Integrale zorg een blijvende ontwikkeling FRITS HUYSE Psychiater, Consulent Integrale Zorg Afdeling Algemene Interne Geneeskunde UMCG GRONINGEN Lid council Academy of Psychosomatic Medicine USA NFZP 9-6-2006 Universitair Medisch Centrum Utrecht UMCG Groningen

Hoofdstuk 6 Complexe patienten Huyse Slaets de Jonge

CONSULTATION-LIAISON PSYCHIATRY THE FUTURE OF CONSULTATION-LIAISON PSYCHIATRY Graeme C Smith Consultation-Liaison Psychiatry Research Unit Monash University Department of Psychological Medicine Keynote speaker Anual meeting Dutch Psychiatric Association Maastricht The Netherlands 2005

CONCLUSIONS Patients with physical/psychiatric comorbidity and somatisation continue to be discriminated against in the public sector, despite the acknowledgement of this in the Second National Mental Health Plan The implication for patients is both primary and secondary; the context in which psychiatrists are training is helping perpetuate the problem Development of a seamless web of pre-admission/admission/post discharge functions is required if patients are to receive effective care and services are to be able to demonstrate efficacy

Zorg coördinatie in relatie tot zorgbehoefte 100 90 80 70 60 50 40 30 20 10 % Verzekerden Kosten/ Verzekerde Beleid Type patiënt Bezorgdheid Voorbijgaande ziekte Minder ernstige acute ziekte Vraag gestuurd Low Chronische ziekte Matig tot ernstige acute ziekte Ziekte gestuurd Medium Complexe medische patiënten Multi-morbiditeit, waaronder psychiatrische Meerder hulpverleners Psychologische, sociale en financiële ontregeling Zorg coördinatie Ambulant`/ Klinisch High Wie? Hoe? Cartesian Solutions Kathol 2002

Results of ECLW Collaborative Study 14470 patients 56 hospitals 11 countries CONSULTATION EMERGENCY equals PSYCHIATRY PSYCHIATRY Consultation psychiatry Rate 1% of all admissions Reactive (wait and see) Doctors and nurses needs driven Liaison Theory not practice Huyse, Herzog, Lobo, Malt e.a. Gen Hosp Psychiatry 23(3):124-132, 2001

General hospital population Consults; psychiatric, psychological, social work

CONSULTATION-LIAISON PSYCHIATRY THE FUTURE OF CONSULTATION-LIAISON PSYCHIATRY Graeme C Smith Consultation-Liaison Psychiatry Research Unit Monash University Department of Psychological Medicine Keynote speaker Anual meeting Dutch Psychiatric Association Maastricht The Netherlands 2005

CONCLUSIONS Patients with physical/psychiatric comorbidity and somatisation continue to be discriminated against in the public sector, despite the acknowledgement of this in the Second National Mental Health Plan The implication for patients is both primary and secondary; the context in which psychiatrists are training is helping perpetuate the problem Development of a seamless web of pre-admission/admission/post discharge functions is required if patients are to receive effective care and services are to be able to demonstrate efficacy

CONSULTATION-LIAISON PSYCHIATRY THE FUTURE OF CONSULTATION-LIAISON PSYCHIATRY Graeme C Smith Consultation-Liaison Psychiatry Research Unit Monash University Department of Psychological Medicine Keynote speaker VJC NVvP Maastricht 2005

CONCLUSIONS 1 Patients with physical/psychiatric comorbidity and somatisation continue to be discriminated against in the public sector, despite the acknowledgement of this in the Second National Mental Health Plan. Huyse NRC mei 2005: Geef psychiaters in ziekenhuizen de ruimte

“De ziekenhuispsychiatrie kan mijns inziens een belangrijke rol vervullen. In dit opzicht sluit ik mij aan bij het standpunt van de heer Huyse. De stelselwijziging in de zorg die nu plaatsvindt, is mede bedoeld om de “ontschotting” van de lichamelijke en psychische zorg te verwezenlijken. …”

CONCLUSIONS 2 The implication for patients is both primary and secondary; the context in which psychiatrists are training is helping perpetuate the problem. Huyse FJ, van der Mast RC, Boenink AD: De psychiater als medisch specialist: de psychiatrie een zorg? Tijdschrift voor Psychiatrie 44:795-802, 2002

