Special Features

Harvard Helps Local Boston Area Primary Care Practices Integrate Behavioral Health Services

Harvard Medical School may be a large academic medical center but its Center for Primary Care (CPC) has long recognized the need to deploy its expertise to help improve the quality of healthcare delivered in local primary care practices. Which is important since primary care is the place where all Americans go for healthcare and as such is the backbone of our national health system.

The CPC has successfully completed two practice change programs in the Boston and surrounding area. Both are consistent with the federal government’s current efforts under CMS/CMMI (Medicare) to reward primary care doctors who improve the quality of their care delivered, as well as patient satisfaction, while also cutting care costs. (See Comprehensive Primary Care Plus and Primary Care First models https://innovation.cms.gov/initiatives/primary-care-first-model-options/).

The first CPC initiative was a 2012-2014 Academic Innovation Collaborative (AIC) that helped teach diverse local internal medicine and family medicine practices how to provide high-quality and cost-conscious care. The second was the 2013-2016 Alice Rosenwald Mental Health Integration Initiative to improve patient care by integrating behavioral health (mental health + addiction) treatment services into the participating local teaching practices.

The Challenges: As part of a nationally-ranked academic medical center, the CPC understands the substantial, unprecedented challenges facing present and future primary care physicians (PCPs). HMS students are stepping into a healthcare landscape marked by transformative change, new innovations, new roles and relationships, new procedures, and new expectations, most, if not all of which, are long overdue.

Today’s young physicians must be prepared to be not just stewards but agents of change of our healthcare delivery system. Moreover, they will need to sustain that role throughout their medical careers, boldly and innovatively shaping and defining new car delivery approaches founded on strong scientific evidence base. While simultaneously keeping their primary focus on the needs of their patients. Among the changes young primary care doctors face are:

System change: The U.S. healthcare system is moving from a care delivery and payment fee-for-service model to a value-based model commencing to increase investment in primary care where scale-able value can be demonstrated.

New Provider Accountability: PCPs are being asked to accept (and get paid for) accountability
for the quality of care and cost of care of their defined patient populations.

New Roles and Relationships: Care delivery is moving to multi-disciplinary team-based care with new relationships between PCPs and other providers, including behavioral health professionals such as psychiatrists, psychologists, with formalized collaborative protocols creating common understandings and processes, improving information-sharing and patient referral tracking, care planning, and care coordination.

New Clinical Tasks: Care management outreach led by care managers consulting closely with
PCPs and the care team, will become a core part of team’s work, educating, counseling and
helping patients overcome the social barriers that impede healthy behaviors.

New Technology Support Tools: New tools like smartphones, sophisticated EHRs, patient
registries, AI, tele-health platforms, health sensors, large-scale data analytics, and need to
ensure clinicians have affordable high-functioning electronic and data systems.

New Science: Individual patient genetic information to guide care plus new
bio-medical-engineering devices.

AIC: The CPC’s Academic Innovation Collaborative under the direction of Dr. Russell Phillips, CPC Director, involved 19 practices across 6 academic medical centers affiliated with HMS and nearly 260,000 patients and 450 residents. Hospital-based and community-based primary care teaching practices were coached and trained on building high-functioning care teams, managing populations of patients, and engaging patients in care and healthy behaviors. Areas of focused attention found to be key were leadership development, ensuring sufficient practice-level resources, and meaningful engagement with patients.

HMS continues to teach its medical students to lead change through Student Leadership Committees where students learn how to function as a true multi-disciplinary care team which wraps around a patient in a coordinated, collaborative way. At HMS, the stress is on students learning to take advantage of a whole team assisting them and letting go when a health problem may indicate the PCP does not lead, rather a nurse, social worker, care manager, etc.

MHII: The CPC’s Mental Health Integration Initiative aimed to improve patient care by integration of behavioral health services into primary care practices in Boston area. The CPC supported Harvard- affiliated practices as they began to implement team-based, measurement-based care for depression and anxiety highly prevalent in patients with chronic medical conditions such as diabetes and cardiovascular disease. They concentrated on depression screening and care management protocols to ensure that all patients who could benefit from mental health services, received them. The program developed a technology platform for clinicians allowing PCPs and their care team to tele-conference with other providers and specialists and patients.

Health policy-makers have long known that clinical practice change must develop organically from sites themselves. In Harvard’s MHII program, the seven local participating practices to advance along a behavioral integration pathway that is evidence-based and sustainable.

In a noteworthy echo from the past, Alice Rosenwald, the granddaughter of Sears Roebuck co-founder and CEO Julius Rosenwald, who transformed public education for black Americans in the deep south through his philanthropy, continued that family tradition funding the CPC’s MHII program. Ms. Rosenwald enabled the MHII to integrate behavioral health care (mental health + substance use) into HMS-affiliated community primary care clinics in the Boston area. Philanthropy, like medicine, adjusting to meet the needs of the times.

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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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.


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