Keynote: Proven Strategies to Advance Integrated Care in the Latino Community
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Transcript of Keynote: Proven Strategies to Advance Integrated Care in the Latino Community
Sea Mar Community Health Centers Presents
9th Annual Latino Health Forum
Proven Strategies to Advance Integrated
Care
in the Latino Community
Anna Ratzliff, MD, PhDAssistant Professor
Associate Director for Education, Division of Integrated Care & Public Health
Department of Psychiatry & Behavioral Sciences
University of Washington
Disclosures
• Consulting Psychiatrist Contract, Community Health Plan of
Washington
• Supported from contracts and grants to the AIMS Center at the
University of Washington
Daniel
Mental health disorders are
common – who gets treatment?
The other 9 patients.
No Treatment Primary Care Provider
Mental Health Provider
Wang et al 2005
Disparities in Depression Care
for Minority Populations
• Worse access to mental health
treatment1
• Less likely to be identified2
• Less likely to receive antidepressant
medications 3
• Have worse outcomes 4
1- Miranda et al. Am J Psychiatry. 2008 Sep;165(9):1102-8.
2- Borowsky et al J Gen Intern Med. 2000 Jun;15(6):381-8.
3- Miranda J, Cooper L. J Gen Intern Med 2004; 19: 120-6.
4- Van Voorhees et al Med Care Res Rev. 2007 Oct;64(5 Suppl):157S-94S.
Why not just refer?
½ do not follow through
2 visit mean
Grembowski, Martin et al. 2002
Simon, Ding et al. 2012
Why not just refer?
Thomas KC et al, 2009
1 in 5: unmet need for non-prescribers
96%: unmet need for prescribers
Is there a better way?
Yes - Collaborative Care!
http://aims.uw.edu/daniels-story-introduction-collaborative-care
Principle 1:
Patient Centered Team Care
PCP
Patient BH Care
Manager
Psychiatric
Consultant
Core
Program
New Roles
Principle 2:
Population Based Treatment
Principle 3: Measurement Based Treatment To Target
Principle 4: Evidence-Based Treatment
STAR-D Summary
Level 1: Citalopram
~30% in remission
Level 2: Switch or Augmentation
~50% in remission
Level 3: Switch or Augmentation
~60% in remission
Level 4: Stop meds and start new
~70% in remission
Rush, 2007
Principle 5: Accountable Care
Pay-for-performance cuts median time to
depression treatment response in half. 0.
000.
250.
500.
751.
00
Est
imat
ed C
umu
lativ
e P
rob
ablil
ity
0 8 16 24 32 40 48 56 64 72 80 88 96 104 112 120 128 136
Weeks
Before P4P After P4P
Unützer et al. 2012.
Collaborative Care:
The Research Evidence
• Now over 80 Randomized Controlled Trials (RCTs)• Meta analysis of collaborative care (CC) for depression in
primary care (US and Europe)
Consistently more effective than usual care
• Since 2006, several additional RCTs in new populations and for other common mental disorders• Including anxiety disorders, PTSD
Archer, J. et al., 2012
Doubles Effectiveness
of Care for Depression
%
Participating Organizations
50 % or greater improvement in depression at 12 months
Unützer et al., JAMA 2002; Psych Clin North America 2004
0
10
20
30
40
50
60
70
1 2 3 4 5 6 7 8
Usual Care IMPACT
43%
54%
42%
19%23%
14%
0%
10%
20%
30%
40%
50%
60%
White Black Latino
IMPACT Care
Care as Usual
IMPACT Care BenefitsDisadvantaged Populations
Arean et al. Medical Care, 2005
50 % or greater improvement in depression at 12 months
IMPACT: Summary
1) Improved Outcomes:• Less depression
• Less physical pain
• Better functioning
• Higher quality of life
2) Greater patient and
provider satisfaction
3) More cost-effective
“I got my life back”
THE TRIPLE
AIM
MHIP: > 30,000 clients served
across Washington State
•Funded by State of Washington and Public Health Seattle & King County (PHSKC)
• Administered by Community Health Plan of Washington and PHSKC in partnership
with the UW AIMS Center
2008
Pilot initiated in King &
Pierce Counties
2009
Expanded state-wide to
over 100 CHCs and 30
CMHCs
MHIP High-Risk Mothers Program
• Low income women who are pregnant or parenting
• Community health clinics in King County
• Identified by primary care provider with mental
health care need
• Enrolled in Collaborative Care
MHIP High-Risk Mothers Program
Outcomes
0
10
20
30
40
50
60
70
All Latina White Black Asian
% of Population with Depression Improvement
Huang et al. Family Practice 2012 20:394-400.
What could you do?
Daniel’s Mom
“I believe it it’s made all the difference for him.”
Menu of Inspiration Options
Patient Centered Team
Population Based Care
Measurement-Based Treatment to Target
Evidence-Based Treatment
Accountable Care
•Use patient
centered goals.
•Communication
with other
providers.
•Track patient
outcomes.
•Set a practice
improvement
goal.
•Participate in
continuing ed.
•Form a learning
collaborative.
• Use screeners
regularly.
•Track patient
goals regularly.
•Use a registry.
•Lead efforts for
implementation.
Acknowledgments:
Daniel and his family
Annie McGuire
Angel Mathis
Rebecca Sladek
Jürgen UnützerAIMS Center Staff
www.aims.uw.edu