Brenda Reiss-Brennan

Association of Integrated Team-Based Care With Health Care Quality, Utilization, and Cost

IMPORTANCE The value of integrated team delivery models is not firmly established. OBJECTIVE To evaluate the association of receiving primary care in integrated team-based care (TBC) practices vs traditional practice management (TPM) practices (usual care) with patient outcomes, health care utilization, and costs. DESIGN A retrospective, longitudinal, cohort study to assess the association of integrating physical and mental health over time in TBC practices with patient outcomes and costs. SETTING AND PARTICIPANTS Adult patients (aged ≥18 years) who received primary care at 113 unique Intermountain Healthcare Medical Group primary care practices from 2003 through 2005 and had yearly encounters with Intermountain Healthcare through 2013, including some patients who received care in both TBC and TPM practices. EXPOSURES Receipt of primary care in TBC practices compared with TPM practices for patients treated in internal medicine, family practice, and geriatrics practices. MAIN OUTCOMES AND MEASURES Outcomes included 7 quality measures, 6 health care utilization measures, payments to the delivery system, and program investment costs. RESULTS During the study period (January 2010-December 2013), 113,452 unique patients (mean age, 56.1 years; women, 58.9%) accounted for 163,226 person-years of exposure in 27 TBC practices and 171,915 person-years in 75 TPM practices. Patients treated in TBC practices compared with those treated in TPM practices had higher rates of active depression screening (46.1% for TBC vs 24.1% for TPM; odds ratio [OR], 1.91 [95% CI, 1.75 to 2.08), adherence to a diabetes care bundle (24.6% for TBC vs 19.5% for TPM; OR, 1.26 [95% CI, 1.11 to 1.42]), and documentation of self-care plans (48.4% for TBC vs 8.7% for TPM; OR, 5.59 [95% CI, 4.27 to 7.33]), lower proportion of patients with controlled hypertension (<140/90 mm Hg) (85.0% for TBC vs 97.7% for TPM; OR, 0.87 [95% CI, 0.80 to 0.95]), and no significant differences in documentation of advanced directives (9.6% for TBC vs 9.9% for TPM; OR, 0.97 [95% CI, 0.91 to 1.03]). Per 100 person-years, rates of health care utilization were lower for TBC patients compared with TPM patients for emergency department visits (18.1 for TBC vs 23.5 for TPM; incidence rate ratio [IRR], 0.77 [95% CI, 0.74 to 0.80]), hospital admissions (9.5 for TBC vs 10.6 for TPM; IRR, 0.89 [95% CI, 0.85 to 0.94]), ambulatory care sensitive visits and admissions (3.3 for TBC vs 4.3 for TPM; IRR, 0.77 [95% CI, 0.70 to 0.85]), and primary care physician encounters (232.8 for TBC vs 250.4 for TPM; IRR, 0.93 [95% CI, 0.92 to 0.94]), with no significant difference in visits to urgent care facilities (55.7 for TBC vs 56.2 for TPM; IRR, 0.99 [95% CI, 0.97 to 1.02]) and visits to specialty care physicians (213.5 for TBC vs 217.9 for TPM; IRR, 0.98 [95% CI, 0.97 to 0.99], P > .008). Payments to the delivery system were lower in the TBC group vs the TPM group (

Cost and Quality Impact of Intermountain's Mental Health Integration Program

3400.62 for TBC vs

Mental Health Integration Normalizing Team Care

3515.71 for TPM; β, -

Evaluation of “Depression in Primary Care” Innovations

115.09 [95% CI, -

Clinically Feasible Stratification of 3-Year Chronic Disease Risk in Primary Care: The Mental Health Integration Risk Score

199.64 to -

Excessive Drinking in Young Women: Reducing harm through quality improvement

30.54]) and were less than investment costs of the TBC program. CONCLUSIONS AND RELEVANCE Among adults enrolled in an integrated health care system, receipt of primary care at TBC practices compared with TPM practices was associated with higher rates of some measures of quality of care, lower rates for some measures of acute care utilization, and lower actual payments received by the delivery system.

Mental health integration: rethinking practitioner roles in the treatment of depression: the specialist, primary care physicians, and the practice nurse.

