NHMH NO HEALTH WITHOUT MENTAL HEALTH A 501(c)(3) non profit   San Francisco - Washington DC Director’s blog


May 20, 2015

“We are learning how to implement evidence-based integrated care well in the real world.”

Robert Ferguson, Director of Government Grants and Policy, PRHI

For the Pittsburgh Regional Health Initiative (PRHI), their three-step journey to become a leader in integrated care implementation all began in 2009 when their research team, delving into hospital admission data in southwestern Pennsylvania, found that approximately 25% of 30-day hospital readmissions with a chronic medical condition also had a co-existing behavioral condition.  

That stunning finding galvanized PRHI—a non-profit operating arm of the Jewish Healthcare Foundation (
www.jhf.org), already a respected leader in quality improvement —into moving in the direction of integrating evidence-based behavioral services in primary care.

In 1997, PRHI became one of the country’s first regional collaboratives of medical, business, and civic leaders with an unwavering mission to improve patient safety and quality improvement practices in healthcare settings.  Their dedicated focus is on meeting patient needs and on achieving optimal patient outcomes, with a high priority on creating value and continuous quality improvement. They have taken proven quality improvement principles from the business world (e.g. Deming and Toyota) and made them appropriately applicable to the medical world.

From 2009 onwards, PRHI has gone through three different groundbreaking behavioral health integration pilots and large-scale dissemination initiatives: ITPC, PIC, and COMPASS.

Integrating Treatment in Primary Care (ITPC) was a local Pittsburgh area integrated care pilot from 2009 through 2010 with three community health centers and the University of Washington AIMS Center. This allowed PRHI to develop an ability to train primary care offices in both the evidence-based IMPACT collaborative care management model for depression and the SBIRT screening and brief intervention model for unhealthy alcohol and other drug use.

Next came the Partners in Integrated Care (PIC) project from 2010 through 2013 to spread comparative effectiveness research findings for integrated care. This meant identifying and addressing primary care patients’ depression and substance use issues in a collaborative team-based approach. The PIC initiative encompassed 57 primary care offices in Massachusetts, Wisconsin, and Minnesota, as well as Pennsylvania.  PIC was a great opportunity for PRHI, as the lead organization, to disseminate their local ITPC integrated pilot with other nationally recognized regional health improvement collaborative.

The PIC project taught PRHI and its partners, including the Institute for Clinical Systems Improvement (ICSI) in Minnesota, how to create a multi-state dissemination infrastructure to put evidence-based integrated care models into practice. This led to participating in the Care of Mental, Physical and Substance Use Syndromes (COMPASS) initiative from 2012-2015.

Led by ICSI, COMPASS is funded by a CMS-CMMI Health Care Innovation Award. It is a larger dissemination and implementation project involving the AIMS Center and 8 regional implementation partners, including PRHI, who are working with 18 medical groups (over 190 primary care offices) across 9 states to implement and evaluate collaborative care management for primary care patients with active depression plus sub-optimally managed diabetes and/or cardiovascular disease.

COMPASS is closing in on the grant’s completion on June 30th. ICSI summarized its preliminary results in April (see CO MPASSprelimresults.pdf) and the final results are due in the fall of 2015. If CMMI models demonstrate a likelihood to reduce future costs, the Affordable Care Act provides a potential path to spread models more broadly which will hopefully spur commercial insurers to follow a similar path. The bottom line is that PRHI has over the past 6 years generated a wealth of lessons learned on how to effectively implement evidence-based integrated care models in a variety of different practice settings.  

The COMPASS results PRHI has seen so far in western Pennsylvania have been impressive:  over 70% have significantly improved their depression; 28% have achieved depression remission, 59% now have an A1c less than 8 (controlled diabetes), and 60% now have a blood pressure below 140/90 who initially had an elevated blood pressure.  As PRHI program manager Robert Ferguson summed up, “we are very pleased with the disease control outcomes both on the medical and behavioral health side; they met the project’s goals and expectations in most respects.”

What are the lessons learned from PRHI’s seminal work in translating integrated care from studies to the real-world?  Foremost, they learned it is harder to implement evidence-based integrated care models without variation in fidelity and outcomes than nearly all expect.  Thus it is important to consider the structural elements that need to be in place to support integrated care delivery services. The “system requirements” to support the essential service of integrated care include:

  1. Unflagging, committed, sustained leadership from the practice leaders is critical. Practice leaders not only have to be champions, they also need to understand clearly how the integrated care model differs from usual care AND how this particular practice change aligns with their other organizational priorities, e.g. ACOs, medical homes, etc
  2. Medical groups implementing evidence-based integrated med/psych care, such as team-based collaborative care, need to modify and customize HIT systems to support this type of care delivery. This requires an up-front investment in time and resources for practices to modify their EHR to prompt the care manager to make systematic follow-up contacts with patients, and to quickly review their entire caseload’s baseline and most recent behavioral and physical health progress scores and contact dates.
  3. Data-driven quality improvement methods are essential. Data reports can be used to monitor the process and outcomes of the integrated services, but in addition, there needs to be a specific quality improvement method at the frontline of patient care that empowers those who do the work to act on the data reports in a systematic way.
  4. Finding the right people for the integrated care team and providing training followed by coaching are pivotal. Effective care managers in integrated care often share these characteristics: they are visible, organized, assertive, empathetic, non-judgmental, collaborative, flexible, and persevering. Once the leadership and collaborative care team are on-board, the practice’s integrated care journey can start with training workshops, but to have a lasting-impact, the initial workshops must be followed by supervision, coaching, and feedback on skill development. The challenge is to infuse quality improvement throughout the medical practice and culture.
  5. The financial sustainability approach PRHI likes best is creating entirely new payment models that don’t rely on traditional billing codes. They see two promising payment reforms to support integrated care services: shared savings with behavioral health quality measures, such as depression symptom improvement and/or depression remission, and a case rate (or capitated per enrolled patient per month) provider payments, where significant pay-for-performance (P4P) is included.

PRHI’s sequential implementation track record shows that integrating evidence-based behavioral health into primary care is a daunting challenge.  However, the more we know at the outset, the higher the likelihood of successful practice transformations, leading to improved patient outcomes.

We congratulate the healthcare innovators of Pittsburgh —an area rapidly becoming a center and driver of 21st century mental health systems reform and improvement.

If you are interested in reading more, please read here.

Florence C. Fee, J.D., M.A.

Executive Director