Collaborative Care

Like healthcare? Fascinated with policy and systems? This might be a place you enjoy. It might not. Either way, let me know.

There will be a focus on primary care and mental health on this site. Join the fun.
Yes, our healthcare system still needs work.

Yes, our healthcare system still needs work.

When will healthcare have its “Occupy Wall Street" moment?
In order to answer this question, let me first define what the occupy wall street movement is about. According to ABC News:
"Their [Occupy Wall Street] causes include everything from global warming to gas prices to  corporate greed, and the Occupy Wall Street website says organizers took  their inspiration in part from the so-called Arab Spring demonstrations  that have tried to bring democracy across the Arab world.
But while their message might be a tad muddled, all are united by their anger over what they say is a broken system, a system that serves the wealthy and powerful at the expense of the rest.
Protester Brendan Burke insists he and the others are fighting for more than 99 percent of the American population.”
Let me highlight one section from above:
"…all are united by their anger over what they say is a broken system…"
Would anyone argue that healthcare is not broken? At the heart of this brokenness lies fragmentation that perpetuates this brokenness.
Those of you who have looked this blog before know that I like to talk a lot about integrating mental health and primary care. No doubt this is a solution to the problem of fragmentation, but I digress.
What I want to know is why the public is not more outraged at the broken healthcare system? 
While healthcare costs continue to grow uncontrollably, the public continues to suffer. In the face of this suffering, there does not appear to be much relief. Thankfully, the Affordable Care Act does try to mitigate some of these issues (especially cost), but is this sufficient without adequate community “outrage” over healthcare?
As Gawande has written - “In every industrialized nation, the movement to reform health care has begun with stories about cruelty.”
Not to be overly melodramatic here, but one needs look no further than “mental health” to see how the system has often failed folks who have this as their presenting problem. Not to imply that this is cruelty, but when one starts to cite statistics about mortality in the severely mentally ill, there should be some outrage. 
There should be a demand from across the community that healthcare should be high quality, affordable and integrated as to avoid fragmentation. Yet where is the demand?
Maybe healthcare has not had it’s “Wall Street” moment because there is no one place the national community can gather to express their outrage. Yes, we advocate in our own unique ways - write letters to our legislators, visit them and on speak up in town hall meetings, but is this sufficient? Even if we had a special street corner to meet to talk about healthcare, would we? 
How can we begin to engage the community so that healthcare can have its “Occupy Wall Street” moment? Or, as the Occupy Wall Street movement has shown, where are the select individuals who will rise up and fight for “the 99%”? 
Isn’t it time?
Maybe soon seen we will start to see the beginning of an Occupy Healthcare movement.

When will healthcare have its “Occupy Wall Street" moment?

In order to answer this question, let me first define what the occupy wall street movement is about. According to ABC News:

"Their [Occupy Wall Street] causes include everything from global warming to gas prices to corporate greed, and the Occupy Wall Street website says organizers took their inspiration in part from the so-called Arab Spring demonstrations that have tried to bring democracy across the Arab world.

But while their message might be a tad muddled, all are united by their anger over what they say is a broken system, a system that serves the wealthy and powerful at the expense of the rest.

Protester Brendan Burke insists he and the others are fighting for more than 99 percent of the American population.”

Let me highlight one section from above:

"…all are united by their anger over what they say is a broken system…"

Would anyone argue that healthcare is not broken? At the heart of this brokenness lies fragmentation that perpetuates this brokenness.

Those of you who have looked this blog before know that I like to talk a lot about integrating mental health and primary care. No doubt this is a solution to the problem of fragmentation, but I digress.

What I want to know is why the public is not more outraged at the broken healthcare system? 

While healthcare costs continue to grow uncontrollably, the public continues to suffer. In the face of this suffering, there does not appear to be much relief. Thankfully, the Affordable Care Act does try to mitigate some of these issues (especially cost), but is this sufficient without adequate community “outrage” over healthcare?

As Gawande has written - “In every industrialized nation, the movement to reform health care has begun with stories about cruelty.”

Not to be overly melodramatic here, but one needs look no further than “mental health” to see how the system has often failed folks who have this as their presenting problem. Not to imply that this is cruelty, but when one starts to cite statistics about mortality in the severely mentally ill, there should be some outrage. 

There should be a demand from across the community that healthcare should be high quality, affordable and integrated as to avoid fragmentation. Yet where is the demand?

Maybe healthcare has not had it’s “Wall Street” moment because there is no one place the national community can gather to express their outrage. Yes, we advocate in our own unique ways - write letters to our legislators, visit them and on speak up in town hall meetings, but is this sufficient? Even if we had a special street corner to meet to talk about healthcare, would we? 

