Noncommunicable Diseases Integrated Care Health Policy Eliot Sorel

Non-communicable Diseases: Integrated Care & Health Policy Eliot Sorel, M. D. Senior Scholar, Clinical Practice Innovations Professor, Global Health, Health Policy and Management Psychiatry and Behavioral Health Sciences The George Washington University Washington, D. C.

Non-communicable Diseases: Integrated Care & Health Policy Eliot Sorel, M. D. Outline • • Overview Epidemiology, Behavioral Health, in Primary Care China, India, Iran, Romania Research Project Evidence-Based Collaborative/Integrated Care Wagner Model of Measurement-Based Care Clinical Outcomes & Economic Consequences Care Implementation & Management Conclusions

Non-communicable Diseases: Integrated Care & Health Policy Eliot Sorel, M. D. Overview • Depression & anxiety & alcohol abuse – prevalence: • In primary care – 20% • In secondary care – 30 -60% • 25% of all these patients receive effective care • 20% of the adult patients seen by specialists • Severely & persistently mentally ill seen by specialists • Their co-morbid medical conditions not well attended to

Non-communicable Diseases: Integrated Care & Health Policy Eliot Sorel, M. D. D. Overview, continued • • • Regular, systematic psychiatric case load reviews For patients who do not show clinical improvement Substantially improve health care outcomes Patients’ functioning Reduced health care costs

Non-communicable Diseases: Integrated Care & Health Policy Eliot Sorel, M. D. Overview, continued • Collaborative/Integrated care is evidence-based • 70 randomized controlled trials show effectiveness & cost effectiveness • Care coordination & management • Regular/proactive monitoring and treatment • Using validated clinical rating scales

Non-communicable Diseases: Integrated Care & Health Policy Eliot Sorel, M. D. Epidemiology, Behavioral Health in Primary Care • • Non-communicable diseases (NCDs) lead global burden of disease Cardiovascular disorders & depression lead among NCDs Mental disorders = 30 -45% of global burden of disability 50% of mental disorders exist by age 14 75% of mental disorders exist by age 24 40% of Americans with mental disorders Receive minimally adequate care

Non-communicable Diseases: Integrated Care & Health Policy Eliot Sorel, M. D. China, India, Iran, Romania Research Project • • • Method: Site: Population: Instrument: Aggregate: multi-centric cross-sectional study primary care health centers all informed/consenting adult patients Patient Health Questionnaire – 9 (PHQ-9) 4090 patients

Non-communicable Diseases: Integrated Care & Health Policy Eliot Sorel, M. D. China, India, Iran, Romania Research Project, continued • China: 2 regions – north, south; 823 patients: 51% female; 49% male • Results: mild depression: 34. 3% moderate depression: 16. 4% moderately severe: 5. 7% sever depression: 2. 4% • Co-Morbid conditions: diabetes mellitus cardiovascular disorders gastrointestinal

Non-communicable Diseases: Integrated Care & Health Policy Eliot Sorel, M. D. China, India, Iran, Romania Research Project, continued • India: • Results: 551 patients: 52. 8% female; 47. 2% male mild depression: moderately severe: severe depression: • Co-Morbid conditions: diabetes mellitus cardiovascular disorders F M 21. 9% 20. 5% 6. 8% 0. 4% 23. 6% 21. 3% 5. 0% 0%

Non-communicable Diseases: Integrated Care & Health Policy Eliot Sorel, M. D. China, India, Iran, Romania Research Project, continued • Iran: 1, 006 patients: 80. 5% female; 19. 5% male • Results: minimal, mild, or moderate depression: 63. 3% moderately severe & severe: 7. 0% • • Co-Morbid conditions: diabetes mellitus cardiovascular disorders

