Collaborative Care Model Series - Episode 3

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Transcript

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You're listening to Vital Signs, a podcast for Sentara providers. Welcome to episode 3 of the collaborative Care Model series.

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In today's episode, we're joined by Tommy Bateman, director of Clinical Practice Management, and Thomas Link,

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director of strategic Initiatives. Before we Turn things over to the team, here are a few important CME announcements.

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This episode is accredited for AMA PRA Category 1 credits. For full accreditation,

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designation, and disclosure information, please refer to the show notes. And now here are Tommy and Thomas.

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Hello and welcome back to Vital Signs a podcast for Sentara Providers. I'm Tommy Bateman,

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the host today, and with me I have for the. I'm Thomas Link, the director of behavioral health for the Centera.

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Uh, we've been talking about the collaborative care model so far we have overviewed in part one what it is in part two we've talked

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about what it takes to build a successful program. And at the end of that we alluded to, uh,

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that this is a numbers driven program that we have to measure our impact and look at the financial realities and today we're gonna talk about how

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we do that, measuring out impact and outcomes. So Thomas, welcome back. Thanks.

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Thank you. So, um, we've already set up in this, in this uh uh dream world we're having right now,

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we've already set up the collaborative care model and it's implemented. So how do we know it's actually working?

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Yeah, so, um,

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Which is, which is a great question and this, and, you know, this, the whole model is based on measurement-based care.

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So,

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again, like we talked about with, you know, PCP, I keep saying primary care physicians. Yeah,

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take, understand that it does not have to be strictly primary care. It's just, you know,

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when we talk about 60 or 70% of antidepressants are prescribed in a primary care setting,

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that's, you know, that's why I bring it up. We can, like I have, I have, I've had experience with rolling out into an OB practice.

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So, so it doesn't have to be

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specific to PCPs, um, it's just that's where the chunk of it is. So, um,

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but, but it's all based on measurement. Um, measurement-based,

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uh, screening tools, all right, evidence-based screening tools. So, you know, the big ones that, you know,

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come to mind are just the GATT 7 PHQ 9, and so,

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um, the, the, the trigger to get into the program to refer is hinges on some kind of threshold within

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those metrics, those, those screening tools, then you, the patient gets put into the model.

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As they progress through the model, there's there's actually 3 stages, so in the in the model.

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So you have an active stage, a monitoring stage, and then a relapse prevention and quote unquote graduation stage,

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you know, and so um there's different thresholds for each of those stages.

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So if they come in, they have a PHQ 9 of score 10, and you know, that's the benchmark,

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right? And so. Um, they'll stay inactive until that improves by 50% or let's say

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it depends on the threshold. Like all this is somewhat variable depending on the organization that implements it, right?

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So I'm just going to go with PHQ 9s of 5. So let's say that's the threshold.

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I'm gonna use myself as a patient again. They come in, I score 10. The the PCP introduces me to the program.

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That's my benchmark, right? It's, it's 10. That's where we're starting from

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and um.

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Normally what it, what the model says is you're going to be an active from 50% until you you're at 10

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until you have a 50% increase in uh increase,

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50% decrease in your PHQ 9 scores or improvement or you go up under. That threshold of 5 of the PHP 9 to 5,

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right? And so that is being tracked on every touch point that that patient has,

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you know, I mean, most people, I don't know about you, Tommy, but like I go to my PCP once a year for annual physical unless I'm like really sick,

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I don't go, um, and, and you know those touch points,

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um. With in this model, in the active model, like active stage of this model,

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you're having two touch points, at least 2 touch points in a month, right? And then monitoring goes down maybe once a month,

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you know, and, and so the graduation is normally like a final follow-up visit, but you're tracking and trending those metrics over

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that time, right? And so um after the University of Washington started this um you know,

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years ago, uh in the 90s. Uh there.

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Uh, a study, uh, it was actually 4 years study called the Impact Trial and Study.

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Um, it, it studied a population of about, I think 1800 older adults. Um,

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so, so this is actually greater than 60, age 60, um, uh, with depression across 18 PCP

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clinics in the US. So, um, and they measured, they used the collaborative care model, but the comparison was just usual primary

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care treatment. Um, the duration was 12 months and, and with follow-up extending up to 24 months,

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but the study showed that um,

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The patients in the impact program, so the collaborative care model, were twice as likely to experience a 50% reduction in

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depressive symptoms. So compared to just usual care. So the, the data,

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I'm gonna pull it up real quick. 45. of impact patients improved significantly versus 19% in usual care.

