Vol. 10, No. 10
David Mee-Lee M.D.
The debate over what to do about guns in the USA has not faded. It so often happens a topic is hot for a few weeks and then disappears as new “breaking news” competes for attention. But I will not saturate your attention this month with some readers’ responses to the December issue on guns – we’ll share those in a future edition.
Instead there’s a couple of healthcare topics that have been close to my heart for many years, and they have been getting more and more attention in the literature. I’ve been writing about them in Tips and Topics for the past decade. I believe these principles are clear and important; nevertheless I am also increasingly aware that many physicians, other healthcare professionals, clinicians and counselors do not share that view. Not only do they not share these values, but some may be outright suspicious and negative about these trends in healthcare.
What I’m talking about is Integrated Care and Collaborative Care.
Review your knowledge and values about Integrated and Collaborative Care.
The President of the American Medical Association (AMA), Jeremy Lazarus, M.D., who happens to be a psychiatrist, told delegates at the Interim Meeting of the AMA House of Delegates recently:
“It’s a new era in American health care – one that calls for physicians to collaborate with other doctors and health care professionals in a new model of integrated care….Integrated care asks us to cultivate mutual trust, to recognize that each team member offers unique skills and knowledge, and to support this trust with open and timely communication…And we must go all in to improve the quality if health care for our patients and the country.”(Psychiatric News, Volume 47, No. 23, December 7, 2012, pp. 1,9)
–> Years ago Parkside Medical Services had a value: “Everyone has a territory but nobody has a kingdom.” Each discipline and stakeholder has an important contribution to the whole, but nobody knows everything about everything, nor can do it all by themselves.
–> And it isn’t just about physicians collaborating with other health care professionals, it is about addiction counselors and mental health clinicians collaborating with primary care; it is in primary care where most people with addiction and mental health concerns actually show up for health care services.
So what is integrated and collaborative care?
Psychiatrist, Jurgen Unutzer, M.D., M.P.H outlined the following principles of integrated care:
- Patient-centered care through close collaboration of mental health and primary care providers. (DML: I would add close collaboration of addiction treatment too)
- “Measurement-based treatment to target” – treatments are actively changed until clinical goals are achieved.
- Population-based care in which patients are tracked in a registry.
- Use of evidence-based treatments.
- A system of accountable care in which providers are reimbursed for quality of care and clinical outcomes, not just the volume of care provided.
(Psychiatric News, Volume 47, No. 21, November 2, 2012, page 5)
Does integrated care work?
Dr. Lazarus cited one example of the Southcentral Foundation in Anchorage, Alaska. Patients are assigned to a health care team consisting of a physician, nurse, medical assistants and even traditional healers. Here is how outcomes improved in the last decade:
- Visits to the emergency department decreased 40%
- Hospitalizations decreased 75%
- Routine doctor visits decreased 30%
- Binge drinking, strokes, heart disease and cancer rates among Alaska Natives are now about the national average whereas before they were much higher.
(Psychiatric News, Volume 47, No. 23, December 7, 2012, page 9)
Collaborative care is also about shared decision-making with patients and clients.
The New England Journal of Medicine (NEJM) published an article “Shared Decision Making to Improve Care and Reduce Costs”. (Emily Oshima Lee and Ezekiel J. Emanuel)
- “In a 2001 report, Crossing the Quality Chasm, the Institute of Medicine recommended redesigning health care processes according to 10 rules, many of which emphasize shared decision-making. One rule, for instance, underlines the importance of the patient as the source of control, envisioning a health care system that encourages shared decision-making and accommodates patients’ preferences.”
- “Randomized trials consistently demonstrate the effectiveness of patient decision aids. A 2011 Cochrane Collaborative review of 86 studies showed that as compared with patients who received usual care, those who used decision aids had increased knowledge, more accurate risk perceptions, reduced internal conflict about decisions, and a greater likelihood of receiving care aligned with their values. Moreover, fewer patients were undecided or passive in the decision-making process – changes essential for patients’ adherence to therapies.”
