Improving Health and Improving Health and Healthcare for Persons With Healthcare for Persons With

SMI: A Public Health SMI: A Public Health PerspectivePerspective

Benjamin Druss MD, MPHBenjamin Druss MD, MPH

January 12, 2011January 12, 2011

ACHMAACHMA

Overview

Defining the problem A public health approach to

addressing it Some examples of ongoing

research Opportunities under health

reform

The Problem: Medical Illness and

Premature Mortality in the Public Mental Health

Sector

An Historical PerspectiveAn Historical Perspective 1928-1931: Malzberg found that 1928-1931: Malzberg found that

patients in NY State’s Psychiatric patients in NY State’s Psychiatric Hospitals die 15 years earlier than Hospitals die 15 years earlier than other NY state residentsother NY state residents11

Most of this excess mortality was due to Most of this excess mortality was due to “natural” rather than “unnatural” “natural” rather than “unnatural” causes:causes: heart disease (33%); pneumonia heart disease (33%); pneumonia (10.1%), tuberculosis (9.5%), and (10.1%), tuberculosis (9.5%), and peripheral artery disease (8.9%)peripheral artery disease (8.9%)

1. Malzberg B. Journal of the American Statistical Association. Mar 1932;27(177A):160-174.

A Widening DisparityA Widening Disparity

The 20The 20thth century saw public health century saw public health victories such as reduced rates of victories such as reduced rates of smoking and development of new smoking and development of new health technologies.health technologies.

As health and life expectancy As health and life expectancy improved in the general population, improved in the general population, persons with SMI lagged behind and persons with SMI lagged behind and disparities widened still further.disparities widened still further. 1 1

1. Saha S et al Arch Gen Psychiatry. Oct 2007;64(10):1123-1131

What Accounts for Excess What Accounts for Excess Morbidity and Mortality in Morbidity and Mortality in

Mental Disorders?Mental Disorders? 1989 Mental Health Supplement to the 1989 Mental Health Supplement to the

NHISNHIS Mortality data collected for subsequent Mortality data collected for subsequent

17-18 years to assess17-18 years to assess All-cause mortalityAll-cause mortality Relative contribution of Relative contribution of

Socioeconomic factors Socioeconomic factors Health system factorsHealth system factors Clinical characteristics Clinical characteristics

In driving that mortalityIn driving that mortality*Medical Care, in press 2011

Age at DeathAge at Death

Factors Contributing to Factors Contributing to MortalityMortality

Excess Hazard of

Death (95% CI)

p value

Adjusted for demographics only 2.06 (1.77 – 2.40) <0.001

Adding socioeconomics 1.77 (1.52 – 2.06) <0.001

Adding health system factors 1.80 (1.54 – 2.11) <0.001

Adding baseline clinical factors 1.32 (1.11 – 1.57) <0.001

Adding all groups of factors 1.19 (1.00 – 1.42) NS

Hypothesized Causes of Hypothesized Causes of Premature Death in the Premature Death in the

General PopulationGeneral Population11

1.N Engl J Med. 2007 Sep 20;357(12):1221-8.

A Public Health Approach to Improving Health and

Healthcare in Persons with SMI

Risk FactorsLifestyle

Medications

Chronic Medical Illnesses

A Public Health Approach To ReducingA Public Health Approach To ReducingMortalityMortality

Primary Prevention

Wellness programs

Environmental Policies

Secondary Prevention Tertiary Prevention

TreatmentScreening

Examples of Primary Prevention

Make psychiatric facilities smoke-free (NASMHPD 2007)

Provide access to exercise facilities either onsite or in the community (e.g. New Hampshire’s “In-SHAPE” program)

Consider the environments/communities in which persons with SMI live and be creative about filling in gaps (e.g. New Haven CMHC’s farmer’s market).

Secondary PreventionSecondary Prevention

Rates of screening among persons Rates of screening among persons on second generation antipsychotics on second generation antipsychotics have remained low even after 2003 have remained low even after 2003 ADA/APA guidelines ADA/APA guidelines

Even when providers do screen, few Even when providers do screen, few sites can follow-up for persons who sites can follow-up for persons who screen positive either onsite or via screen positive either onsite or via referrals.referrals.

1. Arch Gen Psychiatry. 2010 Jan;67(1):17-24. 2. Psychiatr Serv. 2008 Aug;59(8):917-20.

Tertiary Prevention: Effective Tertiary Prevention: Effective Treatment of Chronic IllnessTreatment of Chronic Illness

Applying the Chronic Care Applying the Chronic Care Model for persons with SMIModel for persons with SMI

Developing an Developing an Informed, Activated Informed, Activated Patient:Patient:

Using Using Information TechnologyInformation Technology Developing a Developing a Prepared, Proactive Prepared, Proactive

Practice TeamPractice Team Reorganizing Healthcare:Reorganizing Healthcare:

Activating Patients: Activating Patients: The Role of PeersThe Role of Peers

Certified peer specialists may play a key Certified peer specialists may play a key role in helping consumers become more role in helping consumers become more engaged in self-management and more engaged in self-management and more effective in working within the health effective in working within the health systemsystem

Peers may work in partnership with Peers may work in partnership with providers in the formal medical system or providers in the formal medical system or separately through existing recovery separately through existing recovery networks.networks.

ExamplesExamples The HARP program has adapted the Chronic The HARP program has adapted the Chronic

Disease Self-Management Program (CDSMP), for Disease Self-Management Program (CDSMP), for MH Consumers. Sessions involve action planning MH Consumers. Sessions involve action planning and feedback, modeling of behaviors, training in and feedback, modeling of behaviors, training in specific disease management techniques.specific disease management techniques.

