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Welcome to LPHC!

Welcome to LPHC!

Paul Grundy, MD “agrees that evaluation of LPHC as one possible model of how best fully to integrate behavioral health into the PCMH” should be completed. Other comments below and on relevant pages (Laura Peoples, PhD, Matthew J. Smith, MD, FAAPM&R, Don Galamaga, Neil Kirshner, PhD, CJ Peek, PhD, CJ Peek, PhD, etc.) Your website is very … Continue reading

What is LPHC?

Lifelong Personal Health Care (LPHC) is an innovative patient-centered medical home model of primary medical care that will improve patient health and the cost-effectiveness of care by building on the expertise of behavioral health providers. LPHC fully integrates the behavioral health perspective into routine medical care for all patients, to support health promotion, disease management, and patient engagement in their healthcare more effectively, as well as to address the role of mental health in health and healthcare. This model is designed to achieve effective and affordable care provided by a care team optimized in its collaborative use of complementary skills.

This site describes the theory and evidence behind the model, provides in-depth detail on LPHC primary care practice design and affordability, and provides a framework for evaluating LPHC’s incremental contribution to primary care effectiveness as a key component of healthcare delivery reform.

“Behavior, rather than medicine, is more likely to determine someone’s health. - David Satcher, MD, Former U.S. Surgeon General

“A new health care system could use psychology to figure out ways to give better medical care, not just more health care.” - Peter Orszag, Director of the Office of Management and Budget

“Any PCMH that neglects… the full psychosocial dimension of health and healthcare— mental healthcare, family and community contexts, substance abuse, and health behavior change… is incomplete and will be ineffective. It will fail. A solid edifice of empirical evidence supports this rather uncompromising assertion.”- deGruy & Etz (2010)

With support from the Rhode Island Foundation

This website and the work described were supported by grants from the Rhode Island Foundation for demonstration of different models of co-locating behavioral health providers in primary care settings and most recently, a Strategy Grant to finalize the LPHC model.

The importance of integrating behavioral health in the PCMH has reached consensus; how to integrate has not

The PCPCC calls for evaluation of models (like ours) of how best to integrate behavioral health into the PCMH: http://www.pcpcc.net/behavioral-health

“A key feature of the PCMH is team-based care delivery focused on the needs of the patient and, when appropriate, their family. In contrast to a focus on a specific disease or organ system, the PCMH centers on the whole person. This includes physical health, but also behavioral health, oral health and long-term care. A patient and family-centered orientation embraces patient preferences and culture, recognizes and assists with health literacy, provides tools and resources for self-managing chronic conditions, and is founded on trust and respect between the patient and the clinician in order to develop a true partnership.

Depending on the practice, the team includes primary care physicians; nurse practitioners; physician assistants; mental health practitioners or behavioral health specialists; social workers; care coordinators; pharmacists; palliative care providers; physical, occupational and speech therapists; community health workers; and others offering support services in the community. The PCMH team includes the patients and their families as well, as their input is the key component of realizing the medical home.

Whereas some PCMHs provide most care in a single location, others include virtual teams of professionals who work together, depending upon the specific needs of the patient. Beyond the primary care setting, the PCMH also coordinates the care of patients in the medical neighborhood and across health care settings and transitions—including specialty care and inpatient hospital services—which is vital for patients with chronic illnesses.

As integration of behavioral health, medication management, and other services in the PCMH is evolving, evaluation of different models and options is warranted.”

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ACP:

Five Prescriptions for Ensuring the Future of Primary Care: Proceedings from the Health Education Summit, October, 2010, Atlanta, Georgia. (Carter Center, American College of Physicians, and Health Experts Report Detailing Solutions for Reinvigorating Primary Care System)

"The goal of the Summit was to examine, in a collaborative way, whether the patient-centered medical home could serve as the platform for integrating behavioral health care and health promotion/disease prevention, thereby addressing some of the issues of cost and quality referenced above....

Over the last decade, considerable evidence has shown that the integration of behavioral care and primary care is essential to maximize efficiency and effectiveness. The evidence also reveals that the way in which inte-gration is done also matters. There are functions-such as measurement of treatment results and progress using validated, reliable tools and stepped, evidence-based responses-that reveal clinical progress, or lack thereof....

Ongoing evaluation should be employed to both identify opportunities for improvement and provide evidence for the development of new structures in the primary care sector, specifically those that support the integration of behavioral care and health promotion/disease prevention."

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Integrating Mental Health Treatment Into the Patient Centered Medical Home
(Prepared by Mathematica Policy Research under Contract No. HHSA290200900019I TO2.) AHRQ Publication No. 10-0084-EF, 2010

Consensus has yet to emerge on whether strategies used to deliver mental health treatment in primary care are consistent with the core elements of the PCMH or the extent to which adoption of the PCMH concept will facilitate the delivery of such treatment in primary care.