- “Studies also illustrate the potential for wider adoption of shared decision- making to reduce costs. Consistently, as many as 20% of patients who participate in shared decision-making choose less invasive surgical options and more conservative treatment than do patients who do not use decision aids.”
- “In 2008, the Lewin Group estimated that implementing shared decision-making for just 11 procedures would yield more than $9 billion in savings nationally over 10 years. In addition, a 2012 study by Group Health in Washington State showed that providing decision aids to patients eligible for hip and knee replacements substantially reduced both surgery rates and costs – with up to 38% fewer surgeries and savings of 12 to 21% over 6 months.”
But what has this got to do with addiction and mental health services?
Longtime readers know how often I have talked about the therapeutic alliance, and how four decades of research indicate that the quality of the therapeutic alliance contributes most to successful outcomes. (Mee-Lee D, McLellan AT, Miller SD (2010): “What Works in Substance Abuse and Dependence Treatment”)
- One recent edition on therapeutic alliance is the May 2012 issue of Tips and Topics.
- There is another fascinating study that appeared in the American Medical Association (AMA) News, Volume 56, No.1, January 14, 2013. It was an article about how opening the physicians’ clinical notes increases patient engagement.
Here is one study’s surprising results:
Patients report benefits from open notes
“Patients involved with the pilot program at Beth Israel Deaconess Medical Center (BIDMC), Geisinger Health System (GHS) and Harborview Medical Center (HMC), who were subjects of an Annals of Internal Medicine study, reported benefits to having access to their physicians’ notes. Very few patients reported confusion or concerns, with the exception of privacy.”
|Benefit or risk||Portion of BIDMC patients||Portion of GHS patients||Portion of HMC patients|
|Felt more in control of their care||84%||77%||87%|
|Remembers care plan better||84%||76%||83%|
|Understands health conditions better||84%||77%||85%|
|Takes better care of self||70%||71%||72%|
|Takes medications better||60%||78%||73%|
|Concerned about privacy||36%||32%||26%|
|Found notes more confusing than helpful||2%||3%||8%|
Source: “Inviting Patients to Read Their Doctors’ Notes: A Quasi-experimental Study and a Look Ahead,” Annals of Internal Medicine, Oct. 2 (http://ncbi.nlm.nih.gov/pubmed/23027317/)
Health care is changing in the USA – both in how it will be delivered and in how we engage patients and clients in shared decision-making. The research evidence is too compelling to keep doing business as usual. One last set of statistics from the Institute of Medicine (IOM) and the National Research Council:
- The USA health ranks at the bottom among 17 rich countries.
- Despite spending more per capita on health care than any other country, the United States also ranks at or near the bottom in infant mortality and low birth weight, injuries and homicides, teen pregnancy and sexually transmitted diseases, HIV and AIDS, drug-related deaths, obesity and diabetes, heart disease, chronic lung disease, and disability.
- Health problems are more common among Americans who are poor or uninsured. But the panel also found that even healthy Americans who are insured, college-educated, or have high incomes seemed to be in worse health than are similar groups in other countries.
1. Psychiatric News, Volume 47, No. 23, December 7, 2012, pp. 1,9 written by Mark Moran
2. Psychiatric News, Volume 47, No. 21, November 2, 2012, page 5 written by Mark Moran
3. “Shared Decision Making to Improve Care and Reduce Costs” Emily Oshima Lee, M.A., and Ezekiel J. Emanuel, M.D., Ph.D. N Engl J Med 2013; 368:6-8. January 3, 2013
4. Mee-Lee D, McLellan AT, Miller SD (2010): “What Works in Substance Abuse and Dependence Treatment”, Chapter 13 in Section III, Special Populations in “The Heart & Soul of Change” Eds Barry L. Duncan, Scott D.Miller, Bruce E. Wampold, Mark A. Hubble. Second Edition. American Psychological Association, Washington, DC. pp 393-417.
5. “Unveiling the Doctor’s Notes”, Pamela Lewis Dolan. American Medical Association (AMA) News, Volume 56, No.1, January 14, 2013.
