Improving Patient Care: The community feedback period for this idea began on 5/30/2019 and ended on 7/29/2019.

What is the problem that needs to be addressed? Please describe how it is related to mental health.
There are three major issues with mental healthcare in Orange County: 1) Doctors are not incentivized to provide better care (Pay for Performance) and 2) Care isn’t provided in a Patient-Centered Medical Home (https://pcmh.ahrq.gov/page/defining-pcmh) 3) Discharge Planning for Psych in Orange County needs improvement.

Why is this a concern for Orange County? What can Orange County and other counties learn from this project?
It is assumed that Orange County wants to purchase healthcare services driven by quality with efficiency. Other counties can learn how motivating doctors can create system change.

What is currently being done to resolve this problem in our county and throughout the United States? If applicable: Is it working; why or why not?
In Psych, Fee for service. In Cardiology, the Centers for Medicare and Medicaid (CMS) identified 30-day readmission for Heart Failure as a metric identifying quality. In response, the Cardiologists spent a little bit of time yelling & screaming in private. In public, the American Heart Association and other stakeholders created Target:HF (https://www.heart.org/en/professional/quality-improvement/target-heart-failure/strategies-and-clinical-tools) and doctors became highly motivated to provide better care. The readmissions checklist identifies multiple reasons for readmission for Heart Failure that can be applied to psychiatry. Target:HF also has a Discharge Planning tool/checklist and a phone followup script/checklist. NAMI punted their discharge planning checklist to a little known organization from Oregon and that discharge planning tool/checklist needs improvement. In psych, stovepiped specialty at an isolated facility. In Pediatrics since 1967, the Patient-Centered Medical Home – a single location to get all care with cross-disciplined care teams. It is well known that psych patients have a triad of psych-infectious disease-substance abuse. Psych doctors are trained to do Psych. They are not trained to manage Syphilis, HIV, Human Papilloma Virus, etc. So psych patients are routinely admitted to psych facilities with untreated Syphilis/HIV/HPV etc and these patients have no pathway to followup via a checklist to bring to the doctor that will provide the care psych is deficient in. Furthermore, Psych drugs induce/inhibit the most common cytochrome P450 CYP enzymes that yield medical drugs ineffective. So what happens, for example, is psych patients with HIV get admitted to Psych wards then can be not treated for HIV or get dispensed HIV drugs whose efficacy is decreased by the psych drugs prescribed. Technically the jury is out on whether a patient in a psych ward with untreated HIV or erroneous treatment for HIV suffers increased rates of morbidity or mortality because conducting such a study is unethical (we don’t randomize patients to suboptimal care to see what happens compared to patients given optimal care). It is clear that Orange County isn’t collecting those metrics for this one example. There are likely many, many other possible examples in people with autoimmune disease, heart disease, etc.

What is new or different about this project idea? Please describe how this differs from what is already being done (Question 6). Please list any research that was done on this topic.
Doing it as opposed to what is already being done which is not addressing the team based errors that are common in medicine.

What is the project idea? Please describe how this project will operate.
1) Decrease/suspend payment to facilities/providers that have 1 year readmission issues for Psych Patients. 2) Create a Patient Centered Medical Home with a minimum of a Board Certified Psychiatrist, Board Certified Internal Medicine Doctor, Board Certified Infectious Disease Doctor, and Board Certified Clinical Pharmacist. These are the docs that need to know each others medical records so it makes sense to put them in the same place so they are not faxing/e-sending their records between incompatible systems with the associated lag times that delays care and slows things down. You can even get docs dual board certified in Internal Medicine-Psych, Family Medicine-Psych or even triple boarded in Psych-Pediatrics-Child/Adolescent Psych. 3) Consider other never event / quality metrics that will align a patient’s outcome with the provider’s compensation. 4) Create a discharge planning tool/checklist that is evidence-based and tied to compensation.

 Additional Information:
Respondent skipped this question

 

May 15, 2019

6 comments

Thank you for your submission. The Innovation team needs additional information, please elaborate on your responses as best as possible so that we may work through our review process.