CONCLUSIONS 3 Development of a seamless web of pre-admission/admission/post discharge functions is required if patients are to receive effective care and services are to be able to demonstrate efficacy. Integrated care for the complex medically ill. Editors Huyse FJ, Stiefel FC Medical clinics of North America Elsevier Juli 2006

Crossing the Quality Chasm “Quality problems occur typically not because of failure of goodwill, knowledge, effort or resources devoted to health care, but because of fundamental shortcomings in the ways care is organized” Trying harder will not work: changing systems of care will! The Quality Chasm report well documented that quality problems occur typically not because of failure of goodwill, knowledge, effort or resources devoted to health care, but because of fundamental shortcomings in the ways care is organized. It concluded that trying harder will not work: changing systems of care will! To help change the system, the chasm report articulated: six aims for quality health care, ten rules that redesigned healthcare should follow to achieve the Aims, and components of the health care system that should be the focus of redesign efforts. In the next few slides, I will briefly review the Quality Chasm Aims, Rules, and redesign principles, which served as the analytic framework for this present study on improving the quality of health care for mental and substance-use conditions. a new HEALTH system for the 21st century (IOM, 2001)

The Crossing the Quality Chasm Series To Err is Human (1999) Crossing the Quality Chasm - A New Health System for the 21st Century (2001) Leadership by Example (2002) Fostering Rapid Advances in Health Care (2002) Priority Areas for National Action (2003) Health Professions Education (2003) Keeping Patients Safe – Transforming the Work Environment of Nurses (2004) Patient Safety – Achieving a New Standard for Care (2004) Quality through Collaboration – the Future of Rural Health (2005) Improving the Quality of Health Care for Mental and Substance-use Conditions (2005) www.nap.edu These reports began with a landmark report, To Err is Human, which garnered national attention, not only within the healthcare system, but within the public at large when it called attention to the estimated 44,000 – 98,000 Americans who die every year from errors in the health care delivered in hospitals, alone. While this report was groundbreaking and very effective in calling attention to the need for improvements in the quality of our healthcare system, it was the IOM’s second report on healthcare quality: Crossing the Quality Chasm - A New Health System for the 21st Century which outlined a strategy for achieving the improvements needed – a strategy which has gained considerable traction in the healthcare system.

A Report in the Quality Chasm Series Improving the Quality of Health Care for Mental and Substance-Use Conditions A Report in the Quality Chasm Series Ensure that multiple providers’ care of the same patient is coordinated Plea for integration and removal of dysfunctional barriers This report is the tenth in a series of the reports produced by the Institute of Medicine on how to improve the quality of the nation’s health care system Commission of Quality of Care, Institute of Medicine, USA 2005 www.nap.edu

Six Aims of Quality Health Care Safe – avoids injuries from care bijvoorbeeld psychopharmaca en electieve chirurgie Effective – provides care based on scientific knowledge and avoids services not likely to help bijvoorbeeld Pathway- (diabetes and depression) en IMPACT-studies (ouderen met somatische ziekten en depressies) 3. Patient-centered – respects and responds to patient preferences, needs, and values bijvoorbeeld algemeen ziekenhuis setting en geen RIAGG The six dimensions of good quality care as articulated in the Quality Chasm framework are (Refer to slide) Crossing the Quality Chasm a new HEALTH system for the 21st century (IOM, 2001)

De berg naar Mohammed of …………

……… of de psychiatrie naar de AGZ !

Six Aims (cont.) Timely – reduces waits and sometimes harmful delays for those receiving and giving care bijvoorbeeld geïntegreerde consulten bij onbegrepen klachten poli interne UMCG; gelijktijdig consult internist en psychiater 5. Efficient – avoids waste, including waste of equipment, supplies, ideas and energy bijvoorbeeld rechtstreekse verwijzing naar collega; “snuffel-consult” Equitable – care does not vary in quality due to personal characteristics (gender, ethnicity, geographic location, or socio-economic status) bijvoorbeeld psychiatrische patient heeft gelijke toegang tot somatische zorg vv Crossing the Quality Chasm a new HEALTH system for the 21st century (IOM, 2001)