EXECUTIVE SUMMARY Most patients with mental health (MH) conditions, such as depression, receive care for their conditions from a primary care physician (PCP) in their health/medical home. Providing MH care, however, presents many challenges for the PCP, including (1) the difficulty of getting needed consultation from an MH specialist; (2) the time constraints of a busy PCP practice; (3) the complicated nature of recognizing depression, which may be described with only somatic complaints; (4) the barriers to reimbursement and compensation; and (5) associated medical and social comorbidities. Practice managers, emergency departments, and health plans are stretched to provide care for complex patients with unmet MH needs. At the same time, payment reform linked to accountable care organizations and/or episodic bundle payments, MH parity rules, and increasing MH costs to large employers and payers all highlight the critical need to identify high‐quality, efficient, integrated MH care delivery practices. Over the past ten years, Intermountain Healthcare has developed a team‐based approach—known as mental health integration (MHI)—for caring for these patients and their families. The team includes the PCPs and their staff, and they, in turn, are integrated with MH professionals, community resources, care management, and the patient and his or her family. The integration model goes far beyond co‐location in its team‐based approach; it is operationalized at the clinic, thereby improving both physician and staff satisfaction. Patients treated in MHI clinics also show improved satisfaction, lower costs, and better quality outcomes. The MHI program is financially sustainable in routinized clinics without subsidies. MHI is a successful approach to improving care for patients with MH conditions in primary care health homes.

Abstract 12709: Addition of Depression Severity Indices to the Intermountain Risk Score for Predicting 3-Year Risk of Chronic Disease: The Mental Health Integration Risk Score

This article examines the impact of integrating mental health into primary health care. Mental Health Integration (MHI) within Intermountain Healthcare has changed the culture of primary health care by standardizing a team-based care process that includes mental health as a normal part of the routine medical encounter. Using a quantitative statistical analysis of qualitative reports (mixed methods study), the study reports on health outcomes associated with MHI for patients and staff. Researchers interviewed 59 patients and 50 staff to evaluate the impact of MHI on depression care. Patients receiving MHI reported an improved relationship with caregivers (P < .001) and improved overall functioning in their lives (P < .01). Staff providing care in MHI reported that patients experienced improved access to mental health care, improved overall patient productivity in daily functions (P < .01), and access to team care (P < .001). As MHI became routine, patients discussed complementary team interventions more frequently (P < .0001). Mental health problems rank second in chronic disease today. MHI offers promising results for improving the quality and cost of effective treatment for chronic disease. This research provides guidelines for organizing mental health care, staff productivity, and patient satisfaction, using a team approach to improve outcomes.

Prise en charge intégrée des maladies mentales : l’exemple d’Intermountain Healthcare (USA)

Key stakeholders and executive decision makers in healthcare system require clear and convincing data of the value of chronic illness care models for the primary care treatment of depression. Well-conceived and conducted evaluations provide this necessary information. This case study describes the experience of a large, nonprofit healthcare system’s experience with implementing and evaluating a quality improvement program for integrating depression management into primary care. The commentary that follows discusses specific evaluation questions that are relevant to each of the stakeholder groups involved in deciding whether or not to continue supporting such programs.

Abstract 16347: The Association of Depressive Symptoms and the Intermountain Mortality Risk Score to All-cause Mortality

BACKGROUND Depression is a common illness that imposes a disproportionately large health burden. Depression is generally associated with a higher prevalence of chronic disease risk factors and may contribute to higher chronic disease risk. OBJECTIVE This study aimed to create and validate sex-specific Mental Health Integration Risk Scores (MHIRS) that predict 3-year chronic disease diagnosis. METHODS MHIRS was created to predict the first diagnosis of any of the 10 chronic diseases in patients completing a Patient Health Questionnaire-9 Depression Survey who were free at baseline from those 10 chronic disease diagnoses. MHIRS used sex-specific weightings of Patient Health Questionnaire 9 results, age, and components of the complete metabolic profile and complete blood count in randomly chosen derivation (70%) and validation (30%) groups. RESULTS Among females (N = 10,162, age: 48 ± 16), c-statistics for the composite chronic disease end point were 0.746 (0.725, 0.767) for the derivation group and 0.717 (0.682, 0.753) for the validation group, whereas males (N = 4615, age: 48 ± 15) had 0.755 (0.727, 0.783) and 0.742 (0.702, 0.782). In the validation group, MHIRS strata of low-, moderate-, and high-risk categories had hazard ratios (HR) for any 3-year chronic disease diagnosis among females of HR = 3.42 for moderate vs low and HR = 9.75 for high vs low, whereas males had HR = 4.80 and HR = 10.68, respectively (all p < 0.0001). CONCLUSION A clinical decision tool comprised by depression severity and common laboratory tests, and MHIRS provides very good stratification of a 3-year chronic disease diagnosis. Designed to be calculated electronically by an electronic health record, MHIRS can be efficiently obtained by clinicians to identify patients at higher chronic disease risk who require further evaluation and more precise clinical management.