How can we begin to engage the community so that healthcare can have its “Occupy Wall Street” moment? Or, as the Occupy Wall Street movement has shown, where are the select individuals who will rise up and fight for “the 99%”? 

Isn’t it time?

Maybe soon seen we will start to see the beginning of an Occupy Healthcare movement.

Sometimes it is the simple things that have the most significant impact.
Take for example a recent article published in the European Journal of Applied Physiology - Time magazine had a nice succinct write up on the topic:
"…researchers from the University of Exeter and  the University of Copenhagen tried recruiting homeless men off the  streets of Copenhagen to see whether they could get the men to play  soccer and improve their health.
Fifty-five men enrolled in the study and were randomized either to  receive soccer training two or three times a week or to serve as a  control group. After 12 weeks, the group who regularly played soccer  reduced their body fat and lowered their blood pressure and cholesterol  levels, compared with the control group. The soccer players also  improved other markers of cardiovascular health, which the authors  suggested may help reduce their risk of early death.
The study found high attendance among the homeless men, suggesting  that organized soccer games could have some potential to improve health  outcomes in the homeless or in other underserved populations.”
Soccer, yes soccer began to make a difference in these fifty-five lives. Sometimes health can be so simple. Yes, these folks began moving around more and playing soccer thus improving their health, but is there something else at work here? 
I think so, and I think it is a word we often take for granted in health.
Community.
Think of all the various ways we use the word community healthcare.
Probably the most common use is when we discuss “community health centers" but what do we mean by community in this context? According to the National Association for Community Health Centers:
"Each health center takes a unique approach to meet the needs of the  people in the surrounding community. That local approach to health care,  combined with an innovative emphasis on comprehensive preventative  care, generates $24 billion in annual savings to the health care system –  to taxpayers and private payers alike."
People want to have a sense of belonging. They want to have a sense of being apart of something bigger than them. Community does this. Community single-handedly accomplishes connection, and can be defined in multiple ways.
At the heart of much of the social media movement, there is a sense of engagement and community. Twitter, Facebook, Linked In - they all build off of the idea that people need connection and have a voice. Community.
In primary care, the largest platform of healthcare delivery in the country, continuity is one of the “secret ingredients” for success (and improved health outcomes). At the heart of continuity is a relationship. This relationship may lead the patient to feeling an enhanced sense of a community with their healthcare provider.
This is also the basis for the patient-centered medical home (PCMH) -consider one of the PCMH “joint principles”:
“Care is coordinated and/or  integrated across  all elements of the complex health care system (e.g., subspecialty  care, hospitals, home health agencies, nursing homes) and the patient’s  community (e.g., family, public and private community-based services).  Care is facilitated by registries, information technology, health  information exchange and other means to assure that patients get the  indicated care when and where they need and want it in a culturally and  linguistically appropriate manner.”
Primary care aims to bridge across all elements of healthcare, including the community. In the process, does primary care become its own community for patients. Is it already?
My point with this post is that if we forget about the most simple thing in healthcare, community, we begin to miss the boat entirely for improving people’s lives. How we define community is often unique to us as individuals; however, our health may be more connected to our definition of community than we are willing to admit.

Sometimes it is the simple things that have the most significant impact.

Take for example a recent article published in the European Journal of Applied Physiology - Time magazine had a nice succinct write up on the topic:

"…researchers from the University of Exeter and the University of Copenhagen tried recruiting homeless men off the streets of Copenhagen to see whether they could get the men to play soccer and improve their health.

Fifty-five men enrolled in the study and were randomized either to receive soccer training two or three times a week or to serve as a control group. After 12 weeks, the group who regularly played soccer reduced their body fat and lowered their blood pressure and cholesterol levels, compared with the control group. The soccer players also improved other markers of cardiovascular health, which the authors suggested may help reduce their risk of early death.

The study found high attendance among the homeless men, suggesting that organized soccer games could have some potential to improve health outcomes in the homeless or in other underserved populations.”

Soccer, yes soccer began to make a difference in these fifty-five lives. Sometimes health can be so simple. Yes, these folks began moving around more and playing soccer thus improving their health, but is there something else at work here? 

I think so, and I think it is a word we often take for granted in health.

Community.

Think of all the various ways we use the word community healthcare.

Probably the most common use is when we discuss “community health centers" but what do we mean by community in this context? According to the National Association for Community Health Centers:

"Each health center takes a unique approach to meet the needs of the people in the surrounding community. That local approach to health care, combined with an innovative emphasis on comprehensive preventative care, generates $24 billion in annual savings to the health care system – to taxpayers and private payers alike."

