Value-Based Integrated Case Management at Payor Level: Implementation and Impact.

PURPOSE OF STUDY: Case management is an ideal service for patients with health complexity. However, most case management models do not integrate medical and behavioral health training and interventions, and there are little data evaluating these models in privately insured populations. The purpose of this study was to evaluate impact of an integrated case management (ICM) service at the payor level. PRIMARY PRACTICE SETTING: Health care insurance company. METHODOLOGY AND SAMPLE: A multimethod observational study was conducted at a health care insurance company in the Pacific Northwest of the United States. We conducted focus groups of case managers, leaders, and administrators and statistical analyses of outcomes data. Measures included care quality data (discharge follow-up appointment, cost per case, depression and anxiety measures, customer experience and satisfaction, and audit scores) of members receiving ICM services and employee focus group data (acceptability, adoption, feasibility, appropriateness, fidelity, and sustainability) related to the practice of ICM. RESULTS: Care quality data suggest ICM reduces mental health symptoms and increases discharge follow-up appointments for members. Implementation challenges include new employee orientation to ICM model, traditional views of case management, performance evaluation, documentation, and information technology. Facilitators of implementation include training, autonomy, and leadership support. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: Organizations should be aware both of the benefits and challenges related to implementing ICM. Open communication between case managers and leadership and an improvement-focused culture appear to be important elements of implementation success. Future research should examine the perspective of members receiving ICM services and the implementation of ICM into health care delivery systems.

Specialty Psychiatric Services in US Emergency Departments and General Hospitals: Results From a Nationwide Survey.

OBJECTIVE: To explore the handling of psychiatric patients in medical hospitals and emergency departments (EDs) as well as hospital characteristics associated with the availability of psychiatric services in these settings. METHODS: From October 1, 2017, to April 1, 2018, a telephone survey regarding the presence and nature of psychiatric services was attempted among all US registered Medicare hospitals. RESULTS: Of the included 4812 US hospitals, 2394 (50%) were surveyed. Of these hospitals, 1108 (46%) have some psychiatric services available, either in medical EDs or through psychiatric consultation on general medical inpatient wards. If medical ED patients with active psychiatric issues need admission, 59% of hospitals transfer the patient to a different hospital and 28% admit the patient to a medical ward. Exploration by logistic regression analysis of the association of selected variables and available psychiatric expertise suggested that larger hospitals, nonprofit services, or hospitals in urban settings were more likely to have psychiatrists on staff or available for consultation. CONCLUSION: Despite the growing number of psychiatric patients seeking help in medical EDs and general hospitals, more than 50% of the EDs and general hospitals lack psychiatric services. These results suggest that accessibility to psychiatric care in medical settings requires improvement.

Integrating behavioral health & primary care for multiple chronic diseases: Clinical trial of a practice redesign toolkit.

Context: Most patients in need of behavioral health (BH) care are seen in primary care, which often has difficulty responding. Some practices integrate behavioral health care (IBH), with medical and BH providers at the same location, working as a team. However, it is difficult to achieve high levels of integration. Objective: Test the effectiveness of a practice intervention designed to increase BH integration. Study Design: Pragmatic, cluster-randomized controlled trial. Setting: 43 primary care practices with on-site BH services in 13 states. Population: 2,460 adults with multiple chronic medical and behavioral conditions. Intervention: 24-month practice change process including an online curriculum, a practice redesign and implementation workbook, remote quality improvement coaching services, and an online learning community. Outcomes: Primary outcomes were changes in the 8 Patient-Reported Outcomes Measurement Information System (PROMIS-29) domain scores. Secondary outcomes were changes in medication adherence, self-reported healthcare utilization, time lost due to disability, cardiovascular capacity, patient centeredness, provider empathy, and several condition-specific measures. A sample of practice staff completed the Practice Integration Profile at each time point to estimate the degree of BH integration in that site. Practice-level case studies estimated the typical costs of implementing the intervention. Results: The intervention had no significant effect on any of the primary or secondary outcomes. Subgroup analyses showed no convincing patterns of effect in any populations. COVID-19 was apparently not a moderating influence of the effect of the intervention on outcomes. The intervention had a modest effect on the degree of practice integration, reaching statistical significance in the Workflow domain. The median cost of the intervention was $18,204 per practice. In post-hoc analysis, level of BH integration was associated with improved patient outcomes independent of the intervention, both at baseline and longitudinally. Conclusions: The specific intervention tested in this study was inexpensive, but had only a small impact on the degree of BH integration, and none on patient outcomes. However, practices that had more integration at baseline had better patient outcomes, independent of the intervention. Although this particular intervention was ineffective, IBH remains an attractive strategy for improving patient outcomes.

