Integrating Services and Supports for Primary Care and Behavioral Health Liz Reardon, MPH NCSL Meeting December 4, 2006

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Integration Goals „

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To address access (both access to MH services for those in primary care/not SPMI, and access to primary care for those with SPMI); To create infrastructure within and across the primary care and mental health systems to support effective integration; and To engage consumers in the design of the integration initiatives.

The Care Model Community

Resources and Policies SelfManagement Support

Informed, Activated Patient

Health System

Organization of Health Care Delivery System Design

Productive Interactions

Decision Support

Clinical Information Systems

Prepared Practice Team

Sou rc e: Edw ard Wagner, MD , MPH; Institute fo r Health Care Improvement

Using Wagner’s Model as a Template „

Interaction between the patient and provider is key „ „

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Self Management is a component of Recovery „ „

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IOM “Mutual Healing Relationship” People with disabilities have special needs and skills

Understand “Stages of Change” Must accept and plan for setbacks as well as successes

Community Resource Connections

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Robert Wood Johnson Support Depression in Primary Care – Linking Clinical and Systems Supports http://www.depressioninprimarycare.org/ „ Incentive Demonstration Grant

Center for Health Care Strategies http://www.chcs.org/ „ Medicaid Managed Care Program Grant „ Best Clinical and Administrative Practices in Medicaid Managed Care (BCAP) for People with Disabilities or Chronic Conditions

The Vermont Community Depression Project (2002-2005) „

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RWJF “Depression in Primary Care” Program (www.depressioninprimarycare.org) Administered by University of Pittsburgh Medical School Links Clinical and Economic strategies Focus on Chronic Care and Collaborative Improvement Connecting Safety Net providers for Primary and MH Care

Context „

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Low Income Vermonters in Rural areas Primary Care Practices that serve Medicaid/uninsured populations Community Mental Health Centers

Windsor

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Objectives „

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Integrate primary care and community mental health systems to increase access to services Enhance capacity of primary care practices to provide care to patients with complex psychosocial needs

Springfield

Design, Setting and Participants „

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Co-Location of CMHC case managers (“Care Partners”) in Primary Care Practices 2 Federally Qualified Health Centers 2 Critical Access Hospitals

Waterbury

Interventions „

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“Wellness Action Recovery Planning” self management strategy “How’s Your Health?” online health assessment and care planning tool Clinical Microsystem Improvement approach Web-based reporting system

Burlington

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Main Outcome Measures „

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Changes in PHQ-9 scores Percentage of patients with documented selfmanagement goals Followup after hospitalization Appropriateness of medication

Chelsea

Progress To Date „

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Program began in July 2003; all sites had Care Partners on staff as of July 2004 2100 Vermonters served as of 1/1/06 Over 90% have documented self-management goals Care Partners are still assisting practices in managing comorbidities, such as diabetes and cardiovascular disease Bethel

Potential Significance „

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Castleton

Care partner activities (self management support, community integration) obtained dedicated FFS reimbursement CMHC/Primary Care alliances can offer a wider continuum of care than carveout models

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The Vermont Medical Home Project Funded by an RWJ Grant through the Center for Health Care Strategies, Inc. Medicaid Managed Care Program (20002005) „ Also included in CHCS Best Clinical and Administrative Practices for People with Disabilities and Chronic Conditions (2003) „

Drivers „

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Lessons learned from SSI Enrollment „ “Nothing About Us Without Us” The Importance of a Medical Home for Everybody Primary Care Overload „ “How do you build a Medical Home without any tools?” Vulnerable Populations „ People with Serious/Chronic Mental Illnesses

National Association of MH Medical Directors – Problem Statement „

Recent data from several states have found that people with serious mental illness served by our public mental health systems die, on average, at least 25 years earlier that the general population.

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NASMHMD - Contributing Causes „

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Preventable Medical Conditions „ Metabolic Disorders, Cardiovascular Disease, Diabetes Mellitus „ High Prevalence of Modifiable Risk Factors (Obesity, Smoking) „ Epidemics within Epidemics (e.g., Diabetes, Obesity) Some Psychiatric Medications Contribute to Risk „ Weight gains of 40-100 pounds Established Monitoring and Treatment Guidelines to Lower Risk Are Underutilized in SMI Populations

Other Contributing Causes SMI may be a health risk factor because of: „

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Patient factors, e.g.: fearfulness, homelessness, victimization/trauma, resources, advocacy, unemployment, incarceration, social instability, IV drug use, etc. System factors: Funding, fragmentation Provider factors: Comfort level and attitude of healthcare providers, coordination between mental health and general health care, stigma

Cardiovascular Disease (CVD) Risk Factors Modifiable Risk Factors

Estimated Prevalence and Relative Risk (RR)