People want to have a sense of belonging. They want to have a sense of being apart of something bigger than them. Community does this. Community single-handedly accomplishes connection, and can be defined in multiple ways.

At the heart of much of the social media movement, there is a sense of engagement and community. Twitter, Facebook, Linked In - they all build off of the idea that people need connection and have a voice. Community.

In primary care, the largest platform of healthcare delivery in the country, continuity is one of the “secret ingredients” for success (and improved health outcomes). At the heart of continuity is a relationship. This relationship may lead the patient to feeling an enhanced sense of a community with their healthcare provider.

This is also the basis for the patient-centered medical home (PCMH) -consider one of the PCMH “joint principles”:

Care is coordinated and/or integrated across all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (e.g., family, public and private community-based services). Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.”

Primary care aims to bridge across all elements of healthcare, including the community. In the process, does primary care become its own community for patients. Is it already?

My point with this post is that if we forget about the most simple thing in healthcare, community, we begin to miss the boat entirely for improving people’s lives. How we define community is often unique to us as individuals; however, our health may be more connected to our definition of community than we are willing to admit.

Be afraid, be very afraid.
There are two graphs that I have seen that make me quite worried about healthcare and the majority of the public in need of healthcare. The “one” (really two) above is definitely one of those.
The report from the New York Times summarizes the recent release of the 2011 Employer Health Benefits Annual Survey conducted by the Kaiser Family Foundation.
From the Times:
"A new study by the Kaiser Family Foundation, a nonprofit research group  that tracks employer-sponsored health insurance on a yearly basis, shows  that the average annual premium for family coverage through an employer  reached $15,073 in 2011, an increase of 9 percent over the previous  year."
Yes, healthcare cost continue to rise and often the public must take on these additional costs as employers are running out of places to find the money to pay this benefit.
What happens if nothing changes?
Well it just so happens that the other graph that scares me is  from the Robert Graham Center and is an example of what could happen:

Essentially this graph shows that by the year 2025 the annual household income in the US will be surpassed by the average health insurance premiums.
They conclude:
"Shifting health care coverage from a commodity to a social good could  reduce disparities and produce better population health. Changes in  health care coverage will require more equitable and sustainable models  of health care delivery and aligned advocacy to support them. The  instability of health care financing and delivery provides an  opportunity for family physician leaders to develop new models of  efficient practice, with care that is accessible to everyone."
So in the face of statistics like the ones mentioned above, how will we respond? Healthcare expenditures and premiums are growing at an uncontrollable rate. When cells do this we call it cancer - when healthcare does this, what do we call it? 
Now is the time to start to demonstrate that there are indeed innovative models of healthcare that are out there that can bend the cost curve, improve quality and enhance overall healthcare.
Let your voice be heard.
The CMS Innovations Center has a section where you can send in your ideas on healthcare. How many ideas have you sent in?
Let’s try and avoid coming to a place where the average family cannot afford healthcare insurance.

Be afraid, be very afraid.

There are two graphs that I have seen that make me quite worried about healthcare and the majority of the public in need of healthcare. The “one” (really two) above is definitely one of those.

The report from the New York Times summarizes the recent release of the 2011 Employer Health Benefits Annual Survey conducted by the Kaiser Family Foundation.

From the Times:

"A new study by the Kaiser Family Foundation, a nonprofit research group that tracks employer-sponsored health insurance on a yearly basis, shows that the average annual premium for family coverage through an employer reached $15,073 in 2011, an increase of 9 percent over the previous year."

Yes, healthcare cost continue to rise and often the public must take on these additional costs as employers are running out of places to find the money to pay this benefit.

What happens if nothing changes?

Well it just so happens that the other graph that scares me is  from the Robert Graham Center and is an example of what could happen:

Essentially this graph shows that by the year 2025 the annual household income in the US will be surpassed by the average health insurance premiums.

They conclude:

"Shifting health care coverage from a commodity to a social good could reduce disparities and produce better population health. Changes in health care coverage will require more equitable and sustainable models of health care delivery and aligned advocacy to support them. The instability of health care financing and delivery provides an opportunity for family physician leaders to develop new models of efficient practice, with care that is accessible to everyone."

So in the face of statistics like the ones mentioned above, how will we respond? Healthcare expenditures and premiums are growing at an uncontrollable rate. When cells do this we call it cancer - when healthcare does this, what do we call it? 

Now is the time to start to demonstrate that there are indeed innovative models of healthcare that are out there that can bend the cost curve, improve quality and enhance overall healthcare.

Let your voice be heard.

The CMS Innovations Center has a section where you can send in your ideas on healthcare. How many ideas have you sent in?

