Psychiatrist Leads Effort to Integrate Care at Pioneer ACO

Chung said Montefiore has found what many physician practices and health systems entering the integrated care arena have found: that the highest utilizers are often patients with comorbid general medical and psychiatric conditions. “We have found that a third of our patients have had some form of diagnosed behavioral disorder in the past three years,” he said. “That one-third has 50 percent to 60 percent higher costs in utilization than patients who don’t have those disorders.”

He said Montefiore has been especially aggressive in having primary care physicians use the PHQ-2 and PHQ-9 to screen for depression. “Even before I came to Montefiore three years ago, the institution’s Care Management Organization and the Department of Psychiatry embarked on an educational campaign, with help from the Robert Wood Johnson Foundation, directed toward our primary care physicians around depression screening using the PHQ-9,” Chung said. “So when I came here three years ago, depression screening was already embedded in a large number of our primary care practices.”

Chung explained that in the ACO model as envisioned in the Affordable Care Act, any cost savings achieved are prorated according to how well the organization performs on 33 quality measures (one of which includes screening for depression and documentation of follow-up).

“Traditionally, so much of health care has been driven by the convenience of the health care system, rather than what’s good for the patient,” he said. “If you want to get that patient out of the hospital as quickly as possible, you aren’t going to spend a lot of time investing in aftercare.”

But under “bundled payment” arrangements in the ACO model, specialists take on a fixed payment for a procedure and all follow-up care for up to 90 days after the procedure. That incentivizes collaboration across disciplines toward achieving optimal patient outcomes.

And it is an arrangement in which psychiatry can add enormous value. “At Montefiore, our Cardiology Department on its own has invested in a half-time psychiatrist to manage psychiatric conditions associated with cardiovascular disease,” he said.

It is also a system that encourages novel ways of thinking about how to improve care. Chung said Montefiore has embarked on a pilot program to have a geriatric psychiatrist embedded in the evaluation of patients admitted to the medical inpatient unit. “Typically, consultation-liaison [C-L] psychiatrists are called in too late,” he said. “Historically, the C-L psychiatrist is often called the day before discharge. Especially as lengths of stay have gotten shorter, that is too short a period to help the patient or make a dent in decreasing the possibility of re-admission.

“Geriatric psychiatrists are comfortable in medical settings, and they get a lot of exposure to community-based settings,” he said. “So they are thinking from day one about diagnosis, treatment, and aftercare, about where this patient can get home care and community-based mental health and social services after discharge.”

So how can APA members working in other kinds of settings and other parts of the country use the lessons of Montefiore’s success in their own “medical neighborhoods”?

“Our friends in primary care and specialty medicine are actually very aware of the need for behavioral health and are actively seeking partnerships,” Chung said. “I would like to see APA members cultivate those relationships. And they should not stop there but should ask their primary care and specialty colleagues how they can be helpful in improving outcomes for their patients. At the structural level, I would be out trying to find the ACOs in my area and how I can be at the table with them. Many of these changes are being driven by primary care, so that’s where our members need to go. We can’t be in our office just waiting for referrals.” ■