-Patient Centered Medical Homes (PCMH) have been implemented in many settings. How would this type of PCMH be different?

-Innovation projects are time limited and this idea includes many components. Would this project include only the development of a discharge planning tool and implementation plan or would these be implemented, also?

-What would be the specific learning objectives?

Patient Centered Medical Homes historically are for people/families with chronic health conditions with the mental health component of the medical home being secondary to the chronic health condition. For example, a child has a birth defect and the mental health component of the PCMH exists to help the family and/or child to cope with the birth defect. Constructing a PCMH in the other direction, having a person with mental illness as the qualifying condition for a medical home to handle associated medical conditions/co-morbidity in addition to the mental illness is innovative. Anticipated co-morbidity touches on the following specialties: infectious disease, endocrine/diabetes, addiction medicine, orthopedic surgery, cardiology, dermatology, pathology, nephrology. etc.

There isn’t a PCMH model in Orange County for Serious Mental Illness. Previously, the Short-Doyle act tried to integrate mental health consumers into the community, including community healthcare. The planned BeWell 1.0 center is a nod to pre-1957 Short-Doyle healthcare where psychiatric services were isolated from the rest of the healthcare system. Kaiser Permanente, Hoag-St. Joseph’s and the other major healthcare referral networks are moving in the anti-PCMH direction by their investment in the BeWell 1.0 Center and thus the outcomes/cost is anticipated to be higher than needed. Either BeWell 2.0 or BeWell 3.0 can be structured as a PCMH to compete with the other BeWell centers to see which one has the better resource utilization.

Governments, historically, are able to handle quite a bit of complexity. World War II, fought on another continent with impaired supply chain and little modern information technology, was won in 4 years (December 1941- September 1945). Technically, a World War II scope of work can be completed in a Proposition 63 mandated 5 year time period with a bonus 15 months to rest. This submitter counts at least 13 potential contractors for this project, but – in worst case – a new facility can be constructed to fulfill this project’s goals.

This project submission is for the full scope of work. It may be easier for OC Innovations to break up this project – but the four components are tightly tied together with interdependence. It is expected that all components be considered together as all are considered Innovative by many different criteria when applied to Psychiatry.

The specific learning objectives for this project may include, but are not limited to:
1) Per patient resource utilization comparisons with existing facilities (i.e. $ per person or other metric)
2) Adverse event per person metrics comparisons with existing facilities (there is no known adverse event reporting system for Orange County Mental Health. It should be expected that such a reporting system may be a future Innovations submission)
3) Per patient days off of work comparisons or other proxies for transportation/time/distance/complexity metrics (In 2019 this submitter regularly visits at least five different healthcare facilities across Orange County in at least two different referral networks. In 2018 this submitter visited eleven different healthcare facilities across Orange County in at least four different referral networks)
4) Readmission metrics mentioned above (readmission is expected to be less frequent)
5) Decreases in Drug-Drug interaction errors (assuming drug-drug interaction errors are being tracked)
6) Decreases in number of faxed pages between facilities
7) Decreases in Medical records personnel person-hours
8) Decreases in HIPPA releases signed to share medical records between facilities (technically 55 releases for this submitter in 2018 if medical records are to be completely shared and the release is considered bi-directional. If the release is considered unidirectional than 110 releases).
9) More learning objectives yet to be identified.

Additional information pertinent to this issue came to my attention when researching something unrelated.

I didn’t think there would be documented, published studies about differences in access to care based upon mental illness. I was wrong.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3784991/ https://www.ncbi.nlm.nih.gov/pubmed/23134057

These studies in Medicare recipients show a differential access to care for hip/joint replacement (consequence of confining a person to a wheelchair/scooter or impaired gait), several invasive/minimally invasive cardiac procedures (consequence of reduced cardiovascular activity tolerance – for example can’t walk long distances without getting out of breath), breast reconstruction and organ/tissue transplantation when a person has mental illness. I only expected the transplantation outcome. The rest were a surprise.