Let’s try and avoid coming to a place where the average family cannot afford healthcare insurance.

AHRQ Mental Health Town Hall Meeting

The important investments that AHRQ has made in addressing mental health issues was highlighted during this forum and town hall. Specific topics include the integration of behavioral and mental health into the primary care setting, the role of the PCMH in improving the quality of mental health care, and the AHRQ Academy for Integrating Mental Health and Primary Care.

Awaiting mental health town hall mtg. Interested in how ICSI work with many MH groups and DIAMOND aligns w/ discussion. #ahrqac
norskedoc
September 21, 2011
Hanging out here this morning: AHRQ Mental Health Town Hall Meeting - AHRQAcademy http://t.co/zvm7V6ML <— Worth watching. #ahrqac
unxpctdblessing
September 21, 2011

The AHRQ mental health town hall meeting was set up to be as interactive as possible. Various leaders in healthcare, including Dr. Ofttedahl ( @norskedoc ) were there to participate both in the room and virtually.

There were 9 national leaders in healthcare on the stage prepared to talk about the clinical/community, financing/policy and research aspects of integrating mental health into primary care.

RT @miller7: Starting in 5 minutes - the #mentalhealth town hall forum at #AHRQac http://t.co/EqvhSYRJ
PhilBaumann
September 21, 2011
RT @miller7: We want active questions from the Ustream and Twitter audience - #AHRQac
eHealthcareAll1
September 21, 2011
The event features a series of 3 open ended discussions on the topics of clinical and community questions #AHRQac
vananie
September 21, 2011

Some of the first questions were to provide overview of where mental health integration currently stands.This panel specifically examined the role of clinical integration and the community.

Q1 What is “state of field” for clinicians/pt interested in integration of #mentalhealth & healthcare into the “new” primary care? #AHRQac
miller7
September 21, 2011
Wish we wld be taking more about creating meaningful #mentalhealth conversations btw patients & their HC providers #ahrqac
Annie_LeBlanc
September 21, 2011
Dr. Korsen discussing the importance of integrating #mentalhealth into the patient-centered medical home #AHRQac
miller7
September 21, 2011
Dr. Hogan - commissioner for #mentalhealth #NewYork http://t.co/Gd9ZHCpM discussing urgency of solving problem around #mentalhealth #AHRQac
miller7
September 21, 2011
Believable, but high # RT @miller7: “40% of those referred to psychotherapy (from #primarycare don’t make first visit” - Dr. Hogan #AHRQac
Gigi_Peterkin
September 21, 2011
I cannot believe the battles we still have to fight to integrate #mentalhealth - Dr. Khatri #AHRQac
miller7
September 21, 2011
@epatientdave “there are a ton of really smart people working hard on hard problems but the needle is not moving in right direction” #AHRQac
miller7
September 21, 2011
Recognizing the artificial separation between the mind and the body, a discussion broke out about addressing the whole person.
RT @miller7: @epatientDave coming up with new slogan for #mentalhealth integration - “hello neck” #AHRQac
KansasPCMH
September 21, 2011
@ePatientDave expresses surprise at policy disconnect in MH issues— “need to rediscover the neck” #ahrqac
norskedoc
September 21, 2011
We also wanted to make sure the audience in the room knew that there was an audience outside the room participating - hence the live twitter feed.
Live twitter stream in #AHRQac #mentalhealth town hall http://t.co/4IOGCnk1
miller7
September 21, 2011

Once Dave was done with his panel, he started doing what Dave does best.

I’m out of “the chairs” now, in “the chorus.” Fav guy in panel just ended: Mike Hogan, dir of #mentalhealth for New York State #AHRQac
ePatientDave
September 21, 2011
Numerous Hogan jots about why it’s impt to integrate #mh with primary care. 1: 40 studies show it’s effectiveness in care & costs #AHRQac
ePatientDave
September 21, 2011
2: 40% of ppl who get a psych referral never go (ergo the effectiveness never materializes). #AHRQac
ePatientDave
September 21, 2011
Hogan 3: technical ability in psychotherapy is shown 2b important but QUALITY OF THERELATIONSHIP turns out to have BIGGER impact #AHRQac
ePatientDave
September 21, 2011
Hogan 4: how about “reverse integration” - put med services in #mh institutions? Living in an institution shortens life 25 years(!!) #AHRQac
ePatientDave
September 21, 2011
Hogan 5: cites “the deep end of the pool” - serious illness, which is NOT what all mental well-being is. #AHRQac
ePatientDave
September 21, 2011
Hogan 6 (last): the key place to integrate is pediatrics.(!) Almost all adult problems showed up by age 23. (profound, IMO) #AHRQac
ePatientDave
September 21, 2011
RT @ePatientDave: Yeh, you didn’t know that?? RT @miller7: Apparently, #Medicare used to pay when a surgeon cut off the wrong leg - yikes #AHRQac
ADR_Rocks
September 21, 2011
RT @ReginaHolliday: @ePatientDave is taking on mis-diagnosis, a poorly implemented scientific method and explaining the biology of hope. I love Dave. #AHRQac
ePatientDave
September 21, 2011
Not to be lost in the brilliant discussion, an upcoming project from AHRQ - the Academy for Integrating Mental Health and Primary Care will coming out soon to be a “one stop shop” for resources on integration.
RT @miller7: The video from #AHRQac, and many more resources on #mentalhealth and #primarycare integration to be available soon http://t.co/OhJQ9Vkc
unxpctdblessing
September 21, 2011

