Professor Brenda Reiss-Brennan, Mental Health Integration Director at Intermountain Health Care, examines the critical role of team-based care and integrated mental health.
So Intermountain is a highly integrated delivery system, 22 hospitals, we have our own health plan. We also have an integrated medical group that has over 12,000 employed physicians. We also have physicians in the community that are highly affiliated with us. We are not a staff model like Kaiser.
So one of the things that we are moving very rapidly towards in America, an especially at Intermountain is really caring for the health of the whole population. This is one key example where Intermountain many, many, many years ago did the right thing and they developed a mental health integration programme for their primary care clinics and their speciality care clinics in the ambulatory setting and we built it through five key components. These are the five steps of the clinical work process, learning year after year after year. We started in 1998.
The first: culture and leadership. So what do we do very, very early on in terms of leadership and culture? We listen to our physicians who said, “Yes Brent James, we would love to improve the care for diabetes and asthma in our clinics, we’ll do that evidence-based care. What are we going to do with all the substance abuse, domestic violence and depression that’s coming through the clinic at the same time?” So what did Intermountain do? They said, “Whoops, we’ve got a huge problem here and if we want to engage these docs and the care for all chronic diseases, we have to integrate mental health as a part of that and make that happen together.” So we built a team around the physician and the family; care managers that are nurses that manage all chronic diseases, help advocates that support them, psychiatrist or nurse practitioners not in every single clinic based on the needs and the complexity of the population, talk therapists, peer advocates and mentors and the clinic manager is in charge of everybody at that practice. That is at every single practice across 160 practices over Utah.
The second was workflow. How did we figure out how to match the population, the complexity of all these patient’s and family’s needs coming in the door with the right level of team around them? We used that clinical work process, evidence-based. So what we did is we listened to the patient and the patient fills out an amazing assessment of all the issues facing them in their life right now; it’s the patient’s story and that story then gets organised and stratified, another key element of high-performing systems to be able to sort your population and stratify them based on complexity.
What percent do you think now in these high performing teams is the primary care doctor providing of the mental health care in our clinics? Anybody want to take a guess? 80%, very close. Okay, that flipped them out when we told them that because they were like, “No, no, no we want all the mental health to go over there. We want it all to go to those specialists that were trained to do that,” and then in the collaborative area you have more complexity. So you have families with social burdens, you have families who have poor ability to engage in helping relations. they either have isolated or chaotic, disruptive relationships and then you have high complexity over there which require the higher level of team resource.
Everyone sees the measurement and is all accountable. So this is the third key component of mental health integration. The information system then takes all that data from the patient and the teams and the staff and it gets organised into a very critically detailed data-mart and we have analysts with each of these teams that are working that and it gets fed back. So feeding back to your teams, feeding back to your patients, are you getting better? Are you getting worse? What does this mean? What we found when we interviewed the staff in those clinics and we interviewed the patients receiving care in those clinics is they agreed on seven steps that happen when they went in to see their doctor and a mental health or social issue came up in their visit, any visit.
My doctor explained it to me. Screening happened either using one of our assessment tools or the big MHI packet. We talked about results as the green. We discussed options. Meds were started. A team was activated; either a care manager, a mental health person or out into the community and light blue is a follow-up plan. In clinics that were thinking about integrating as a team which are a potential, clinics that had started adopting mental health integration, and then clinics over there that had been running mental health integration for over three to four years, had gotten the outcomes and it was regular life to them. They would not run their clinics without their labs and their mental health integration.
So these multiple connected team touches with trusted people around them, there was a connection there, became as important an intervention as psychotherapy and medications because patients were telling us this is what helped them get their outcomes.
So after all this investment of 15 years Intermountain said, “Well wait a minute, we’re moving to shared accountability, we have to do population health, how are we going to get every clinic up to this? How are we going to scale this?” And we decided to measure; do clinics with these high performing teams provide greater value to Intermountain Health Care than traditional medical practice?
So here you see in the dark blue no mental health integration, no integrated teams back to 2000, and then you see the progression and scaling of all of our clinics in the red planning, green adoption and then the darker colour routinized as we move towards mental health integration and team-based care for a trajectory of 15 years.
We looked at all the patients that were seen in our medical group practices between the years 2003 and 2005, they were 18 and over, and then we compared all the patients that had exposure to those highly routinized teams, high performing teams, and those that didn’t, and this is within Intermountain. So this is all in a very high performing system. So in those patients that were seen in those high performing groups of clinics and teams that were cooperating and talking to each other, patients improved incredible on their depression detection. Their adherence to their diabetes bundle was off the charts for us as well, and you see here that those patients that had high team-based care were in the emergency room less, hospital less and ambulatory sensitive measures were also significantly less.
So what was the impact on cost? What was the value for us? Well it cost us $22 per patient per year to put all those teams together from 2010 to 2014 and we saved $115. Moving forward in a fee for service market, we’re not saving any money with team-based care. We are saving money because it’s the whole system and we need to really incentivise global payments for the whole population to be able to really get the value of over long time, and we know that and that’s where our shared accountability is moving.
Great, any questions?