Such a study in a younger population aged 16-64 isn’t easy because the data is partitioned across Medicare, Medicaid, Private Insurance, Employer Insurance and Cash pay. It is expected that similar findings exist for the younger population, but good luck finding anyone willing to work publishing such a study. Anecdotally, it is observed that treating hip fracture with a joint replacement for the population served by Medicaid and/or with mental illness in Orange County is a challenge with similar barriers to referral. A valid hypothesis is that the patient would need to do their own care coordination to get a doctor to prescribe a hip X-Ray, get the hip X-Ray CD-ROM to take to an Orthopedic Surgeon, self-refer to an Orthopedic Surgeon (probably UCI since their medical residents need hip replacement cases to practice the procedure) and get the procedure. To accomplish such a feat shows cognition is intact, the patient is able to handle responsibility, and has the will/hope to survive/thrive.

The American Medical Association Policy on Medical, Surgical, and Psychiatric Service Integration and Reimbursement H-345.983 ( https://policysearch.ama-assn.org/policyfinder/detail/*?uri=%2FAMADoc%2FHOD.xml-0-2956.xml ) states:

“Our AMA advocates for: (1) health care policies that insure access to and reimbursement for integrated and concurrent medical, surgical, and psychiatric care regardless of the clinical setting; and (2) standards that encourage medically appropriate treatment of medical and surgical disorders in psychiatric patients and of psychiatric disorders in medical and surgical patients.”

Thus, building an isolated PCMH implied by the original posting may not be the best strategy but the general issue still exists. However, the way Psychiatric wards are currently structured doesn’t fit the AMA position either.

It is unclear what regional incentives exist in Orange County, CA that may prevent treating the whole person. There is not much research on recognizing acute delirium on chronic mental illness outside of dementia. There are not much outcomes research that attempts to separate the modifiable risk factors for bad outcomes (i.e. lack of support system, lack of housing, lack of adequate nutrition, etc) from non-modifiable risk factors (i.e. chronic non-dementia mental illness diagnosis that follows a patient for a lifetime). Anecdotally, a Psychiatric consult in an Orange County, CA inpatient setting is typically to assess DTS/DTO/GD for a Psychiatric Emergency. A facility needs to make a conscious decision to have a Psychiatry Consultation & Liaison Service that provides more than a mere Psych Emergency assessment.

In England (https://bmjopen.bmj.com/content/8/8/e023091 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4967779/ https://pdfs.semanticscholar.org/3811/22f0be2ee8b572e40f51050aed3edc59f341.pdf) Consultation & Liaison Psychiatric Services are widespread and shown to save 5 million British pounds annually (between $5 and $10 million US depending on the exchange rate) per hospital facility. Across the 179 acute care hospitals in England this equates to between $895 million and $1.79 billion US annually. England has integrated payer/data/provider systems and thus has an incentive to seek such savings. The structure of United States healthcare doesn’t have the incentive for such savings (fee for service vs pay for performance/accountable care). Even with PFP/ACO, it isn’t clear that a facility would make the step to improve Psychiatric care as a first, second or even third line measure. Orange County regional facilities face the investment decision between Psych C&L and high revenue specialties (Ortho, Derm, Transplant, Oncology, Cardiac, Ophthal) that drive significant amounts of hospital revenue (Transplant can drive 33% of annual hospital revenue due to the imaging, laboratory services, pathology, anesthesiology, etc required). Psych doesn’t drive a typical hospital’s revenue, is labor intensive and many other features that don’t make it an attractive investment.

Recall the Psychiatry Clinical Extender Program project submission – Psychiatry consistently attracts the worst performing medical students as measured by USMLE Step 1 and Step 2 CK (meaning the medical student was less able to recognize classic presentations of illness in a standardized paper-pencil test format compared to colleagues). Future Psychiatrists entering residency also have much fewer papers, presentations and abstracts (measures of expressing curiosity or sharing experiences).