Regina Holliday, live painting throughout the town hall, was not content - rather disappointed at the number of attendees in the room.

RT @miller7: @ReginaHolliday painting live at #AHRQac http://t.co/Py2OqLYe
norskedoc
September 21, 2011
RT @kaitbr: RT@ReginaHolliday: The size of the crowd in the mental track is unacceptably small. Twitter folks spread this stream! #AHRQac @kaitbr
CedarHillMom
September 21, 2011
Thanks to @ReginaHolliday for putting out the call for mental health advocates to attend meetings such as #ahrqac where is everyone?
soulflsepulcher
September 21, 2011
RT @ReginaHolliday: @postpartumprogr Maybe if more folks realized mental health affects all of us they would be here.. #AHRQac
postpartumprogr
September 21, 2011
Regina also made her presence felt with brilliant insight and commentary.
@ReginaHolliday told yet another moving story of toy store customer who in years of kid’s devel NEVER heard of autism. Integrate MH! #ahrqac
ePatientDave
September 21, 2011
@ReginaHolliday Discussing the importance of involving lots of people with lots of viewpoints #AHRQac
miller7
September 21, 2011
The second panel took on the challenges of integration and policy/financing.
Next panel on #mentalhealth policy and financing http://t.co/TLh5TBLw #AHRQac
miller7
September 21, 2011
Discussion on the Need to make sure clinical and financial support is in place for the #mentalhealth and #primarycare workforce #AHRQac
laura3530
September 21, 2011
RT @miller7: We need disruptive innovation in #healthcare financing - we pay too much for the wrong things #AHRQac
s_eller
September 21, 2011
Dr. Kavita Patel from @brookingsinst discussing the need for better data to inform #Medicare around integration http://t.co/ALLRBoDw #AHRQac
miller7
September 21, 2011
Dr. Patel - describing the importance of, and how to, apply metrics in #healthcare for policy #AHRQac
miller7
September 21, 2011
"The carve out system makes it impossible to integrate services" - Dr. Kathol regarding #mentalhealth integration #AHRQac
miller7
September 21, 2011
RT @miller7: Having the separation of payment is an impediment for better integrated #healthcare delivery - Dr. Kathol #AHRQac
JoelHigh
September 21, 2011
RT @miller7: “From a policy standpoint, we need to put the management of payment as a parallel process to the changes in the delivery system” #AHRQac
janine_payne
September 21, 2011
Finally, the last panel addressed the importance of researching integration.
RT @norskedoc: Not many of us live in a randomly controlled world— many variables occurring at once, adding to complexity! #ahrqac
apjonas
September 21, 2011
Need research, but based on DIAMOND experience, need to think differently—“partnership research” #ahrqac
norskedoc
September 21, 2011
There is a difference between rigidity and rigor in research #AHRQac
miller7
September 21, 2011
The patient-centered medical home (#PCMH) is one opportunity for integrating #mentalhealth #AHRQac
miller7
September 21, 2011
Don’t know about the patient-centered medical home? Check out #AHRQ resources http://bit.ly/aK917Q #AHRQac #PCMH
miller7
September 21, 2011
Dr. Peikes http://bit.ly/riJpuO asking what are the different types of #mentalhealth integration - #AHRQac
miller7
September 21, 2011
RT @miller7: RT @ePatientDave: Can we introduce high-tech “agile” methods into research? Can we distinguish between rigidity and rigor? #ahrqac
apjonas
September 21, 2011
Drs. Peikes, Chapa and Korsen about to discuss #mentalhealth research http://bit.ly/p0p55x #AHRQac
miller7
September 21, 2011
Dr. Korsen from Maine Health http://bit.ly/o34Qju discussing the Collaborative Family Healthcare Association www.cfha.net #CFHA #AHRQac
miller7
September 21, 2011
RT @miller7 The field of integrating #mentalhealth and #primarycare has a research agenda: http://t.co/2eYsFfwf (PDF) #AHRQac
cherylholt
September 21, 2011
Overall, the event was a success. There was tremendous audience participation throughout! Thanks to all that joined!
RT @miller7: How can we activate the entire populous to be disruptive in #healthcare? via @ReginaHolliday at #AHRQac
janine_payne
September 21, 2011
Pt-md relatship shld include 3) discussion/agreemnt about how best meet preferences in relatn to information #ahrqac #Shareddecisionmaking
Annie_LeBlanc
September 21, 2011
RT @healthythinker: RT @ReginaHolliday: Yes! Someone is talking about mental health in relation to the spirit and a FAITH! Whole body medicine #AHRQac #epatcon
chronicbabe
September 21, 2011
The #mentalhealth system is dysfunctional, entities and doctors do not know the others’ jobs; as a whole it needs WORK, CHANGE #ahrqac
soulflsepulcher
September 21, 2011
great discussion this morning #ahrqac
soulflsepulcher
September 21, 2011