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So,

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um what's kind of at the time, it was the largest randomized trial depression care in older adults at the time and it just really showed that

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effectiveness, um.

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So, so that's just one study. There's been now recently there's been a lot of other studies that that have been driven by payers

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to show the cost effectiveness, right? Um, and so,

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you know, if we see such a difference between, um, you know,

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our, our, our tests where 45% are reduced versus 19% of the people had reduced depressive symptoms,

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how did that translate. To, uh, let's say inpatient admissions that are way costly compared to outpatient treatment.

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So yeah,

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on the financial side. Yeah, what do you think Tommy? I mean, if you, if you have 100 patients that are coming in and that 100 are

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in the model, 100 aren't, they have the same symptoms and the people that are in the model are going to have a 45%

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um

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improved.

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Symptoms, symptoms that are improved versus 19%. I mean how do you think downstream that affects it?

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Well, let's say, you know, the difference of 26% of the people, right, uh, potentially not going to the emergency room or to inpatient facilities which

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costs, I don't know, $100 an episode.

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If we impact just a few of those, we've already paid for the model itself, it seems. Yeah, yeah, yeah,

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so, so actually, you know, it's it's interesting you brought that up that that that study, and I'm gonna bring up the,

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the, I'm gonna read from the paper. So from that impact study, actually the net savings that were estimated were

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uh $3300 per patient over four years. So um so it it.

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That and that's, that was a study in 1998 to 2002. So I mean it's, you know, it was a long,

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it was a while ago. um I, I saw something recently and I'm not going to quote it because I don't have it in front of me,

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but

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that um Kaiser Permanente did and it was, and, and I, I don't quote me, but I think it was close to that number,

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but it was over a one year span, which is a lot different, but, you know, I mean that this is.

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Anybody in the healthcare system understands that like, look, if we can reduce people's symptoms and provide care upstream,

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then it is less costly downstream when they have to go to ED or acute care or,

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um, you know, so the patients in that, that impact study, um,

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from, you know, ending in 2002, which is what, 2023 years ago, I mean,

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um, patients reported better, better physical functioning, higher vitality.

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And improved quality, uh, overall quality of life. Um, they were more satisfied with the the the

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depression treatment, um, and the benefits persisted beyond the initial year at 24 months,

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um, continued to show better depression outcomes than those in the usual care. So, um. So not only has the system benefited financially,

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um, so let's say $3300 over the course of four years. Well, let's say the population is $100,000 or $100 excuse me,

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well, that's, uh, that's quite a lot of, uh, a lot of dough that's swinging in the right direction.

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And of course, among that population, not all of them are going inpatient and they wouldn't have gone inpatient to begin with,

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right? They, they, but we have those. You know, top 10% of people that are the very, very expensive ones and reducing it overall kind of spread

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the spread the benefit all around. Um, so yeah, it's not only did the, the financial side win,

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but it sounds like the, uh, the, the patients one, which is the biggest one. So yeah,

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and I mean, you know, unfortunately sometimes.

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You know, with our, um, how our industry is set up, that's not always the,

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the consideration, and it's all, you know, financial stability, right? And so, um, you know,

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these, these integrated, uh, delivery networks that are across our system.enttara is actually one of them,

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but you know, a lot of the health systems, they don't have. Um,

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an insurance plan, right? So if we're talking about direct finance, financials,

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savings that you know, we talked about 3300 over four years, that's, that's directly impacting the health plan.

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So, you know, when we talked about in the last episode of the barriers, that's another barrier,

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right? So if I'm, I'm only a health system, I have 5 hospitals and 200 clinics.

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And I'm wanting to implement this model. Well, that 3300 isn't directly impacting my books,

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right? So, so that is another barrier of of that. So you know,

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now you see all kinds of incentive programs across the country for payers saying, hey, we'll, we'll give you a You know,

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PMPM so per member per month, we're gonna, we'll give you seed money to start up these kind of programs.