We outline five essential measures—normalize mental health into mainstream medical practice, integrate reimbursement mechanisms, create a roadmap for implementation, determine mechanisms to address the needs of those with complex mental health problems, and disseminate the tools needs by PCPs—that collectively will facilitate integrated mental health treatment in primary care settings and that are needed for the PCMH to achieve its full potential.

Normalizing treatment of mental health problems in primary care practice will thus require significant cultural shifts.

Normalizing treatment of mental health problems also involves redesigning workflows to allow mental health evaluation and treatment protocols to fit the context of primary care practice.

Current reimbursement mechanisms do not provide sufficient resources for team-based care and care coordination activities, creating a barrier to implementation of the PCMH.

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MA health care quality and cost improvement bill of 2012

Goal “to support efforts to integrate mental health, behavioral, and substance use disorder services with overall medical care” (p. 6).

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Joint Principles; Integrating Behavioral Healthcare* into the Patient-Centered Medical Home (2012)

*“Behavioral healthcare” is a problematic term for a number of reasons, but until a more widely accepted alternative arises will be used here to mean mental healthcare, substance abuse care, health behavior change, and attention to family and other psychosocial factors.

Released by the Council of Academic Family Medicine and endorsed by the American Academy of Family Physicians (AAFP), the AAFP Foundation, the American Board of Family Medicine (ABFM), the Society of Teachers of Family Medicine (STFM), The North American Primary Care Research Group (NAPCRG), the Association of Departments of Family Medicine (ADFM), and the Association of Family Medicine Residency Directors (AFMRD).

However, there is an element running implicitly through these joint principles that is difficult to achieve yet indispensible to the success of the entire PCMH concept. The incorporation of behavioral healthcare has not always been included as practices transform to accommodate to the PCMH ideals. This is an alarming development because the PCMH will be incomplete and ineffective without the full incorporation of this element, and retrofitting will be much more difficult than prospectively integrating into the original design of the PCMH.

A whole person orientation simply cannot be imagined without including the behavioral together with the physical.

Care is coordinated or integrated across all elements of the complex healthcare system. Perhaps the single factor that most seriously harms the quality and integrity of our healthcare system is fragmentation. Fragmentation is the problem this particular principle addresses, and yet the most serious fracture in our healthcare system, the most fully institutionalized separation of elements of care, is the separation of behavioral healthcare from primary care. Carved out funding streams, behavioral health organizations (BHOs), separate medical records, different rules of confidentiality, different traditions of training, different practice cultures, and other factors have conspired to maintain this fragmentation. Healthcare must be coordinated and integrated via shared registries, shared medical records, (especially shared problem and medication lists), shared decision-making, shared revenue streams, and shared responsibility for the patient’s care plan. The real and perceived barriers to communication among healthcare professionals must be clarified and addressed in a way that makes regular sharing of information for purposes of better care the rule rather than the exception.

In order to realize these Behavioral Joint Principles there are critical needs that must be addressed, including:

5. Research to better define the optimal provision of whole person health services in the PCMH, with attention to patient, practice, training and financing issues.

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MassHealth Comprehensive Primary Care Payment Reform; Clinical Delivery Model

To achieve patient-centered care in the medical home, it is important that a comprehensive approach is taken, addressing not only medical issues but also health-related behaviors, mental health, and unhealthy substance use…. In addition to increasing patient-centeredness, there are economic arguments in support of integrating behavioral health and primary care.

This delivery model divides care management into care coordination (provided by a paraprofessional) and “clinical care management”, provided by a “licensed clinical professional”.

All patients receive a focus on wellness and prevention, as well as diagnosis and treatment of inter-current or chronic conditions. All also receive planned and pro-active care at every visit that includes full use of the multidisciplinary team to ensure the implementation of evidence-based guidelines as well as tracking and monitoring of care and outcomes. Care coordination occurs for a smaller population of patients in need of services who have a current medical/behavioral health condition and/or risk factors or which is healthy but in need of services to prevent decline in health status. Care management is full management of care, for the most complex, highest risk (& most costly) patients. This entails the identification of high-risk patients and intensive monitoring, follow-up, and clinical management of such patients. Clinical care management activities generally include frequent patient contact, clinical assessment, medication review and reconciliation, communication with treating clinicians, and medication adjustment by protocol in coordination with a licensed professional.

Fully Integrated- Behavioral health and primary care providers are located at the same site and work side by side as part of the “Medical Home” team.

PCPs and BHPs are part of the same care team…. Primary care and behavioral health practice leaders collaborate on developing protocols, standards of practice and interventions to ensure successful communication and integration. Interventions may include the designation of primary care and behavioral health champions who foster communication and collaboration across the two disciplines. Patients are routinely screened prior to or during annual physical exams with a standardized tool for depression, anxiety, substance use, intimate partner violence, suicide risk and symptoms of trauma. Screening also includes bio-psychosocial and quality of life assessments.

Patients have access to BHPs to support lifestyle changes and self-management. Patients considered for this referral include those with or having risk factors for chronic medical or behavioral health conditions, reporting unhealthy lifestyle behaviors and who have somatic complaints that have a lifestyle or stress component.