This week is the Agency for Healthcare Research and Quality (AHRQ) annual meeting. For those not familiar with AHRQ, from their website:
"The Agency for Healthcare Research and Quality&#8217;s (AHRQ) mission is to  improve the quality, safety, efficiency, and effectiveness of health  care for all Americans. As 1 of 12 agencies within the Department of  Health and Human Services,  AHRQ supports research that helps people  make more informed decisions and improves the quality of health care  services. AHRQ was formerly known as the Agency for Health Care Policy  and Research."
While the AHRQ annual meeting has had sessions that address mental health in the past, what is happening this Wednesday is quite spectacular. AHRQ is hosting a half day mental health town hall meeting. This town hall will address the future of mental health in a transformed delivery system. Undoubtedly, there will be a great deal of discussion on the research behind integrating mental health, the various ways to clinically integrate mental health and the need for patient and community engagement with any redesign effort. There will be various leaders from the healthcare community there dialoguing around mental health. No doubt, this will be a very exciting event.
To add a layer of innovation to an already innovative event, the event this year will be broadcast online through ustream (URL to be announced) and have a robust active twitter feed (#AHRQac is the general hashtag for meeting).
Want to participate?
Join us this Wednesday (September 21) from 8:00 AM to 11:30 AM at the AHRQ  meeting to discuss mental health and healthcare.   

This week is the Agency for Healthcare Research and Quality (AHRQ) annual meeting. For those not familiar with AHRQ, from their website:

"The Agency for Healthcare Research and Quality’s (AHRQ) mission is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans. As 1 of 12 agencies within the Department of Health and Human Services, AHRQ supports research that helps people make more informed decisions and improves the quality of health care services. AHRQ was formerly known as the Agency for Health Care Policy and Research."

While the AHRQ annual meeting has had sessions that address mental health in the past, what is happening this Wednesday is quite spectacular. AHRQ is hosting a half day mental health town hall meeting. This town hall will address the future of mental health in a transformed delivery system. Undoubtedly, there will be a great deal of discussion on the research behind integrating mental health, the various ways to clinically integrate mental health and the need for patient and community engagement with any redesign effort. There will be various leaders from the healthcare community there dialoguing around mental health. No doubt, this will be a very exciting event.

To add a layer of innovation to an already innovative event, the event this year will be broadcast online through ustream (URL to be announced) and have a robust active twitter feed (#AHRQac is the general hashtag for meeting).

Want to participate?

Join us this Wednesday (September 21) from 8:00 AM to 11:30 AM at the AHRQ  meeting to discuss mental health and healthcare.   

