Interview

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
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San Francisco's Fragmented Mental Health Services Are Literally Killing Its CitizensSan Francisco’s fragmented city services are harming – and killing – the most vulnerable,S.F. Chronicle, Michael Cabanatuan Sep. 27, 2022 “A small number of San Franciscans — almost all of them unhoused — are responsible for overly heavy use of both the city’s medical and legal systems — but the systems’ fragmented approach is failing, according to a new study. The study, from the nonpartisan California Policy Lab and the Benioff Homelessness and Housing Initiative at UCSF, shows that a small group of people are repeatedly cycling in and out of both the county’s health and criminal legal systems each year and represent a disproportionately high amount of utilization of these systems.The systems provide fragmented care that fails those who use it, the study’s authors said, and one finding backs that up: Nearly one in four of the people with heavy use of both systems in 2011 were dead by 2020, “reflecting how vulnerable these individuals are and how high the stakes are for improving the systems that support them,” said co-author Dr. Hemal Kanzaria, medical director at Zuckerberg San Francisco General Hospital and an associate professor of emergency medicine at UCSF.The study underscores what health care workers and public hospital officials told city leaders in July — that far too many people struggling with severe mental illness and addiction cycle through San Francisco’s overburdened emergency rooms, failing to get long-term help, and at a high cost to the city. For instance, just five people in the past five years accounted for 1,781 ambulance transports, possibly up to 2,000, at a cost of $4 million.The study’s authors called for a more coordinated approach, such as connecting people released from the emergency room or jail with housing and continued care. “Our research highlights the need for coordinated, evidence-based interventions to address these individuals’ complex needs, promote stable housing, and prevent poor health outcomes including untimely death,” said co-author Dr. Maria Raven, chief of emergency medicine at UCSF Medical Center and co-lead of the Benioff Homelessness and Housing Initiative program on adults with complex needs.The study looked at 10 years of data from 270,000 people who used the city’s acute medical care or legal systems between 2011 and 2020. It narrowed its focus to two groups of people who had interactions with both systems in the same year, one from 2011 and one from 2020, to investigate trends among frequent users of city services.The study is unusual, researchers say, because it links data from multiple agencies to see how people are using critical city services including mental and physical health care and housing over a several-year period.Among the study’s findings, according to the Policy Lab:• About 24% of the 2011 group continued their high use of both systems the following years but their use declined each of the following years. • Between 80% and 90% of the people in the 2011 and 2020 groups had substance use problems and many also had chronic mental and and physical health issues. • More than 90% of the individuals in both groups had been booked into jail for a felony and a misdemeanor. • The research team determined that many of the people in the 2020 group were in San Francisco in 2011 and had contact with both health and criminal legal systems in the prior 10 years. For example, 30% of the 2020 cohort was booked into jail in 2011.” Michael Cabanatuan is a San Francisco Chronicle staff writer, email: mcabanatuan@sfchronicle.com ... See MoreSee Less
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