C&L services are not the answer to the PCMH issue as the barrier to medical service still exists that needs to be served by non-psychiatric doctors willing to make the referrals for care and accept referrals for care.

Transferring the responsibility & risk to the mental health consumer, a common trend in today’s healthcare environment, can be one strategy for this issue. TechSuite/Help@Hand could provide a workflow to step a mental health consumer through what a PCMH would do. It would be an extensive mental health scavenger hunt that is a typical experience for mental health consumers and not well tolerated. Done with the right human-device interaction/human factors of design it could help address some of these issues.

After reviewing the BeWell Center Website (www.bewelloc.org), specifically the “Partners” section of the website and the size of the facility, it isn’t fair to compare a PCMH to the first BeWell Center and thus my initial comments about BeWell 1.0 aren’t appropriate. Comparing like with like is important when designing an intervention and measuring outcomes. Communicating what BeWell 1.0 is and isn’t should be a priority.

The World Bank’s Policy Research Working Paper 8610 – Living Life: Assessing Bureaucratic Complexity in Citizen-Government Interactions (https://openknowledge.worldbank.org/handle/10986/30578) probably gives quite a bit of insight into the advertised BeWell Center 1.0 purpose: to facilitate the bureaucratic interactions required of a person experiencing mental illness with the Federal Government, State of California Government, County of Orange Government, City Government, Employer, Law Enforcement, Housing and other public/private entities. I find the Emergency Rooms in Hospitals as the venue of choice for throwing a medical exception. Medical exceptions are like computer science exceptions (https://en.wikipedia.org/wiki/Exception_handling) something has occurred that wasn’t expected that requires special handling. Medical exceptions I have observed include: 1) Lifesaving/life preserving medication denied by insurance – no route to resolution outside of full price pharma cash pay; 2) Doctor doesn’t exist to address a medical problem – no route to resolution; 3) Doctor exists, but unable to prescribe treatment for medical/psychiatric condition – no route to resolution; 4) Longstanding treatment not recognized by new doctor in treatment team – denies value of longstanding treatment that has worked and changes everything about the treatment – patient doesn’t believe/trust the new doctor and fires the doctor; etc. There are probably many other themes of medical exceptions. If the patient faces cost-sharing or co-pays with these exceptions it can drive up the patient’s financial risk considerably.

I view the “hide the patient from the doctor” strategy to address mental illness neutrally and with interest. It would be interesting to me to randomize a cohort of people with new onset mental illness into two different paths: 1) The 5150 Path as we currently know it to an eventual diagnosis; or 2) The BeWell mental “tune-up” path that addresses the exceptions, deficiencies, etc. prior to visiting a doctor for diagnosis. The classical conditioning involved in living with mental illness is interesting (https://en.wikipedia.org/wiki/Classical_conditioning). I observe classical conditioning linked with using money, employment, interviews, writing a resume, seeing a new Psychiatrist, etc. for people living with serious mental illness.

Regardless, addressing the referral network issues listed above is important. As it stands right now, I would advise the people I encounter with Serious Mental Illness to drop any health insurance they pay for (why should they pay into a system that won’t refer for needed care, accepts poor outcomes, has little curiosity, and gives the run-around), enroll in Medicaid, tank their income to the Medicaid FPL, declare bankruptcy (if needed), go on food stamps (which forces an improved diet), freeze credit reports, embrace the barter system, figure out how to make that work, and wait for what happens next.

Abraham Flexner (Deceased)

After standardized patient audit, Orange County fails on all five Patient Centered Medical Home Criteria (https://pcmh.ahrq.gov/page/defining-pcmh) : 1) Comprehensive Care; 2) Patient Centered; 3) Coordinated Care; 4) Accessable; and 5) Quality and Safety.

This is a self-reported standardized patient audit and comes with the risks/benefits of such a classification. Please consult your local MD/MPH/PHD/other for understanding what this submission truly means.

Best.

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