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We'll give you, um, we're gonna, if you have 200 of our members, you know, from a health plan standpoint,

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you have 200 members in our in your program, we'll pay you per month per member that's in your program,

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right? I mean, there's a huge incentive from a payer standpoint, but

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so, um. So it's really getting those,

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those all those initiatives, those strategic imperatives aligned across different entities within our health

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system to push something like this forward, right?

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Um. So,

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absolutely, and I, I think of being on the payer side myself of seeing, you know,

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I could easily want to hire a case manager and embed them into a PCP or OB or any practice,

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substance use practice, whatever, and uh and, and uh cause I, you know, from the payer standpoint I could absolutely see the financial impact towards us

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immediately um and uh uh but I, I do understand if somebody was uh uh um.

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A provider that seeing that immediate financial impact that's going towards them may be more difficult unless there's incentives unless we're the,

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the, and it brings up the CPT codes specifically for collaborative care model are those, are those reimbursing at a rate that's acceptable,

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uh, that would, that would, uh, incentivize a provider to start up that that model, right?

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Yeah, they actually are. I don't have them right in front of me, but they're, they're. Somewhat substantial,

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right? I mean, you look at it from a PCP is getting their billing for the services they're rendering,

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right? So this is. But then you're tabulating all the time spent with the patient from the care manager to the psychiatric consultant

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and dropping a charge, but it's a monthly charge, right? So it's very,

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quote unquote case management focused billing,

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which, um, you know, incentivizes volume, right? The more you have in it, the more revenue you bring in.

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So, um, so I think we've made big strides in that, um,

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and

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And so, you know, but

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again, when, if it's a health system that doesn't have a health plan involved with their strategic planning,

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they're really coming at it from a different angle, right? So it's going to be more of

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Uh, resiliency and team member engagement for our PCP practices,

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right? They need support. They're literally managing 60 to 7% of the depression in our community,

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right? That that is that, I mean, that's, they don't have a choice. That's what's coming to them,

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right? So like how from a health system, like how do we support them in a very meaningful way.

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Um, in this, right? And so that's, that's really a big one. And I mean, look, we're all,

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we're all here to the ultimate goal is to support the people in our communities. I mean, that's, I mean that's why I got into healthcare,

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right? And so this is a very great tool to in doing that, especially with,

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you know, like we mentioned there, it's probably a top 5 topic on all community needs assessments across our country,

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right?

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Absolutely. And as a uh less professional counselor, that sounds like uh uh uh another avenue we could take as counselors

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to uh impact the community, not just the traditional outpatient setting, you know,

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one on one counseling or even working in community mental health. This is something we can get involved in and really impact people's uh uh medical health

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and physical health as well, um, by getting involved in this as as uh providers. Yeah,

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and, and, and let me jump on that real quick. So you, you, you know,

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I'm, I've said this, they can be licensed or unlicensed, right? So someone, so,

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and, and what do licensed clinicians do? They often supervise unlicensed clinicians.

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I think that's a very meaningful way to help scale these kind of programs is, is,

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you know, someone like you that is fully licensed to support people that are working toward license. That this is a great role for them to be

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in to, to help, right? How do we, how do you as a clinician support um early career possibly

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that, that want to be in part of this kind of program in a meaningful way, right? Right.

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Absolutely. And, and so I think that brings this part to a close, you know, that we talked about how do we know it's working by measuring,

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you know, pre-post uh testing scores for things like the depression screening PHQ-9 or the anxiety GAT7 and related measures

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and and what it takes to financially sustain this model. So I, you know, we talked about a lot of what it,

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uh, kind of the idea of it, the, uh, structure of it, but let's in the next part, talk about kind of the real world application things that,

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uh, things that you're actually seeing on the street level that that are actually happening. So, uh,

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everybody stay tuned for the next part we're gonna be talking about real world applications and future directions. Thank you again,

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Thomas.

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Thank you for joining us. Be sure to keep an eye out for episode 4 of the Collaborative Care Model series.

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You've been listening to Sentara Vital Signs, a podcast created for Sentara providers.

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As a reminder, please check today's show notes for details on how to claim your continuing education credits.

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That's it for now. But we'll be back soon with another episode of Vital Signs, the podcast that delivers evidence-based education

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for physicians and healthcare providers on the go.