Rodger Kessler, PhD, and Constance van Eeghen, Dr.P.H.
University of Vermont
A key aim of health care reform is to shift the focus of primary care from individual patients to “panels” of patients to improve the health status of an entire population. Shifting to population-focused health will require changing care processes, care provider roles, and financing of care. Taken together, these transformations can have an impact on the Triple Aim outcomes of improved patient experience, enhanced clinical outcomes, and reduced costs of care (Berwick, Nolan, & Whittington, 2008). This overview describes the background of panel-based behavioral primary care and focuses on four foundational elements that have the potential to improve population health under reform.
The idea of panel-based care dates back to the emergence of public health policy in the late 1800s. In the present era of health care, patients in primary care settings present with complex chronic problems that frequently include behavioral co-morbidities (Academy of Psychosomatic Medicine, 1996; Katon, 1987). The care needs of patients with complex disease clusters must receive special attention to support patient functioning and prevent disease progression. However, this requires more attention and services than can be delivered in the traditional primary care visit, presenting an opportunity for health psychologists to take a prominent role in primary care teams. A new description of the care model for population health management provides some guidance in defining panel-based care (Peterson, Raj, & Luethke, 2014). The key element of such a shift is the change in focus from intensive strategies for assessment and treatment of individuals to systematic assessment and protocol-based care of entire subpopulations (panels) of patients in a practice. An example is routine screening of all patients for smoking, with an evidence-supported protocol followed for all smokers.
Health care reform and panel-based care
The Affordable Care Act (ACA) expands coverage, focuses on reducing costs, and incentivizes quality and innovation in our health care system (US Department of Health and Human Services, 2010). This includes performance-based global contracting for all care, with payment dependent on outcomes generated (i.e., reduction of emergency room use, or capitated payment for all care delivered to the population of patients). Meeting these outcome expectations will rely in part on using new practice support tools such as electronic health records (EHRs), registries, and decision support systems (Chaudhry et al., 2006). Accomplishing the outcomes required for payment favors panel-based care as defined above and, by extension, greater use of psychological evidence and practice in primary care.
The foundations of panel-based care
Bodenheimer and colleagues (2014) identified four foundational elements necessary to accomplish this new care model: (a) engaged organizational leadership, (b) data-driven improvement of care, (c) a focus on panels of patients, and (d) team-based care. A transformed primary care practice redefines the physician role as leader for a well trained, highly functioning primary care team rather than as sole care provider in most patient visits. The team is accountable for advancing the health status of an entire patient panel. New payment models will be central to this transformation (Margolius & Bodenheimer, 2010).
Progress report: Incomplete
Population-based care (i.e., care for clusters of patients sharing a common chronic disease, as well as multi-morbidities and high utilizers of care) will address groups of patients with primary psychological or substance abuse issues or with behavioral comorbidities linked to medical problems that contribute to decreased functioning. Many had hoped that recent efforts toward collaborative medical and behavioral care (”integration”) would accomplish this. To date, they have not. A recent survey of National Committee for Quality Assurance Patient Centered Medical Homes (PCMHs) suggested that only a minority of primary care practices have behavioral clinicians as part of the practice. Furthermore, behavioral clinicians are generally not integrated into practice flow or operations, and there is minimal use of evidence-based behavioral interventions for complex medical problems or for common mental health and substance abuse issues (Kessler et al., 2014).
Perhaps that is not surprising. Panel-based primary care based population management is in its youth. Implementation requires the foundational changes described above. In addition, successful transformation also requires attention to the myriad implementation issues necessary for integrated behavioral medical care (Kessler & Glasgow, 2011).
A case example
We received support from NIMH R-03 99157 to develop a toolkit for implementing behavioral health into primary care practices using a workflow improvement strategy called “Lean.” One implementation site is a family medicine practice in Northern Vermont. During the last 5 months we have provided 16 hours of structured practice facilitation to the team. Key aspects of this ongoing project are presented here to exemplify how the foundational elements identified above can be applied to integrate behavioral health into population-based patient care.
Team-based: The practice improvement team consists of physician champion, practice manager, psychologist, nurse care manager, community health team nurse, and medical assistant. Non-physician staff are expected to operate at the peak of their licenses and are responsible for many patient care functions formerly assumed by physicians.
Panel focus: The team developed an integrated, panel-based care process to engage patients with uncontrolled Type 2 diabetes. After excluding patients under the care of an endocrinology service or in a long-term care facility, a group of 135 patients was selected from the diabetes registry in the EHR as likely to engage in self-management.
Data-driven: All selected patients are invited to complete the My Own Health Report (MOHR) behavioral health risk appraisal (Krist et. al., 2013) on the web or on paper. The MOHR is a 16-item, 10-domain health risk self-appraisal, developed with NIH support. It includes mental health and substance abuse measures, but also evaluates stress, sleep, sugary beverage consumption, activity, body mass index, and health status. When completed by a patient, the MOHR summarizes behavioral risks and encourages the patient to identify those risks that they are interested in working on, forming the start of patient goal-setting and self-management plans.
Leadership: The documentation process is currently paper-based but is scheduled for inclusion in the EHR based on strong support from leadership. The process supports the patient by proposing evidence-supported risk reducing interventions to incorporate into the patient’s personal self-management plan.
The patient’s care team will build on the proposed set of evidence-supported behavioral interventions and provide support to engage the patient in the planned activity. The integrated algorithm will be implemented in fall 2014. The team’s progress has been necessarily deliberate and careful, taking more time than anticipated to clarify the need for multiple levels of organizational understanding and approval and to arrange access to scarce EHR resources. The care provided will be stepped, utilizing staff at all levels including nursing assistants to provide services, measure ongoing effectiveness, and engage with other team members. Our current effort is focused on Type 2 diabetes, but once implementation is effective we will expand the range of medical/behavioral issues targeted.
What we have learned to date
There is clear justification for health psychologists to be integrated into panel-based care, but not necessarily as primary providers of behavioral services. In our diabetes project we anticipate that a minority of patients will need face-to-face psychology interventions. Instead, the psychologist is a primary member of the team that is planning and implementing the care and supervises other practice staff in implementation of procedures.
The process has been neither easy nor smooth. Attention to behavioral issues in primary care is generally underdeveloped and poorly resourced. Organizations often have conflicting priorities that take precedence over such efforts. Thus, it will take a substantial amount time and energy to move in this direction. However, we expect that the return on this investment will make it worth this effort. This transformation should improve care for high-risk patients that have overall poor functioning, consume excess practice resources, and do not have access to evidence-supported health psychology.
Our eventual goal is to establish an efficient EHR-based algorithm for long-term self-management of the large subgroups of patients with medical conditions whose behavioral comorbidity influences health status. Along the way, we hope this will solve multiple physician and organizational needs. We expect to apply these principles to the broad range of medical problems that our health psychology interventions support. It is our belief that this is an excellent use of health psychology time.
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