There are few things that we know for certain about mental health in healthcare:
1) Half of Americans will experience some form of mental health problem within their lifetime
Consider the recent CDC report on the topic. USA Today reported:
"There are &#8216;unacceptably high levels of mental illness in the United  States,&#8217; said Ileana Arias, principal deputy director of the CDC. &#8216;Essentially, about 25 percent of adult Americans reported having a  mental illness in the previous year. In addition to the high level, we  were surprised by the cost associated with that &#8212; we estimated about  $300 billion in 2002.&#8217;&#8221;
Take away: Mental health issues are real, growing, and becoming increasingly more visible within healthcare.
2) Mental health and primary care are inseparable.
With more mental health being seen in primary care than anywhere else, it seems like there is a unique opportunity to impact mental health by better identifying, treating and studying mental health in primary care.
From the seminal IOM report on mental health and primary care:
"Most likely this country will retain a parallel primary mental health  system. Among the most interesting and complex issues we face are those  having to do with the complementarity and integration of services  between these two systems, the proportion and makeup of the population  that will avail themselves of these respective systems, the factors that  affect the interface between primary care and specialty mental health care, and the relative cost and effectiveness of  mental health care rendered by clinicians within these different  systems."
3) When mental health conditions are often identified in primary care, accessing mental health services can sometimes be tricky.
From a Health Affairs article examining the impact of mental health parity on primary care:
"About two-thirds of primary care physicians (PCPs) reported in 2004–05  that they could not get outpatient mental health services                      for patients—a rate that was at least twice as high  as that for other services. Shortages of mental health care providers,                      health plan barriers, and lack of coverage or  inadequate coverage were all cited by PCPs as important barriers to  mental health                      care access. The probability of having mental  health access problems for patients varied by physician practice, health  system,                      and policy factors. The results suggest that  implementing mental health parity nationally will reduce some but not  all of                      the barriers to mental health care."
Next steps? In the face of adversity, we must seek opportunities for innovation. Nowhere is this more evident than in integrating mental health providers into primary care.
While the road to accomplishing this is fraught with challenges, isn&#8217;t it time to consider an alternative to what is currently happening in healthcare? Isn&#8217;t it time to consider that some of the things we have taken for granted in healthcare are in need of refinement?
I believe so. If we do not start changing, more and more reports like the one the CDC released will emerge. It is time to get a grip on this critically important issue - mental health.

There are few things that we know for certain about mental health in healthcare:

1) Half of Americans will experience some form of mental health problem within their lifetime

Consider the recent CDC report on the topic. USA Today reported:

"There are ‘unacceptably high levels of mental illness in the United States,’ said Ileana Arias, principal deputy director of the CDC. ‘Essentially, about 25 percent of adult Americans reported having a mental illness in the previous year. In addition to the high level, we were surprised by the cost associated with that — we estimated about $300 billion in 2002.’”

Take away: Mental health issues are real, growing, and becoming increasingly more visible within healthcare.

2) Mental health and primary care are inseparable.

With more mental health being seen in primary care than anywhere else, it seems like there is a unique opportunity to impact mental health by better identifying, treating and studying mental health in primary care.

From the seminal IOM report on mental health and primary care:

"Most likely this country will retain a parallel primary mental health system. Among the most interesting and complex issues we face are those having to do with the complementarity and integration of services between these two systems, the proportion and makeup of the population that will avail themselves of these respective systems, the factors that affect the interface between primary care and specialty mental health care, and the relative cost and effectiveness of mental health care rendered by clinicians within these different systems."

3) When mental health conditions are often identified in primary care, accessing mental health services can sometimes be tricky.

From a Health Affairs article examining the impact of mental health parity on primary care:

"About two-thirds of primary care physicians (PCPs) reported in 2004–05 that they could not get outpatient mental health services for patients—a rate that was at least twice as high as that for other services. Shortages of mental health care providers, health plan barriers, and lack of coverage or inadequate coverage were all cited by PCPs as important barriers to mental health care access. The probability of having mental health access problems for patients varied by physician practice, health system, and policy factors. The results suggest that implementing mental health parity nationally will reduce some but not all of the barriers to mental health care."

Next steps?

In the face of adversity, we must seek opportunities for innovation. Nowhere is this more evident than in integrating mental health providers into primary care.

While the road to accomplishing this is fraught with challenges, isn’t it time to consider an alternative to what is currently happening in healthcare? Isn’t it time to consider that some of the things we have taken for granted in healthcare are in need of refinement?

I believe so. If we do not start changing, more and more reports like the one the CDC released will emerge. It is time to get a grip on this critically important issue - mental health.

Balance.
In my work, there is a fine line and need for balance around challenging the field to move forward and supporting those on the ground who may not be as ready as others to change. This can be a complicated dance.
Take for example the need to screen for mental health conditions in primary care.
A recent article in the Wall Street Journal highlighted the importance of screening for mental health in school based health clinics. No doubt, this is important, yields positive outcomes and is useful and meaningful for the community.
Other studies have shown the significance and importance of screening for mental health conditions, like depression, in primary care.
The problem around most screening is twofold:
1) Positive screens often highlight the lack of immediate mental health treatment for those who may need it at the time of the screening;
2) Paying for screening (and subsequent treatment ESPECIALLY if it is immediate, onsite and integrated) is complicated and often not paid for.
Based on the research, the United States Preventive Services Task Force (USPSTF) recommended that for adults, screening in primary care for depression should really only occur with &#8220;staff assisted supports&#8221; in place to help treat patients who are identified.
Here is the balancing act.
While wanting to advance mental health in primary care, there needs to be more research and policy work done to change policies that would better support treating mental health in primary care.
Screening is just one example.
So, does the field charge forward making the case that more screening should be done for depression in primary care? Does the field attempt to fix some of the problematic policies that prevent financially sustaining mental health in primary care that often are barriers for robust screening, treatment and healthcare integration?
The needs of the community should be placed first. We should work on doing what is right. Better healthcare integration, including mental health, is complicated and challenging, but does that mean it should not be pursued because policies don&#8217;t necessarily align properly? 
A fine line. A balance.

