Mayo Clinic experience integrating behavioral healthcare

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The Mayo Clinic, in Rochester, Minnesota, is widely known as a world-class healthcare destination for patients with rare, difficult-to-treat conditions. Less well-known is the fact that Mayo has an extensive primary care system, with a diverse patient population of over 140,000, some including employees and their families, as well as those patients living in Olmsted County, Minnesota who choose Mayo for their primary care. NHMH recently asked a leading Mayo physician about efforts at Mayo to integrate the care of mental health issues into primary care.

Dr. Mark Williams is a Mayo physician with a specialty in psychiatry who was closely involved in bringing the collaborative care model to Mayo’s primary care system. After training at Mayo in Psychiatry, he spent nine years working in a variety of psychiatric settings before returning to Mayo to practice his specialty

“Mayo has always been good at forming teams,” he says explaining why he chose to return to treat primary care based patients. Shortly after coming to Mayo, Dr. Williams had the opportunity to help lead a Mayo team to attempt to integrate a collaborative care model for adult depression into one of several primary care clinics at Mayo. This project, led by the Institute for Healthcare Improvement (IHI), was attempting to see if teams could use concepts from Dr. Ed Wagner’s chronic care model to address the chronic illnesses of depression and asthma in primary care clinics around the country. The details of the model were very similar to the IMPACT (Improving Mood: Providing Access to Collaborative Treatment) collaborative care model designed by Jurgen Unutzer, M.D. and others at the University of Washington.

Despite showing improved patient outcomes from this project, the program failed to continue in the primary care clinic involved. “This was a good lesson” says Williams because it illustrates how hard it is to sustain good improvements in the complex world of clinical care. Some of the barriers included a need to reorganize the IT support, a need to have more consistent psychiatric availability, a need for a standard tool across the practice to measure outcomes for depression, and the need to develop the role of a care coordinator for nursing. It was clear true integration meant more than sharing space.

In the years following IHI’s project at Mayo, broader changes began occurring: disease management developed, Mayo merged its three primary care groups, community pediatrics, internal medicine and family medicine, into one entity. Also, the cost of high-use patients, especially those with untreated behavioral conditions and co-occurring medical conditions, became more obvious, with concerns that disease management techniques were not necessarily focused on this group. The PHQ-9 (patient questionnaire on depression symptoms) became the go-to tool for screening patients for behavioral issues in both primary and specialty medical care.

Phase Two in Mayo’s integration arc commenced in 2007 with development and implementation of the DIAMOND program (Depression Improvement Across Minnesota, Offering a New Direction) aimed at adult depression in primary care. DIAMOND was again based on a caremodel created by Wayne Katon, M.D. and tested as IMPACT in a randomized controlled trial by Dr. Unutzer. DIAMOND’s key features were use of the PHQ-9 for screening and ongoing management of depression symptoms; a registry to track patients’ progress; stepped-care approach for treatment modification if patient not improving; a relapse program; a care manager to support and coordinate care and facilitate inter-team communication; and a psychiatric consultant engaged with care manager and PCP in weekly patient caseload review. Fidelity to these components was essential.

Showing success, by 2010 Mayo had spread the DIAMOND program to all its primary care clinics. The results were even better than earlier attempts. Now sustainable good outcomes were happening and there was increased interest in integrating behavioral health on a permanent basis. Mayo formed its first Integrated Behavioral Health (IBH) group under David Katzelnick, M.D. as chair of IBH for all its clinics.

The IBH then went on to further develop the EMERALD (Evidence-Based Recognition of Adolescents Living with Depression) program for teens with depression in primary care; the CALM (Coordinated Anxiety Learning and Management) program for adults with anxiety disorders in primary care, and models for collaborative care for primary care patients with co-existing depression and cardiovascular or diabetes disease.

Mayo’s Phase Three began in 2012 when the Centers for Medicare and Medicaid Services (CMS) awarded $18 million to a national consortium led by the Institute for Clinical Systems Improvement (ICSI). The consortium, comprised of ten healthcare organizations, including the Mayo Clinic, is implementing the COMPASS (Care of Mental, Physical and Substance-Use Syndromes) collaborative care management (team-based) model to manage patients with depression and diabetes and/ or CVD in almost 200 primary care clinics in eight states. The project’s results are due in June 2015.

COMPASS is based on the TEAMcare model developed at the University of Washington, now considered the gold standard of integrated programs. Two and one-half years into the project, results are comparable to earlier TEAMcare outcomes. The COMPASS team is hopeful that the learnings from this project will help inform Medicare and Medicaid services delivery in the future, and the way those services are reimbursed, in order to support integrated care.

Dr. Williams indicates real challenges lie ahead in figuring out how to proceed in bringing quality, cost effective behavioral care into the PC setting after COMPASS. What will be the right patient population to apply this intervention? How to ensure the right resources are in place? How to measure change? So far we have seen that most health outcomes changes occur early on, while financial changes usually lag, yet timelines for decision-making come early and the pressure to save money is persistent.