Ten Rules for Achieving the Aims Old Rules 1. Care is based on visits 2. Professional autonomy drives variability 3. Professionals control care 4. Information is a record 5. Decisions are based upon training and experience New Rules 1. Care is based upon continuous healing relationships 2. Care is customized to patient needs and values 3. The patient is the source of control 4. Knowledge is shared and information flows freely 5. Decision making is evidence-based Crossing the Quality Chasm also articulated ten rules to guide the redesign of healthcare so that the six aims can be achieved. In contrast to some of the old paradigms that have guided the provision of health care, the new rules call for (refer to slide) Crossing the Quality Chasm a new HEALTH system for the 21st century (IOM, 2001)

Ten Rules for Achieving the Aims Old Rules “Do no harm” is an individual clinician responsibility Secrecy is necessary The system reacts to needs Cost reduction is sought Preference for professional roles over the system New Rule Safety is a system responsibility Transparency is necessary 8. Needs are anticipated 9. Waste continuously decreased Cooperation among clinicians is a priority Crossing the Quality Chasm a new HEALTH system for the 21st century (IOM, 2001)

Achieving Aims and Rules Requires News ways of delivering care Effective use of information technology (IT) Managing the clinical knowledge, skills, and deployment of the workforce Effective teams and coordination of care across patient conditions, services and settings Improvements in how quality is measured Payment methods conducive to good quality Finally, Crossing the Quality Chasm identified components of the healthcare systems that will need to be re-engineered in accord with the rules in order to achieve the aims. These include (refer to slide) Crossing the Quality Chasm a new HEALTH system for the 21st century (IOM, 2001)

Interdisciplinaire Opleidingen Een kans voor Interne Geneeskunde en Psychiatrie? ROB Gans Hoogleraar Interne UMCG VJC NVvP Amsterdam, April 4, 2003 Thisbee en ….

Mental health services in the general hospital 1. Emergency services Attempted suicide Acute behavioral disturbances Deliria Withdrawal 2. Integrated services Screening and integrated assessment Patient tailored multidisciplinary care (horizontal integration) and care trajectories (vertical integration)

his views on integrated health care. Arie Querido (1901-1983) A Dutch psychiatrist: his views on integrated health care. Boenink AD, Huyse FJ. J Psychosom Res. 1997 Dec;43(6):551-7.

Visie Querido 1935: Psychiatrie d’urgence 1955: Integrale geneeskunde Naast gestichtspsychiatrie moet ambulante psychiatrie ontwikkeld worden tbv voor en nazorg Dit is de motor achter de RIAGG vorming (70er jaren) en zorgcircuitgedachte (negentiger jaren) geweest 1955: Integrale geneeskunde Populatie gebaseerde studie in Weesperplein ziekenhuis waarin hij als een van de eersten aantoonde dat PS-comorbiditeit leidt tot slechte uitkomsten van somatische zorg

Ontwikkeling integrale geneeskunde Querido verliet de psychiatrie en werkte uiteindelijk in de sociale geneeskunde Rooijmans, voormalig voorzitter van de NVvP, zette de ziekenhuispsychiatrie op de kaart De huidige academische psychiatrie heeft geen visie op dit vakgebied

Ontwikkeling integrale geneeskunde Querido verliet de psychiatrie en werkte uiteindelijk in de sociale geneeskunde Rooijmans, voormalig voorzitter van de NVvP, zette de ziekenhuispsychiatrie op de kaart De huidige academische psychiatrie heeft geen visie op dit vakgebied USA 1980: alle kernhoogleraren psychiatrie zijn psychoanalytici 1990: geen kernhoogleraar is psychoanalyticus

Ontwikkeling integrale geneeskunde Querido verliet de psychiatrie en werkte uiteindelijk in de sociale geneeskunde Rooijmans, voormalig voorzitter van de NVvP, zette de ziekenhuispsychiatrie op de kaart De huidige academische psychiatrie heeft geen visie op dit vakgebied USA 1980: alle kernhoogleraren psychiatrie zijn psychoanalytici 1990: geen kernhoogleraar is psychoanalyticus 2004: Ziekenhuispsychiatrie subspecialisatie in USA