Non-communicable Diseases: Integrated Care & Health Policy Eliot Sorel, M. D. China, India, Iran, Romania Research Project, continued • Romania: • Results: 1, 710 patients: 61. 3% female; 38. 7% male minimal depression: mild depression: moderately severe: severe depression: • Co-Morbid conditions: diabetes mellitus cardiovascular disorders gastrointestinal F 55. 8% 26. 8% 10. 5% 5. 1% 1. 6% M 71. 2% 9. 2% 5. 0% 3. 3% 1. 2%

Non-communicable Diseases: Integrated Care & Health Policy Eliot Sorel, M. D. Percentage of Total Disease Burden – Depression • • Sub-Saharan Africa Latin America & the Caribbean Middle East & North Africa Europe & Central Asia South Asia East Asia & the Pacific High Income Countries 28. 62% 27. 79% 24. 39% 30. 26% 38. 64% 32. 69% 26. 92%

Non-communicable Diseases: Integrated Care & Health Policy Eliot Sorel, M. D. Evidence-Based Collaborative/Integrated Care • Primary care provider • Family physician, nurse practitioner, physician assistant • Care management staff • Nurse, clinical social worker, psychologist • Evidence-based cognitive behavioral therapy • Monitoring adherence to treatment plan • Psychiatric consultant • Advises/consults with primary care treatment team • Diagnostic, treatment progress challenges

Non-communicable Diseases: Integrated Care & Health Policy Eliot Sorel, M. D. Wagner Model of Measurement-Based Care • • Progress is closely tracked Using validated clinical rating scales PHQ-9 for depression screening Analogous to patients with diabetes Monitored via Hb. A 1 c lab tests Treatment systematically adjusted if no improvement Lack of progress&/or acute crises referred to specialists

Non-communicable Diseases: Integrated Care & Health Policy Eliot Sorel, M. D. Wagner Model, continued The IMPACT Program (Clinical Outcomes) • • • 1801 adults age 60+ with depression 18 primary care clinics in 5 states Sites with fee for service & capitated Medicare & Medicaid Patients averaged 3. 5 chronic medical disorders Randomly assigned to collaborative care program Or to usual care

Non-communicable Diseases: Integrated Care & Health Policy Eliot Sorel, M. D. Economic Consequences • • • Depression increases health care costs by 50 -100% Depression reduces productivity & diminishes return to work Collaborative & integrated care enhances productivity Augments return to work Diminishes absenteeism & presenteeism US $1 collaborative care saves US $6. 50 in total health care costs

Non-communicable Diseases: Integrated Care & Health Policy Eliot Sorel, M. D. Care Implementation & Management • • US Affordable Care Act health home provision (§ 2703) Vehicle to incorporate principles of collaborative care Comprehensive care management Care coordination & health promotion Comprehensive transitional care from inpatient out Individual & family support Referral to community & social services Health IT to link services

Non-communicable Diseases: Integrated Care & Health Policy Eliot Sorel, M. D. Conclusions • • NCDs lead in the global burden of disease & disability Cardiovascular disorders & depression lead among NCDs frequently are comorbid with each other Collaborative & integrated care teams effective response Clinically most effective & economically beneficial New challenges & opportunities Education, training, research, services, systems, & policy

Non-communicable Diseases: Integrated Care & Health Policy Eliot Sorel, M. D. References • Wagner, E. H. , et al. , “Organizing Care for Patients with Chronic Illness, ” The Milbank Quarterly 1996; 74 (4): 511 -544 • Sorel, E. & Lopez-Ibor, Jr. , J. J. , “Reconnecting Mind & body in Contemporary Health Systems, ” European Congress of Psychiatry, Munich (March 2014) • Hyman, S. , et al. , “Mental Disorders, ” in Disease Control Priorites in Developing Countries, Jamison, D. T. , editor, Oxford University Press (2006) pp 605 -625. • Unützer, J. , et al. , “The Collaborative Care Model: An Approach for Integrating Physical & Mental Health Care in Medicaid Health Homes, ” Centers for Medicare & Medicaid Services (May 2013) • U. S. Affordable Care Act, § 2703