting
The level of integration is on a continuum -- from minimal
collaboration to fully integrated, whole person care.
Snapshot: An Integrated Care Program
Nurse screens clients to
establish care and annual
appointments
Physician sees client
and validates screening
Physician introduces
client and therapist
Physician and therapist
provide team approach
for coordinated care
• Screening
• Assessment
• Brief supportive counseling
• Therapy
• Case management
• Medication monitoring
• Coordinated team care
Behavioral Health Services integrated
with Primary Health Care:
Adapted from Mendenhall, Lamson, & Hodgson, 2010
Common Goals for
Integrated Healthcare
Recognition and treatment of mental health,
substance use, and medical disorders with a focus
on functioning;
Early detection of “at risk” clients, with the aim of
preventing further mental or physical deterioration;
Prevention of relapse or morbidity in conditions
that tend to recur over time and go hand in hand;
Prevention and management of addiction to pain
medicine or tranquilizers;
There are many faces of
aging…
You can not know how age
thinks…
What stories remain to be told…
What gifts still to give…
What work remains to be
done…
What wisdom remains to be
taught…
What love remains to share
DEPRESSION IS A THIEF
LATE LIFE DEPRESSION
Profound effects on quality of life, functioning
and healthcare costs.
5 million out of 31 million adults over 65 in the
U.S. have significant depressive symptoms
Few receive specialty mental health care
compared to a younger population
IMPACT – Improving Mood, Promoting
Access to Collaborative Treatment
Designed to address the unmet needs of these older adults
Gellis, Kenaley, & McCracken, 2014
IMPACT WORKS TO
RESTORE… FUNCTIONING
Connection…
And Meaning….
IMPACT Study Results
1998-2003 – 80 research studies show:
Less depression
Less physical pain
Better functioning
Higher quality of life
Greater patient and provider satisfaction
Cost effective
Effective with minority populations
Unützer, et all, 2002
Model Effectiveness
At 12 months, about half of the patients
receiving IMPACT care reported at least a 50
percent reduction in depressive symptoms
(19% in usual care i.e.: ANYTHING ELSE!)
A survey conducted one year after IMPACT
shows that the benefits of the intervention
persist after 1 year and last up to 4 years
Unützer, et all, 2002
What we are doing
CCWNC was invited by Kate B. Reynolds Charitable Trust to
apply for a grant to implement the IMPACT model
KBR mission: serve the needy and unserved population
2 counties each with 1 practice
Each practice has 3 sites
Provide model for a 3 year period
Pilot project to determine
Can we achieve the same outcomes as the studies
Can this model be expanded across the state
Is it sustainable
IMPLEMENTING THE MODEL
The Implementation Team
Critical to success of the program
Identified 6 months before launch date
Comprised of key staff
Charged with making system wide changes
Staff training and orientation to the model
Changes to the EMR to accommodate referral flow
Patient Education Material
Designate space for the ICM to meet with patients
Develop the work flow
http://uwaims.org/img/Collaborative_Team_Approach.png
Work Flow
Contact with Patient is made
Initial Assessment conducted
Begin treatment – Medications and/or
Therapy
Track progress in EMR and Registry
Case Review with PCP champ, Psychiatrist and
ICM for those not improving
Registry
Patient Work List
Registry Functions
Tracks patient success
Makes sure patients don’t fall in between the cracks
Determines clinical decision making at key milestones
Ensures that 70% of patients are receiving Psychiatric
consult
Helps with oversite work load balance and referrals by
team members
Cost Effectiveness
Average cost ~ $580./participant
Cost of IMPACT to an insured older
population ~ $1 /member/month
(PMPM)
Overall Health care in 4 yr period
(IMPACT included) was ~ $3,300. less
Unützer, et all, 2008
Sustainability
Payment reform to capitated value-based care
Accountable Care Organizations: forming but data outcomes
and realized savings at the practice-level are far off
Intermountain Study: 113, 452 Patients. NCQA influenced
practices (have PCMH activities and team-based care) who also
have BH integration have significantly better cost and health
outcomes than those without Team-Based Care. In addition, the
cost of implementation and support needed to build these
routines is covered by the financial savings realized by Team-
Based care.
Cost Effectiveness continued: Kaiser Permanente results are
encouraging for value based care.
Reiss-Brennan B, Brunisholz KD, Dredge C, et al., 2016
CMS Proposed G Codes
GPPP1 - Initial psychiatric collaborative care management, first
70 minutes in the first calendar month .
Outreach to and engagement in treatment of a patient
Initial assessment review by the psychiatric consultant
Entering patient in a registry/ tracking patient follow-up and progress
Weekly caseload consultation with the psychiatric consultant
Provision of brief interventions: behavioral activation, motivational
interviewing, and other focused treatment strategies.
https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2016-Press-releases-items/2016-07-07.html
CMS Proposed G Codes
GPPP2 - Subsequent psychiatric collaborative care management,
first 60 minutes in a subsequent month .
Tracking patient follow-up and progress using the registry
Weekly caseload consultation with the psychiatric consultant
Ongoing collaboration with and coordination of the patient's mental
health care with the treating physician or other mental health providers
Review of progress and recommendations for changes in treatment
Monitoring of patient outcomes using validated rating scales
Relapse prevention planning with patients as they achieve remission of
symptoms and/or other treatment goals and are prepared for discharge
from active treatment.
CMS Proposed G Codes
GPPP3 - Initial or subsequent psychiatric collaborative
care management, each additional 30 minutes in a
calendar month
(List separately in addition to code for primary
procedure)
(Use GPPP3 in conjunction with GPPP1, GPPP2)
https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2016-Press-releases-items/2016-07-07.html
Key Points for Success
Importance of leadership and organizational
commitment
Integrated health care as part of the “culture” of an
organization
Orientation/Education is important for patients and
clinic staff
Registry functionality is a necessity
Pre-screening with PHQ2 is more effective than
PHQ9 to determine eligibility in older adults
Bauer, A. M., Azzone, V., Goldman, H. H., et al. (2011)
Birrer, R. B., & Vemuri, S. P. (2004). Depression in later life: a diagnostic and therapeutic challenge. American Family
Physician, 69, 2375-2382.
Bogner, H., Morales, K., Post, E., Bruce, M. (2007). Diabetes, depression, and death: A randomized controlled trial of
a depression treatment program for older adults based in primary care (PROSPECT), Diabetes Care, 30, 3005–3010.
Boult, C., Green, A.F., Boult, L.B., Pacala, J.T., Snyder, C., & Leff, B. (2009). Successful models of comprehensive care
for older adults with chronic conditions: Evidence for the Institute of Medicine’s “retooling for an aging America”
report. Journal of the American Geriatrics Society, 57, 2328-2337.
Bruce, M. L., & Pearson, J. L. (1999). Designing an intervention to prevent suicide: PROSPECT (Prevention of Suicide
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Callahan, C.M., Boustani, M., Sachs, G.A., & Hendrie, H.C. (2009). Integrating care for older adults with cognitive
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Center for Substance Abuse Treatment. Substance Abuse Among Older Adults. (1998). Treatment improvement
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References and Resources
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http://uwaims.org/img/Collaborative_Team_Approach.png
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https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2016-Press-releases-items/2016-07-07.html
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Obstacles such as transportation and financial concerns
make it less likely for older adults to be able to access
mental health treatment outside of primary care.
Older adults and providers may have maladaptive beliefs
about aging and mental health. (Rybarczyk et al., 2013)
Older patients are generally less likely to perceive a need
for mental health care and are less likely to receive
referrals for specialty mental health care (Klap et al., 2003).
Barriers to Mental Health
Treatment for Older Adults