Ontwikkeling integrale geneeskunde Querido verliet de psychiatrie en werkte uiteindelijk in de sociale geneeskunde Rooijmans, voormalig voorzitter van de NVvP, zette de ziekenhuispsychiatrie op de kaart De huidige academische psychiatrie heeft geen visie op dit vakgebied USA 1980: alle kernhoogleraren psychiatrie zijn psychoanalytici 1990: geen kernhoogleraar is psychoanalyticus 2004: Ziekenhuispsychiatrie subspecialisatie in USA Nederland 2006: Geen hoogleraren ziekenhuispsychiatrie 2010: Kernhoogleraren psychiatrie zijn ziekenhuispsychiaters

General hospital population MPU MPU = Medical- Psychiatric- Unit Multidisciplinary care Physical: High acuity/intensity no artificial respiration Psychiatric: High acuity no severe behavioral dist MPU MPU = Medical- Psychiatric- Unit Screening for complexity Indicator-INTERMED Nurse specialist Multidisciplinary care Integrated assessment Psychiatrist/geriatrician Nurse specialist psychiatry Psychologist Social work

Chronische ziekte en depressie Verhoogde prevalentie Versterkt de symptomen van de somatische ziekte Vergroot de functionele beperkingen Vermindert de compliance met somatische behandeling Gaat gepaard met negatief gezondheidsgedrag (dieet, lichamelijke oefening, roken) Gaat gepaard met een verhoogde mortaliteit

Adverse Bidirectional Interaction Physical illness Smoking Sedentary lifestyle Obesity Lack of adherence to medical regimens Medical illness at earlier age Poor symptom control  functional impairment  complications of medical illness Major Depression Adverse Bidirectional Interaction After Katon

the DEPRESSED MEDICALLY ILL HELP ? DOES TREATMENT of the DEPRESSED MEDICALLY ILL HELP ? SYSTEMATIC REVIEW OF ANTIDEPRESSANTS IN THE PHYSICALLY ILL N of RCTs = 18 Adverse reactions: No differences of placebo No difference between drugs Number needed to treat 4 Gill and Hatcher Cochrane Review 2001

Behavioral change can be considered according to a hierarchy of behavioral challenge, ranging from those that are least difficult (i.e., the initiation of new practices in which there is no preexisting habit that needs to be broken) to the most difficult (i.e., breaking addictive habits which satisfy physiological drives). Rozanski: Psychosom Med 2005; 67 [Suppl 1]: s67-s73

MODELLEN VOOR INTEGRALE ZORG

MODELLEN VOOR INTEGRALE ZORG Depressie en somatische ziekte

Multifactorial Interventions for Depression in Primary Care Literature synthesis 12 RCTs involving 6,274 patients Most trials had 3-4 components All 12 had care management; 7 had augmented mental health 10 studies → improved outcomes Gerrity et al, J Gen Intern Med 2004 (abstract)

Stepped Care Patient self-management Primary care provider Care manager Collaborative care Indirect (TCM) – MHS supervises CM Direct – MHS sees pt in consultation Referral to Mental Health Specialist PC MH

PHQ - 9 More than Nearly Not Several half the every at all days days day 0 1 2 3 Over the last 2 weeks, how often have you been bothered by the following problems? a. Little interest or pleasure in doing things b. Feeling down, depressed, or hopeless c. Trouble falling or staying asleep, or sleeping too much d. Feeling tired or having little energy e. Poor appetite or overeating f. Feeling bad about yourself, or that you are a failure . . . g. Trouble concentrating on things, such as reading . . . h. Moving or speaking so slowly . . . i. Thoughts that you would be better off dead . . . Subtotals: 0 3 4 9 TOTAL = 16

PHQ-9 as Severity Measure Cutpoints proposed on PHQ-9 for depression severity are:  5 = mild  10 = moderate  15 = moderately severe  20 = severe Response to therapy = 5 point ↓ Remission = score < 5

Translating PHQ-9 Scores into Action 0 – 4 No action (community norms) 5 – 9 Watchful waiting in most 10 – 14 Education, counseling, active rx based upon diagnosis, duration, impairment, patient preferences 15 – 19 Active treatment in most 20 + May need combination of Rx and/or referral