Integrating Behavioral Health and Primary Care (IBH-PC) to improve patient-centered outcomes in adults with multiple chronic medical and behavioral health conditions: study protocol for a pragmatic cluster-randomized control trial.

BACKGROUND: Chronic diseases that drive morbidity, mortality, and health care costs are largely influenced by human behavior. Behavioral health conditions such as anxiety, depression, and substance use disorders can often be effectively managed. The majority of patients in need of behavioral health care are seen in primary care, which often has difficulty responding. Some primary care practices are providing integrated behavioral health care (IBH), where primary care and behavioral health providers work together, in one location, using a team-based approach. Research suggests there may be an association between IBH and improved patient outcomes. However, it is often difficult for practices to achieve high levels of integration. The Integrating Behavioral Health and Primary Care study responds to this need by testing the effectiveness of a comprehensive practice-level intervention designed to improve outcomes in patients with multiple chronic medical and behavioral health conditions by increasing the practice's degree of behavioral health integration. METHODS: Forty-five primary care practices, with existing onsite behavioral health care, will be recruited for this study. Forty-three practices will be randomized to the intervention or usual care arm, while 2 practices will be considered "Vanguard" (pilot) practices for developing the intervention. The intervention is a 24-month supported practice change process including an online curriculum, a practice redesign and implementation workbook, remote quality improvement coaching services, and an online learning community. Each practice's degree of behavioral health integration will be measured using the Practice Integration Profile. Approximately 75 patients with both chronic medical and behavioral health conditions from each practice will be asked to complete a series of surveys to measure patient-centered outcomes. Change in practice degree of behavioral health integration and patient-centered outcomes will be compared between the two groups. Practice-level case studies will be conducted to better understand the contextual factors influencing integration. DISCUSSION: As primary care practices are encouraged to provide IBH services, evidence-based interventions to increase practice integration will be needed. This study will demonstrate the effectiveness of one such intervention in a pragmatic, real-world setting. TRIAL REGISTRATION: ClinicalTrials.gov NCT02868983 . Registered on August 16, 2016.

Impact of Behavioral Health Comorbidities on Health Care Costs Among Japanese Patients With Cancer.

BACKGROUND: Little is known about how behavioral health (BH) conditions affect health care costs of patients with cancer in Japan. OBJECTIVE: The purpose of this study is to evaluate the magnitude of general medical claims expenditures for individuals with cancer who use or do not use BH services in Japan. METHODS: The study used a health insurance claims database for more than 3 million enrollees in Japan. All health plan enrollees (18 y or older) who had tumors without metastasis or metastatic solid tumors defined by the Charlson Comorbidity Index were included in the study (n = 20,260). Measurements included total claims expenditures for BH and medical services. RESULTS: The proportion of enrollees using BH services was 12.8%. BH service users accounted for 17.7% of total health service spending. Mean annual cost of total health care services were 1.5 times higher in BH users than those with no BH use, whereas the median was 1.8 times higher. Mean annual medical cost alone for BH users was 1.3 times higher than that for non-BH users, whereas the median was 1.5 times higher. CONCLUSIONS: The findings suggest the importance for the Japanese medical system to address BH needs of patients with cancer and introduce fiscal efficiencies to cancer care. Strategic implementation of effective integrated care services for patients with cancer should be considered in Japan.

General medical claims for behavioral health patients in Japan.

OBJECTIVES: To evaluate the magnitude of general medical claims expenditures (ie, medical service use) for individuals who use and do not use behavioral health (BH) services in the Japanese free-access medical insurance system to determine if BH patients use substantially more health services, as has consistently been reported in the United States. STUDY DESIGN: Retrospective comparison of Japanese occupation-based total health services use for enrollees with and without comorbid BH conditions. METHODS: The study used a health insurance claims database for more than 3 million enrollees in Japan. All health plan enrollees (18 years and older) who had at least 1 diagnosis of a chronic medical condition were included in the study (N = 192,613). Measurements were total claims expenditures for BH and medical services. RESULTS: The proportion of enrollees using BH services was 14.3%. BH service users accounted for 21.1% of total health service spending. Annual total costs of BH service users were 1.6 times higher than those of non-BH users. Annual medical costs of BH users were 1.3 times higher than those of non-BH users. CONCLUSIONS: The results of this Japanese cohort study show that patients with concurrent BH conditions and chronic medical illnesses have substantially lower total health care costs than numerous studies have demonstrated in US populations. This is perhaps in part due to the integration of medical and BH claims payment and care delivery in Japan, an approach that the US health system may wish to consider testing.