NHMH asked Dr. Williams to sum up Mayo’s experience with behavioral health integration so far:

Use proven models (e.g. TEAMcare, IMPACT etc)

It is helpful to have an external group involved ( in their case, IHI or ICSI)
Sustainability is a real challenge: practice change in primary care is more than just outcomes, it is a lot of cultural change, and those changes can be disruptive, affecting every aspect of how a clinic functions Patient active engagement in treatment and understanding their role is critical, You don’t always need payment reform to be in place before beginning practice change, it is possible to improve patient care before funding comes, it may be hard, but it is important to not always wait Integrated care is not always needed by all patients for every problem but when patients have needs that go beyond usual primary care, integrated care gets better outcomes
Mental health conditions are chronic. The delay in receiving care can lead to significant functional disruption. With an average wait to see a psychiatrist of months, how many employers are willing to have their employees missing work or functioning at a lower capacity while waiting on a psychiatric visit? If a person starts to develop a serious mental health problem and loses their job and thus their insurance, their recovery is all the more difficult
It is a mistake to think only mild, common mental disorders are seen in primary care; rather, many patients with serious mental disorders will not go to mental health clinics preferring their primary clinic, hence many cases of mental disorders in primary care;
We need to intervene earlier in behavioral disorders trajectory which means catching early signs in primary care, with increasing screens and treatment for children and teens
There are a lot more mental health conditions than we have capacity to handle, and applying team-based collaborative care is effective and cost efficient; it should be a care priority.

Integrating medical care into behavioral health clinics is also very important — we need to do both, not one or the other. By investing in primary care integration, we may have a chance to reduce the complexity of patients needing to be treated in overloaded mental health community clinics.

Dr. Williams’ final thoughts: “If you have doubts about the efficacy of offering collaborative care in primary care setting, just ask a PCP who has been exposed to this efficient consultative support, and ask patients who have seen both their physical and behavioral issues addressed in one place in a coordinated fashion – and see what response you get!

**(Source: Mark Williams, M.D., Mayo Clinic, Wayne Katon, M.D., AIMS Center at University of Washington).

Florence C. Fee, J.D., M.A.
Executive Director
NHMH, Inc.
No Health without Mental Health
T: 415.279.2192

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NHMH Salutes the Passing of American Scientist Dr. Paul Greengard, a Pioneer in Brain Research and Mental Health Treament. We owe Dr. Greengard a great debt for his incredible, break-through work, and his amazing life of service.

Schizophrenia Second Only To Age as Greatest Risk Factor for COVID-19 Death25-Jan-2021 7:00 PM EST, by NYU Langone Health Contact Patient ServicesNewswise — People with schizophrenia, a mental disorder that affects mood and perception of reality, are almost three times more likely to die from the coronavirus than those without the psychiatric illness, a new study shows. Their higher risk, the investigators say, cannot be explained by other factors that often accompany serious mental health disorders, such as higher rates of heart disease, diabetes, and smoking.Led by researchers at NYU Grossman School of Medicine, the investigation showed that schizophrenia is by far the biggest risk factor (2.7 times increased odds of dying) after age (being 75 or older increased the odds of dying 35.7 times). Male sex, heart disease, and race ranked next after schizophrenia in order. “Our findings illustrate that people with schizophrenia are extremely vulnerable to the effects of COVID-19,” says study lead author Katlyn Nemani, MD. “With this newfound understanding, health care providers can better prioritize vaccine distribution, testing, and medical care for this group,” adds Nemani, a research assistant professor in the Department of Psychiatry at NYU Langone Health. The study also showed that people with other mental health problems such as mood or anxiety disorders were not at increased risk of death from coronavirus infection.Since the beginning of the pandemic, experts have searched for risk factors that make people more likely to succumb to the disease to bolster protective measures and allocate limited resources to people with the greatest need. Although previous studies have linked psychiatric disorders in general to an increased risk of dying from the virus, the relationship between the coronavirus and schizophrenia specifically has remained unclear. A higher risk of mortality was expected among those with schizophrenia, but not at the magnitude the study found, the researchers say.The new investigation is publishing Jan. 27 in the journal JAMA Psychiatry. Researchers believed that other issues such as heart disease, depression, and barriers in getting care were behind the low life expectancy seen in schizophrenia patients, who on average die 15 years earlier than those without the disorder. The results of the new study, however, suggest that there may be something about the biology of schizophrenia itself that is making those who have it more vulnerable to COVID-19 and other viral infections. One likely explanation is an immune system disturbance, possibly tied to the genetics of the disorder, says Nemani.For the investigation, the research team analyzed 7,348 patient records of men and women treated for COVID-19 at the height of the pandemic in NYU Langone hospitals in New York City and Long Island between March 3 and May 31, 2020. Of these cases, they identified 14 percent who were diagnosed with schizophrenia, mood disorders, or anxiety. Then, the researchers calculated patient death rates within 45 days of testing positive for the virus.They note that this large sample of patients who all were infected with the same virus provided a unique opportunity to study the underlying effects of schizophrenia on the body.“Now that we have a better understanding of the disease, we can more deeply examine what, if any, immune system problems might contribute to the high death rates seen in these patients with schizophrenia,” says study senior author Donald Goff, MD. Goff is the Marvin Stern Professor of Psychiatry at NYU Langone.Goff, also the director of the Nathan S. Kline Institute for Psychiatric Research at NYU Langone, says the study investigators plan to explore whether medications used to treat schizophrenia, such as antipsychotic drugs, may play a role as well.He cautions that the study authors could only determine the risk for patients with schizophrenia who had access to testing and medical care. Further research is needed, he says, to clarify how dangerous the virus may be for those who lack these resources. Goff is also the vice chair for research in the Department of Psychiatry at NYU Langone.Study funding was provided by NYU Langone.In addition to Nemani and Goff, other NYU Langone researchers included Chenxiang Li, PhD; Esther Blessing, MD; PhD; Narges Razavian, PhD; Ji Chen, MS; and Eva Petkova, PhD. Another study investigator was Mark Olfson, MD, MPH, at Columbia University in New York. ... See MoreSee Less
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