Lifelong Personal Health Care (LPHC) team: Paul Block, Jeff Migneault, Kelly Madden

1. Lifelong Personal Health Care:Transforming health care throughfull integration of behavioral health intothe patient-centered medical home Lifelong Personal Health Care (LPHC) team: Paul Block, Jeff Migneault, Kelly Madden Theresa Costello, Renee Rulin, Jen Bowdoin Jonathan Leviss, Steve Schwartz

2. Patient care is team based with a central role given to a behavioral care provider (BCP, a health psychologist) for all patients: The BCP manages barriers to patient participation in self-care and in treatment, provides clinical evaluation, diagnosis, consultation, brief intervention, and behavioral medicine treatments to address specific behavioral targets of care All treatment plans are jointly developed Lifelong Primary Health Care (LPHC): • Fully integrated Patient-Centered Medical Home practice model • Development funded by grant from Rhode Island Foundation (a community foundation) • Currently finalizing implementation of first demonstration practice

3. What is integrated primary care? Integration is exquisitely difficult and is at the heart of what makes primary care work. Integration should not be confused with coordination. Coordination implies ordering and sequencing, while integration implies creating something new - in this case, something fitted to a particular individual patient. - deGruy & Etz (2010) • Integrated care is based on the principle that mental, social, and physical are indivisible, and accordingly that health care must target the whole person. • Integrated services routinely define all healthcare issues in terms of physical, social, and behavioral components. • The integrated healthcare team includes medical and behavioral providers who mutually design one treatment plan for each person receiving care, presented to the patient as a single treatment approach designed to best serve their needs. • Integrated healthcare services are offered concurrently and actively coordinated by all members of the team as relevant, each addressing every issue for which their perspective and expertise can make a significant contribution. - Building on Blount, Kathol, O’Donohue, Peek, Rollman, Schoenbaum, & Thompson (2005), the Allied Advocacy Group for Collaborative Care (2002), the Rhode Island Policy Roundtable on Collaborative Care (2003), and Block, Costello, & Fine (2004)

4. LPHC care

5. LPHC is financially sustainable under existing funding models available in Rhode Island Lifelong Primary Health Care (LPHC): • Care management in LPHC is divided between Administrative and Clinical • Administrative care management is provided by a specialized Care Coordinator (vs. a Nurse Care Manager or Medical Assistant) • Clinical care management is provided by the BCP (vs. a Nurse Care Manager)

6. How LPHC differs from standard PCMH team models

7. Most "integrated care" designs offer limited availability of behavioral health specialists: Services include immediate consultation and brief, well-coordinated interventions Behavioral targets are identified based on physician referral or patient match to criteria in care protocols Behavioral health is typically an adjunctive service Lifelong Primary Health Care (LPHC): • Compared to other medical home models that co-locate behavioral health services, LPHC: • Focuses on health behavior in addition to mental health (and substance abuse) • builds behavioral health into all care without requiring physician or other prior identification • addresses health behavior for every patient, as clinically relevant

8. Modest pmpm funding: supports implementation of the team model and integration of the behavioral perspective into routine care with additional flexibility and coordination among team members Without pmpm funding: The practice is still able to offer fully integrated behavioral care and care management as part of routine care Projected savings: Behavioral care management as part of routine care for all patients is expected to improve management of the health-related behaviors that are drivers of inefficiency and ineffectiveness of health care as it is now practiced Financial models available in Rhode Island

9. Later is here “It is inconceivable that whole person care can occur absent attention to and incorporation of the full psychosocial dimension of health and healthcare— mental healthcare, family and community contexts, substance abuse, and health behavior change (here collectively referred to as behavioral healthcare). Any PCMH that neglects this dimension is incomplete and will be ineffective. It will fail. A solid edifice of empirical evidence supports this rather uncompromising assertion.” “Comprehensive Primary Care Requires Negotiation Of Team Roles With Other Clinicians. We call this horizontal collaboration, which means collaboration with clinicians of more or less equal status… to produce functional team-based care…. Integration of behavioral healthcare into the PCMH is difficult…. The wins - for the health of our citizens, the restoration of our workforce, the effectiveness of our healthcare system, the advances in our science, and the health or our nation’s economy - far outweigh [the] costs.” - deGruy & Etz (2010)

10. Some reasons for supporting integration of behavioral health expertise into the core of the medical home team • People are not likely to do anything that's hard, such as… taking care of one's health — no matter how good the incentives are…. A new health care system could use psychology to figure out ways to give better medical care, not just more health care. • Peter Orszag, director of the Office of Management and Budget • Integrating behavioral health into medical care improves outcomes and reduces costs for mental health/substance abuse and medical problems, with potential for generating the largest untapped healthcare savings • e.g., Blount, Kathol, O’Donohue, Peek, Rollman, Schoenbaum, & Thompson, 2007; Chiles, Lambert, & Hatch, 1999; Pincus, Pechura, Keyser, Bachman, & Huntsinger, 2006 • PCPs report deteriorating work satisfaction. Their numbers are shrinking (e.g., National Resident Matching Program, 2006), but satisfaction is significantly higher among providers co-located with behavioral health specialists (Gallo et al., 2007)