The Pathway Study RCT: depressie en diabetes mellitus Verbetert diabetes door verbeterde depressie zorg? Intervention: stepped care Tx depression N=329 (int: 164; CAU 165) 9 primary care klinieken Outcomes: Verbetering depressie 6 en 12 mnd Verbetering algemeen gevoel na 6 en 12 mnd Meer satisfactie met type zorg na 6 en 12 mnd HBA-1C gelijk in interventie en controle groep Katon, Von Korff (2004) Arch Gen Psych 61:1042-1049

IMPACT Improving Mood – Promoting Access to Collaborative Treatment for Late-Life Depression 1801 depressive elderly (>/60 years) 18 clinical practices 8 healthplans Funded by John A. Hartford Foundation California HealthCare Foundation California Geriatric Education Center (via the Bureau of Health Professions, HRSA) Unutzer J, Katon W, Callahan CM ea. IMPACT. JAMA 2002;288(22):2835-45

IMPACT Improving Mood – Promoting Access to Collaborative Treatment for Late-Life Depression 1801 depressive elderly (>/60 years) 18 clinical practices 8 healthplans Funded by John A. Hartford Foundation California HealthCare Foundation California Geriatric Education Center (via the Bureau of Health Professions, HRSA) 3.8 chronic conditions Unutzer J, Katon W, Callahan CM ea. IMPACT. JAMA 2002;288(22):2835-45

In the IMPACT study the patients had 3.8 chronic conditions in addition to depression e.g. cardiac diabetes parkinson ....

In the IMPACT study the patients had 3.8 chronic conditions in addition to depression e.g. cardiac diabetes parkinson .... What about patients with psychiatric co-morbidities? As comorbidity is rather the rule then the exception! Kroenke and Rosmalen Symptoms, syndromes and psychiatric diagnosis in Huyse and Stiefel “Integrated care for the complex medically ill”

In the IMPACT study the patients had 3.8 chronic conditions in addition to depression e.g. cardiac diabetes parkinson - add anxiety substance abuse somatization xx - managers! What about patients with psychiatric co-morbidities? As comorbidity is rather the rule then the exception! Kroenke and Rosmalen Symptoms, syndromes and psychiatric diagnosis in Huyse and Stiefel “Integrated care for the complex medically ill”

Chronic Disease Focused Depression Care: New Grant Nurse will provide depression, heart disease and diabetes case management Behavior intervention-especially exercise, positive life activities Optimize medication for depression, heart disease and diabetes Supervision of nurses by psychiatrists and PCPs Katon and Unutzer

Chronic Disease Focused Depression Care: New Grant Nurse will provide depression, heart disease and diabetes case management Behavior intervention-especially exercise, positive life activities Optimize medication for depression, heart disease and diabetes Supervision of nurses by psychiatrists and PCPs Katon and Unutzer = Complexity management

MODELLEN VOOR INTEGRALE ZORG Depressie en somatische ziekte Ziekte specifiek

MODELLEN VOOR INTEGRALE ZORG Depressie en somatische ziekte Ziekte specifiek Complexiteit

MODELLEN VOOR INTEGRALE ZORG Depressie en somatische ziekte Ziekte specifiek Complexiteit Generiek

INTERMEDc PROGRAM GROUP RESEARCH COORDINATOR Groningen Peter De Jonge PARTICIPATING CENTERS Lausanne Fritz Stiefel Groningen Frits Huyse Groningen Joris Slaets Nürnberg Wolfgang Söllner CONSULTANTS John Lyons Chicago Corine Latour Amsterdam Roger Kathol Burnsville CHuyse, Lyons, Stiefel, Slaets, De Jonge ea Gen Hosp Psychiatry 21:39-48, 1999 www.vumc.nl/INTERMED

Step wise method for detection and assessment of COMPLEXITY

Step wise method for detection and assessment of COMPLEXITY Possible indicators: Excess utilization Non-Compliance Questionnaires COMPRI)1 Groningen Frailty Index Type of illness Transplant Cancer Research Etcetera = filter =

Step wise method for detection and assessment of COMPLEXITY = Integrated health risks and needs

