Partners in Integrated Care (PIC)
Behavioral health problems often complicate and exacerbate other chronic health problems that require coordination and chronic care management from a primary care provider. Without effective identification and treatment, patients with co-occurring physical and behavioral health conditions incur significant medical costs due to the systems of care.
With funding from the Agency for Healthcare Research and Quality (AHRQ), PRHI led a three-year initiative called Partners in Integrated Care (PIC) to disseminate and implement evidence-based depression and unhealthy alcohol and other drug services in primary care settings. PIC consisted of a multi-state partnership among organizations that are renowned for implementing Screening, Brief Intervention, and Referral to Treatment (SBIRT) for unhealthy alcohol and other drug use and Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) for collaborative depression care management in primary care offices.
The PIC partners include PRHI and the following organizations:
- The Institute for Clinical Systems Improvement (ICSI)
- The Wisconsin Initiative to Promote Healthy Lifestyles (WIPHL)
- The Wisconsin Collaborative for Healthcare Quality (WCHQ)
- The Network for Regional Healthcare Improvement (NRHI)
- The Massachusetts Health Quality Partners (MHQP)
Objectives were to:
- Develop a combined model of the two evidence-based interventions (IMPACT and SBIRT)
- Develop an implementation toolkit and marketing plan that can be adopted by multiple communities
- Train and provide implementation support to 50-90 primary care sites in MN, WI, and PA
- Disseminate through the Network for Regional Healthcare Improvement (NRHI)
Core components of the PIC care delivery model:
- Screening for depression and unhealthy alcohol and other drug use
- Dedicated role in primary care for patient engagement, brief behavioral interventions, longitudinal monitoring, and facilitation of team-based collaboration (a care manger)
- Brief interventions for patient feedback, goal-setting, and behavior change, using motivational interviewing and behavioral activation
- Systematic caseload review by a consulting psychiatrist
- Systematic follow-up and tracking
- Treatment adjustments by the primary care provider, using a stepped care approach
Continuing the Work: Care Management of Mental and Physical Co-morbidities
In partnership with the Institute for Clinical Systems Improvement (ICSI), PRHI was able to leverage additional resources to improve care for high-risk adult patients in Pennsylvania with depression plus diabetes or cardiovascular disease. In June 2012, the Center for Medicare and Medicaid Innovation (CMMI) awarded a $17.9 million Innovation Challenge grant to ICSI. The project, Care Management of Mental and Physical Co-Morbidities (COMPASS), is training and coaching care managers and healthcare teams to assess condition severity, monitor care through a computerized registry, provide relapse and exacerbation prevention, intensify or change treatment as warranted, and transition beneficiaries to self-management.
As one of eight implementation partner organizations in eight states, PRHI is providing training and practice coaching to three medical groups, which are providing COMPASS care in 31 primary care offices in western Pennsylvania.