Schizophrenia

Bipolar Disorder

Obesity

45–55%, 1.5-2X RR1

26%5

Smoking

50–80%, 2-3X RR2

55%6

Diabetes

10–14%, 2X RR3

10%7

Hypertension

≥18%4

15%5

Dyslipidemia

Up to 5X RR8

1. Davidson S, et al. Aust N Z J Psychiatry. 2001;35:196-202. 2. Allison DB, et al. J Clin Psychiatry. 1999; 60:215-220. 3. Dixon L, et al. J Nerv Ment Dis. 1999;187:496-502. 4. Herran A, et al. Schizophr Res. 2000;41:373-381. 5. MeElroy SL, et al. J Clin Psychiatry. 2002;63:207-213. 6. Ucok A, et al. Psychiatry Clin Neurosci. 2004;58:434-437. 7. Cassidy F, et al. Am J Psychiatry. 1999;156:1417-1420. 8. Allebeck. Schizophr Bull. 1999;15(1)81-89.

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Massachusetts Study: Deaths from Heart Disease by Age Group/DMH Enrollees with SMI Compared to Massachusetts 1998-2000 40 DMH MA

Rates per 100,0

35 30 25 20 15 10 5 0

25-34

35-44

45-54

55-64

Elevated Risk of Mortality for Vermonters with Severe/Persistent Mental Illness Compared to the General Population - 2001

25 Heart Disease or Lung Cancer 20

Not Heart Disease or Lung Cancer

15 10

5

0 18-34

35-49

50-64 Male

65-79

18-34

35-49 Female

50-64

65-79

The Project and the Partners „

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Enhancing systems and supports for care of individuals with disabilities or chronic conditions For SPMI population - building connections between primary care and community mental heath services Consumers, State agencies, primary and mental health clinicians worked together on design and implementation

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Key Concepts „

Wellness Recovery Action Planning „ „ „

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www.mentalhealthrecovery.com Wellness Tool Box Maintenance, triggers, crisis and post-crisis planning Connection with other chronic conditions such as diabetes

Co-location of “Care Partner” Nurses in Community MH Centers

Where We Are Now

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Demonstrated that people with chronic mental illnesses are the highest cost population seen in Primary Care Shown that onsite nursing support can improve health status (HgbA1C, Cholesterol, BP) Wellness is not expensive

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Integrating Medical Care and Recovery

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“Benchmarking Project”

Care Changes in MH System „

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Health care questions posed more often by case managers and other staff Greater attention to involvement of health care provider for all consumers. Persons in crisis more often viewed in context of how health issues may be impacting on them versus seeing them as psychiatric issues first

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Comments from case managers “…[for] those with serious co-morbidity issues like diabetes, the addition of this critical coordination and oversight of medical services to help the client navigate through the myriad of issues and potentially conflicting information around their physical and mental health care, is essential.” “…it has provided something that case managers, lacking sufficient medical knowledge, cannot. I couldn’t articulate how much of a burden is lifted for a case manager when this happens” -

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Recommendations - Consumer Supports Shared decision making around medication Motivational interviewing re: health behaviors Peer supports for nutrition and exercise Empowerment of families to support and advocate for wellness Community connections to foster natural supports and combat stigma

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Recommendations – Care System Care Partner roles „

Nurses with ambulatory care and/or home health experience co located in Community Mental Health programs.

Consultation liaison between RN and CMHC Case Manager „

Physical health status’ impact on psychiatric symptoms and vice versa

Continuum of care – from total wraparound to information and referral

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Recommendations – Care System Connection with co-occurring disorders „ Integration of harm reduction and stages of change approaches to both addiction treatment and health promotion/disease management Trauma sensitivity „ Especially concerning physical exams, GYN care, etc „ Awareness of effect of PTSD on behavior, addictions, etc. PC/CMHC connection „ Primary Care Providers „ Advanced practice nurses may serve as PCP’s and liaison with MH system „ Connection with Federally Qualified Health Centers /Rural Health Centers

Lessons Learned „

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Recovery is key – treatment is part of recovery rather than vice versa Integrate or Stagnate „ „ „

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BH-Primary Care and Primary Care-BH Comorbid BH can double costs Don’t overlook Trauma

Long term ROI „

Significant Costs but Significant Opportunities

Resources SAMHSA/CMHS Building Bridges: Mental Health Consumers and Primary Health Care Representatives in Dialogue „ http://download.ncadi.samhsa.gov/ken/pdf/SMA064040/Policy_Makers_Booklet.pdf NASMHPD Position Paper „ http://www.nasmhpd.org/general_files/publications/med_ directors_pubs/Technical%20Report%20on%20Morbidit y%20and%20Mortaility%20-%20Final%2011-06.pdf NCCBH Integration Overview „ http://www.nccbh.org/SERVICE/Newsletters/NCNews/S ept06.pdf

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