6. “U.S. Health in International Perspective: Shorter Lives, Poorer Health” Jan 9, 2013. Institute of Medicine.
So if the research on integrated and collaborative care is compelling, why are some -perhaps many- physicians, clinicians and counselors suspicious and even antagonistic to these changes in health care?
See if you agree with these “people” obstacles to Integrated and Collaborative care.
There are different strokes for different folks and each discipline and health care provider may have different reasons for wanting to maintain the status quo. (In Motivational Interviewing this is called “sustain talk” in contrast to “change talk”.)
Reasons physicians might struggle with the move to integrated and collaborative care:
- It requires a change in the core values that have motivated physicians – shifting from autonomy to shared decision-making and teamwork (Dr. Lazarus, Psychiatric News, December 7, 2012)
- For decades, health care was organized and practiced “in an era when doctors could hold all the key information patients needed in their heads and manage everything required themselves.” (Dr. Atul Gawande, Psychiatric News, December 7, 2012)
- Society has rewarded physicians for taking on life and death responsibility with financial and social status. As stressful as great responsibility is, shared power and decision-making requires a major shift and collaborative spirit./li>
- Physicians have been trained to ask questions, quickly diagnose the disease, prescribe the treatment, often making life and death decisions very quickly. Patients are expected to answer questions, trust the doctor’s judgment and comply with doctor’s orders. And now the doctor is just one of the team and patients get to share decisions!
Reasons counselors might struggle with the move to integrated and collaborative care:
- Counselors who have come to the profession through their own life experience may have been misdiagnosed by physicians and prescribed psychotropic or addicting medication for years, before finally finding recovery. There is suspicion of physicians, the primary health care and mental health systems that often rejected people with addiction.
- Addiction treatment has predominantly been abstinence-based with only recent acknowledgement of the possible role of psychotropic medication, opioid treatment services and an array of anti-addiction medications. Many counselors are still very uncomfortable with medication-assisted treatment and recovery.
- For many addiction program models there has been a strongly held anti-medical, Twelve Step or social model ideology. The Therapeutic Community model, based on social learning theory, holds the power of the community and peers as being much more significant than doctors, nurses and other professionals. The Twelve-Step model has traditionally seen taking medication as “chewing your booze” and invalidating the AA member’s sobriety date. Whole counties and states have in the past prided themselves as being explicitly a social model system antagonistic to the so-called “medical model”. Even if these systems are changing, attitudes persist.
- Addiction programs see a tiny sliver (1.5%) of the estimated 19.3 million persons aged 12 or older needing, but not receiving treatment for illicit drug or alcohol use. (2011 national Survey on Drug Use and Health, SAMHSA, Sept., 2012)
http://www.samhsa.gov/data/NSDUH/2k11Results/NSDUHresults2011.htm#1.1With the busyness of waiting lists, limited resources and service demands already, there is little energy or interest to reach out to the millions of people with addiction who are in primary care settings.
- Federal confidentiality regulations like 42 CFR Part 2 has reinforced separation of addiction and physical health records and flow of information.
Mental Health Clinicians:
Reasons clinicians might struggle with the move to integrated and collaborative care:
- Insurance payers and managed care organizations have usually “carved out” behavioral health payments and care management from general health insurance. This has kept mental health and addiction fragmented from physical health.
- The Health Insurance Portability and Accountability Act (HIPAA) and the real or perceived privacy requirements can lead physicians and others to withhold information from those who may have a right to have it. So much for integrated and holistic care!
- The pecking order of different disciplines, reinforced by differing pay often for similar therapy work maintains boundary, turf and guild battles fighting for a piece of the health care pie.
Check if you can identify with any of these obstacles to Shared Decision Making and Collaborative Care with Clients and Patients.
- Here’s what one reader asked a while ago:
“I have been in mental health and drugs and alcohol for over ten years (no not ill or using- helping!) and I am having difficulty understanding why I would allow my client to determine their own treatment, when it is their poor decision-making over the years that have led them to where they are presently: several court cases, social services, probation, children removed from the home, unemployed again etc., so why all of a sudden would they now demonstrate good judgment?…..Would you be so kind as to explain the reasoning again for allowing the client to determine their own treatment?”