Balance.

In my work, there is a fine line and need for balance around challenging the field to move forward and supporting those on the ground who may not be as ready as others to change. This can be a complicated dance.

Take for example the need to screen for mental health conditions in primary care.

A recent article in the Wall Street Journal highlighted the importance of screening for mental health in school based health clinics. No doubt, this is important, yields positive outcomes and is useful and meaningful for the community.

Other studies have shown the significance and importance of screening for mental health conditions, like depression, in primary care.

The problem around most screening is twofold:

1) Positive screens often highlight the lack of immediate mental health treatment for those who may need it at the time of the screening;

2) Paying for screening (and subsequent treatment ESPECIALLY if it is immediate, onsite and integrated) is complicated and often not paid for.

Based on the research, the United States Preventive Services Task Force (USPSTF) recommended that for adults, screening in primary care for depression should really only occur with “staff assisted supports” in place to help treat patients who are identified.

Here is the balancing act.

While wanting to advance mental health in primary care, there needs to be more research and policy work done to change policies that would better support treating mental health in primary care.

Screening is just one example.

So, does the field charge forward making the case that more screening should be done for depression in primary care? Does the field attempt to fix some of the problematic policies that prevent financially sustaining mental health in primary care that often are barriers for robust screening, treatment and healthcare integration?

The needs of the community should be placed first. We should work on doing what is right. Better healthcare integration, including mental health, is complicated and challenging, but does that mean it should not be pursued because policies don’t necessarily align properly? 

A fine line. A balance.

Being a policy wonk researcher who cares a great deal about primary care and mental health integration, I thought I would take a stab at trying to present some of our work on integration in Austin next year for SXSW.
SXSW is a innovative and exciting &#8220;conference&#8221; held each year in Austin. Most commonly associated with music, SXSW is so much more. Not familiar - learn more here.
So I decided to take a chance and submit a proposal. Here is the abstract from my 2012 SXSW Abstract:
"The current healthcare system is broken and incapable of meeting the  needs of the American public. Fragmentation abounds, costs are soaring  and our health is not getting any better. It is time to disrupt; it is  time to innovate. Since more mental health is seen in primary care then  anywhere else, there appears an opportunity to change the way healthcare  is delivered and make it much more comprehensive and patient-centered.  By placing mental health providers in primary care, the largest platform  of healthcare delivery in the country, we take a step towards  disruption and innovation simultaneously in healthcare policy.  This presentation will take on of the most significant issues in  healthcare, the separation of mental health from the larger healthcare  system, describe how disrupting the status quo in healthcare can be as  simple as consolidating two separate systems (mental health and physical  health) into one, and challenge the community to demand more from  healthcare."
Will this make it through to be a presentation at SXSW? I hope so. To help, you can always vote to support this presentation here.

Being a policy wonk researcher who cares a great deal about primary care and mental health integration, I thought I would take a stab at trying to present some of our work on integration in Austin next year for SXSW.

SXSW is a innovative and exciting “conference” held each year in Austin. Most commonly associated with music, SXSW is so much more. Not familiar - learn more here.

So I decided to take a chance and submit a proposal. Here is the abstract from my 2012 SXSW Abstract:

"The current healthcare system is broken and incapable of meeting the needs of the American public. Fragmentation abounds, costs are soaring and our health is not getting any better. It is time to disrupt; it is time to innovate. Since more mental health is seen in primary care then anywhere else, there appears an opportunity to change the way healthcare is delivered and make it much more comprehensive and patient-centered. By placing mental health providers in primary care, the largest platform of healthcare delivery in the country, we take a step towards disruption and innovation simultaneously in healthcare policy. This presentation will take on of the most significant issues in healthcare, the separation of mental health from the larger healthcare system, describe how disrupting the status quo in healthcare can be as simple as consolidating two separate systems (mental health and physical health) into one, and challenge the community to demand more from healthcare."

Will this make it through to be a presentation at SXSW? I hope so. To help, you can always vote to support this presentation here.