Intervention studies Pre/post internal medicine IP (NL) Reduction of LOS in elderly (16 -> 11 days) Improvement in psychological functioning RCT prevention readmission post discharge (NL) No effects; restricted funding and lack of cooperation/integration

Intervention Study Internal Medicine Vumc Effect on QoL: specifically Mental Health (SF36) P 0.03 (Z -2.17) Effect on LOS: specifically in elderly P 0.05 (Z -1.95) from 16 to 11.5 days Costs of the intervention 1 nurse specialist 1/4 C-L psychiatrist de Jonge P, Latour CH, Huyse FJ. Implementing psychiatric interventions on a medical ward Psychosom Med. 2003 Nov-Dec;65(6):997-1002

Intervention studies Pre/post internal medicine IP (NL) Reduction of LOS in elderly (16 -> 11 days) Improvement in psychological functioning RCT prevention readmission post discharge (NL) No effects; restricted funding and lack of cooperation/integration RCT depression and DM or Rheuma (SU) In analysis; positive effects on most outcomes

A randomised psychiatric intervention in complex medical patients: Effects on depression Outpatients of department of endocrinology and rheumatology University center Complexity screen with INTERMED; inclusion > 20 Assessment of depression with MINI and CES-D Randomisation Intervention based on risks and needs as assessed with the INTERMED Stiefel F, Bel Hadj B, Zdrojewski C, Boffa D, (announcement poster) de Jonge P Dorogi Y, Miéville JC, Ruiz J, So A. J Psychosomatic Res 2004,56:578-9

Sample No INT CAU Age 50.9 (14.1) 53.1 (15.3) INTERMED 24.6 (3.7) 50.9 (14.1) 53.1 (15.3) INTERMED 24.6 (3.7) 26.1 (4.6) EuroQuol 44.7 (22.2) 45.1 (21.2) CES-D 27.1 (11.4) 27.5 (10.8) SF-36 physical 31.8 (10.9) 29.6 (10.0) SF-36 mental 34.8 (11.6) 35.4 (10.4) Female sex 58.3%% 57.5% Major depression 60.5% 55.8% Stiefel, ... , So Lausanne Suisse No significant differences

Sample No INT CAU Age 50.9 (14.1) 53.1 (15.3) INTERMED 24.6 (3.7) 50.9 (14.1) 53.1 (15.3) INTERMED 24.6 (3.7) 26.1 (4.6) EuroQuol 44.7 (22.2) 45.1 (21.2) CES-D 27.1 (11.4) 27.5 (10.8) SF-36 physical 31.8 (10.9) 29.6 (10.0) SF-36 mental 34.8 (11.6) 35.4 (10.4) Female sex 58.3%% 57.5% Major depression 60.5% 55.8% Stiefel, ... , So Lausanne Suisse No significant differences

Intervention (N=120) Psycho education 43.3% Emotional expression 72.6% Psychodynamic 47.2% Pragmatic 70.8% # of Follow-ups (median) 7 Stiefel, ... , So Lausanne Suisse

Effects on general health perception (Euroqol)

Effects on physical health (SF-36)

Effects on prevalence (%) of major depression (MINI) T=3: P=0.06 T=6: P=0.12 T=9: P=0.15 T=12: P=0.01

7 talen: Engels, Nederlands, Frans, Duits, Spaans, Italiaans, Turks 9 praktijken in Minnesota hebben interesse oa huisartsen geneeskunde Univ of Mineapolis RCT in voorbereiding 2 zorgverzekeraars hebben interesse 7 talen: Engels, Nederlands, Frans, Duits, Spaans, Italiaans, Turks Jaarlijkse Cursussen NL Wenckebach Groningen EU EACLPP satelite USA Chicago CANS satelite

Developments Several studies on their way and in preparation Transplant MC outcome prediction study Europe MC RCT in oncology Germany Preassessment in elective surgery Groningen RCT depression and rheuma/diabetes Minneapolis USA RCT Functional neurologic complaints AMC NL Touchscreen module for patient self assessment Groningen INTERMEDFoundation January 2006 INTERMED BV Beginning 2007 webbased training webbased clinical support

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