Payment reform in the patient-centered medical home: Enabling and sustaining integrated behavioral health care.

The patient-centered medical home (PCMH) is a promising framework for the redesign of primary care and more recently specialty care. As defined by the Agency for Healthcare Research and Quality, the PCMH framework has 5 attributes: comprehensive care, patient-centered care, coordinated care, accessible services, and quality and safety. Evidence increasingly demonstrates that for the PCMH to best achieve the Triple Aim (improved outcomes, decreased cost, and enhanced patient experience), treatment for behavioral health (including mental health, substance use, and life stressors) must be integrated as a central tenet. However, challenges to implementing the PCMH framework are compounded for real-world practitioners because payment reform rarely happens concurrently. Nowhere is this more evident than in attempts to integrate behavioral health clinicians into primary care. As behavioral health clinicians find opportunities to work in integrated settings, a comprehensive understanding of payment models is integral to the dialogue. This article describes alternatives to the traditional fee for service (FFS) model, including modified FFS, pay for performance, bundled payments, and global payments (i.e., capitation). We suggest that global payment structures provide the best fit to enable and sustain integrated behavioral health clinicians in ways that align with the Triple Aim. Finally, we present recommendations that offer specific, actionable steps to achieve payment reform, complement PCMH, and support integration efforts through policy. (PsycINFO Database Record

The role of behavioral health services in accountable care organizations.

Nationally, care delivery organizations are developing accountable care organizations (ACOs), but few have an appreciation of the importance of behavioral health services or knowledge about how to include them in an ACO since their funding and delivery are currently segregated from other medical services. This commentary reviews data on the impact of patients with concurrent medical and behavioral health conditions. They indicate that three-fourths of patients with behavioral health disorders are seen in the medical setting, but are largely untreated because few medical patients choose to access the behavioral health sector, which is where behavioral health providers are paid to work. Untreated behavioral health conditions in medical patients are associated with persistent medical illness and significantly increased total medical healthcare service use and cost, especially in those with chronic medical conditions. At a national level, those with behavioral health conditions use one-third of total healthcare resources. This will not change unless at-risk ACOs can effectively correct the mismatch between behavioral health patients and behavioral healthcare delivery. The authors suggest that ACO subcontracting for traditional segregated behavioral health services, whether from local provider groups or external vendors, will not achieve ACO-mandated access, treatment, and cost reduction goals. Rather, behavioral health specialists will need to become core ACO member providers. This will allow them to be deployed along with other member providers using value-added delivery approaches in the medical setting to integrate medical and behavioral health service delivery, and to achieve synergistic health and cost improvement.

Using the INTERMED complexity instrument for a retrospective analysis of patients presenting with medical illness, substance use disorder, and other psychiatric illnesses.

BACKGROUND: The financial and treatment challenges of complex patients must be addressed with adequate assessment and evaluation. The INTERMED complexity instrument (INTERMED) has been developed for this purpose, but to date has not been used retrospectively. The current study represents a retrospective validity investigation of INTERMED with patients with substance use disorder comorbid with other psychiatric and medical conditions (triple diagnoses). Such patients were expected to generate high complexity scores on the INTERMED instrument. METHODS: Information on 66 patients with triple diagnoses was submitted to the INTERMED complexity grid. These data were subjected to cluster analysis and other analytic procedures. RESULTS: Total INTERMED scores reflected elevated complexity for patients with triple diagnoses. As a group, they represented a single cluster of complex patients. CONCLUSIONS: The validity of the INTERMED complexity assessment was corroborated in relation to retrospective data. In addition to elevations in the biological domain that hospital personnel typically confront, findings related to coping deficiencies and problems in living conditions were noteworthy in requiring comprehensive interventions.

Value-based financially sustainable behavioral health components in patient-centered medical homes.

Because a high percentage of primary care patients have behavioral problems, patient-centered medical homes (PCMHs) that wish to attain true comprehensive whole-person care will find ways to integrate behavioral health services into their structure. Yet in today's health care environment, the incorporation of behavioral services into primary care is exceptional rather than usual practice. In this article, we discuss the components considered necessary to provide sustainable, value-added integrated behavioral health care in the PCMH. These components are to: (1) combine medical and behavioral benefits into one payment pool; (2) target complex patients for priority behavioral health care; (3) use proactive onsite behavioral "teams;" (4) match behavioral professional expertise to the need for treatment escalation inherent in stepped care; (5) define, measure, and systematically pursue desired outcomes; (6) apply evidence-based behavioral treatments; and (7) use cross-disciplinary care managers in assisting the most complicated and vulnerable. By adopting these 7 components, PCHMs will augment their ability to achieve improved health in their patients at lower cost in a setting that enhances ease of access to commonly needed services.