Here’s why shared decision-making makes sense especially for someone described as above: All change is self-change and people do what they want to do anyway. If there is to be real change, they have to be the one to choose the healthy choice in the dark of night when nobody is watching. Telling them what to do does not translate into sustainable action, otherwise we could send all our clients memos on how they need to change and to get busy.
- Some might say:
“I went to school for all those years, went into debt for the tuition and now have expertise and experience. Are you telling me that my expertise is to take second place to some collaborative care approach with patients and clients who are out of control?”
Shared decision-making with patients and clients isn’t some “touchy feely, politically correct” approach to appease some consumer movement. And it doesn’t mean you abdicate your responsibility and expertise to do a good assessment and share with clients the very best, effective and efficient way to reach their goals. It is a recognition that if accountable, self-propelled change is the outcome you want from your treatment, then the client has to be as engaged and committed to changing as you are. In fact, if you think about your own resolutions to change, it is hard enough to sustain change even if you really want it and know what to do.
Positive and lasting change has little chance of success if the client doesn’t share the same fervor for the goal as you; nor share the same decisions on how to get there; and doesn’t really trust you anyway.
- “Righting reflex” – “the desire to fix what seems wrong with people and to set them promptly on a better course, relying in particular on directing” ((Miller, William R; Rollnick, Stephen (2013): “Motivational Interviewing – Helping People Change” Third Edition, New York, NY., Guilford Press. page 6). Clinicians have a hard time resisting the reflexive, clinical response to fix such obvious pathology and poor choices. People who choose the “helping professions” are particularly vulnerable to the “righting reflex”. Motivational Interviewing “guides” not “directs” people to change through collaboration and shared decision making.
This morning at 4 AM I was jarred out of sleep with the phone ringing. Being a physician for forty years, it is imprinted to answer the phone and try to think clearly quickly. But I’m not on call anymore and there aren’t any training and consulting emergencies at 4 o’clock in the morning.
So I squinted to see if caller ID would help get me oriented quickly. “Skype caller” it said. Must be my son traveling in Southeast Asia. Fatherly anxiety rising.
“Hello, hello, can you hear me?”
“Tay (Taylor named after James Taylor one of my favorite singer-songwriters just like my son is), Tay what’s wrong and where are you?”
“I’m in Luang Provang, Laos and I’m sick.”
I kicked into doctor mode and took a careful timeline history of symptoms: eating at a supposedly clean tourist-friendly restaurant but still symptoms of diarrhea, lethargy, no appetite; OK the next two days; then some more diarrhea, fever with stomach cramping after taking strong antibiotics.
My initial diagnosis: travelers’ diarrhea related to food contamination complicated by antibiotic side effects. Treatment: water, rest, eat when body says it is ready, avoid risky foods like salad washed in unclean water and uncooked food.
That was 14 hours ago as I write this and no word back, which I hope means “no news is good news”. But I won’t rest well until I know he is really OK. It got me thinking though about all the parents out there with military children and loved ones in harm’s way all over the world.
My son is on a happy adventure. Their children are on a dangerous mission.
I’m worried about food poisoning and diarrhea. They’re worried if their kid will get a limb blown off or suffer from Traumatic Brain Injury, or not even come back home.
A parent’s anxiety for their children’s safety and well-being is powerful, no matter how big or small the danger is. So I count my blessings that, right now, it’s only about diarrhea for this father.
PS. E-mail from Taylor:
“It is 11:41 AM here and just got up and out of the shower. I am significantly better. I woke up around 1 AM and could feel my fever breaking. I have no tummy ache and have an appetite again. I am still very weak and tired though, probably to be expected after 1.5 days of no food and lots of diarrhea. Man, being sick sucks. It really takes it out of you. It is an exciting trip, but you also realize how having your basic health and safety is a must for any type of enjoyment.
We will go out now and get some food and plan our next move. I’ll keep you informed. Thanks for your help and support.
Until next time
Thanks for joining us for the start of 2013. See you again in late February.