Fostering sustainable, integrated medical and behavioral health services in medical settings.

The integration of behavioral health (BH) and primary care services has been the subject of considerable attention for almost a decade. Such work has been motivated by the prevalence of chronic health problems in persons with BH conditions and correspondingly high rates of early death. Service integration efforts typically included cross-referral or bidirectional efforts to add some features of primary care to specialty BH settings or the reverse. This article proposes a third approach based on full service and financial integration and shows how it differs substantially from the other 2 models. This new model has the potential to bring much-needed BH services to persons served in primary care settings who have these conditions, while fostering integrated services in specialty settings for those with the most severe mental or substance use conditions. The Patient Protection and Affordable Care Act could provide a valuable opportunity to implement this third model.

What is integrated care?

Increasing awareness of mental illness's impact on medical and psychiatric health has accelerated global efforts to integrate medical and behavioural health services. As the field of integration has advanced, numerous integrated programmes have been implemented. In examining the impact of these programmes, it is important to maintain a standardized vocabulary to describe the various components of their integration. Additionally important is examination of how these programmes impact elements of patient care and the healthcare system. Specifically, what value do they bring? This article will discuss the importance of carefully assessing the value integrated services bring to patients, and questioning whether they do so in ways in which today's segregated world of medical and behavioural health cannot. This article will also explore the various settings in which medical and behavioural integration can bring added value.

Creating clinical and economic "wins" through integrated case management: lessons for physicians and health system administrators.

OBJECTIVE: This article describes an innovative integrated approach to case management using a standardized complexity assessment grid and communication tool, which is designed to identify barriers to improvement in 4 domains: biological, psychological, social, and health system; to create and implement holistic care plans based on "anchored barriers; and to document ongoing targeted outcomes. PRACTICE SETTINGS: Adult and pediatric case and disease managers working for hospitals or clinics, health care delivery systems, general medical health plans, care management vendors, government agencies, and employers can effectively employ integrated case management procedures. INTEGRATED CASE MANAGEMENT: Integrated case management augments traditional care coordination by allowing trained medical or mental health managers to assist with cross-disciplinary barriers without handoffs; to connect multidomain barriers to mutually agreed-upon care plan goals and activities; and to measure clinical, functional, fiscal, quality of life, and satisfaction outcomes as a part of the management process, especially in high-cost, complex patients. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: Integrated case management provides a step-by-step interdisciplinary approach for helping complex patients that has the potential to maximize clinical and functional value, while reducing total health-related costs.

Reprint of: Psychosomatic medicine and consultation-liaison psychiatry: scope of practice, processes, and competencies for psychiatrists working in the field of CL psychiatry or psychosomatics. A consensus statement of the European Association of Consultation-Liaison Psychiatry and Psychosomatics (EACLPP) and the Academy of Psychosomatic Medicine (APM).

OBJECTIVE: In 2008, the Board of the European Association of Consultation-Liaison Psychiatry and Psychosomatics (EACLPP) and the Academy of Psychosomatic Medicine (APM) Council commissioned the creation of a task force to study consensus-based summaries of core roles, scope of clinical practice, and basic competencies for psychiatrists working in the field of Psychosomatic Medicine (PM) and/or Consultation-Liaison Psychiatry (CLP). METHOD: The task force used existing statements of competencies and feedback from EACLPP and APM symposia and workshops to develop a draft document. After review by the EACLPP and APM committees, and the EACLPP Board and APM Council, a period of comment from the field preceded a final draft resubmitted for consideration of the EACLPP Board and APM Council in February 2010. RESULTS: The two organizations completed approval of final publication of the consensus statement on June 11, 2010. This consensus statement is a summary of clinical competencies, scope of clinical effort, and roles considered by the sponsoring organizations to be fundamental to the practice of this subspecialty or special area of expertise, anywhere, of PM or CLP. CONCLUSION: This consensus statement delineates a set of basic competencies and roles of a PM/CLP psychiatrist to serve as an internationally recognized base that may be used by national societies and institutions to formulate their own competencies, scope of practice, and roles or help with guideline formulation.

Does integrated care improve treatment for depression? A systematic review.

Care management-based interventions promoting integrated care by combining primary care with mental health services in a coordinated and colocated manner are increasingly popular; yet, the benefits of specific approaches are not well established. We conducted a systematic review of integrated care trials in US primary care settings to assess whether the level of integration of provider roles or care process affects clinical outcomes. Although most trials showed positive effects, the degree of integration was not significantly related to depression outcomes. Integrated care appears to improve depression management in primary care patients, but questions remain about its specific form and implementation.