Pilot test suggested improvement in activation, Pilot test suggested improvement in activation, primary care visit, and trends towards primary care visit, and trends towards improvement in other health outcomes. Full improvement in other health outcomes. Full multisite trial to follow.multisite trial to follow.

HARP helped inspire “Whole Health” program HARP helped inspire “Whole Health” program developed by Larry Fricks to train certified peers developed by Larry Fricks to train certified peers nationwide. nationwide.

1. Schizophr Res. 2010 May;118(1-3):264-70.

Using Information TechnologyUsing Information Technology Need to harness IT to help coordinate care Need to harness IT to help coordinate care

and activate patients and activate patients Promising techniques include shared/common Promising techniques include shared/common

electronic records (with appropriate privacy electronic records (with appropriate privacy protections), personal health records, protections), personal health records, handheld devices/smartphoneshandheld devices/smartphones

Example: My Health Record study developing Example: My Health Record study developing a medical PHR for MH consumers, and in a a medical PHR for MH consumers, and in a randomized trial, is studying the impact on randomized trial, is studying the impact on activation and quality of careactivation and quality of care

1. Funded by AHRQ R18HS017829

Care Delivery: Building a Medical Care Delivery: Building a Medical Home for People with SMI Home for People with SMI

Collocated Models: Bring care onsiteCollocated Models: Bring care onsite Facilitated Referral: Link to Facilitated Referral: Link to

community medical providerscommunity medical providers Partnership: Develop a relationship Partnership: Develop a relationship

between a CMHC and medical between a CMHC and medical providerprovider

Providing Care OnsiteProviding Care Onsite

Advantages: Potential for maximal Advantages: Potential for maximal integration of services, control over integration of services, control over services providedservices provided

Disadvantages: Requires substantial Disadvantages: Requires substantial economies of scale, financing may be economies of scale, financing may be difficultdifficult

Sites to implement: Large, quasi Sites to implement: Large, quasi integrated systems such as the VA or integrated systems such as the VA or HMOs. HMOs.

•Medical care for a VA mental health clinic providedonsite through a multidisciplinary team•Randomized trial showed improved quality ofpreventive care, better health outcomes, and that theprogram was cost-neutral from the VA perspective

Collocated Care Example: Integrated Care Clinic

Archives of General Psychiatry 2001; 58: 861-8

Referral ModelReferral Model

AdvantageAdvantages: Easy to implement, inexpensive, can retrain existing care management staff

Disadvantages: Care is only as good as available community resources

PCAREPCARE

PCARE (Primary Care Access, Referral, and PCARE (Primary Care Access, Referral, and Evaluation) studying a medical nurse-care Evaluation) studying a medical nurse-care manager to improve primary care for persons manager to improve primary care for persons with SMI (n=407).with SMI (n=407).

One year f/u data found greater improvements in One year f/u data found greater improvements in quality of preventive services, cardiometabolic quality of preventive services, cardiometabolic care, mental health quality of life, and care, mental health quality of life, and cardiovascular risk among those with lab valuescardiovascular risk among those with lab values

Two year f/u analyses (in progress) indicate Two year f/u analyses (in progress) indicate persistent clinical improvements and favorable persistent clinical improvements and favorable cost findingscost findings

Am J Psychiatry. 2010 Feb;167(2):151-9. Epub 2009 Dec 15.

Partnership-Based Partnership-Based ModelsModels

Advantages: Access both to onsite Advantages: Access both to onsite staff and full resources of partner site staff and full resources of partner site for more complex problems.for more complex problems.

Disadvantages: Need to identify and Disadvantages: Need to identify and develop relationship with partnerdevelop relationship with partner

This is the predominant model now This is the predominant model now being used in the SAMHSA PBHCI being used in the SAMHSA PBHCI grant program and by states grant program and by states developing integration collaboratives.developing integration collaboratives.

The HOME studyThe HOME study

HOME study (Health Outcomes, Monitoring HOME study (Health Outcomes, Monitoring and Evaluation) has established partnership-and Evaluation) has established partnership-based medical home for persons with SMI.based medical home for persons with SMI.

West End FQHC established a satellite clinic West End FQHC established a satellite clinic onsite at Cobb County CMHConsite at Cobb County CMHC

Electronic health records are being used to a Electronic health records are being used to a “virtual medical home spanning the two “virtual medical home spanning the two systems.systems.

The partners have now received SAMHSA The partners have now received SAMHSA funding to implement a similar model in two funding to implement a similar model in two other clinic sites.other clinic sites.

2R01MH070437-06A1

How might Healthcare Reform How might Healthcare Reform Affect Health and Healthcare for Affect Health and Healthcare for

Persons with SMI?Persons with SMI?1.1. Expansion of InsuranceExpansion of Insurance

2.2. Medical Home DemonstrationsMedical Home Demonstrations

3.3. Expansion of SAMHSA integration Expansion of SAMHSA integration programprogram

4.4. Addressing prevention and Addressing prevention and promotionpromotion

Medicaid ExpansionMedicaid Expansion

Expansion of insurance, Medicaid in Expansion of insurance, Medicaid in particular, will ensure that more particular, will ensure that more people with SMI have access to people with SMI have access to health and mental health serviceshealth and mental health services

Will need adequate scope of benefits Will need adequate scope of benefits to cover full range of services for to cover full range of services for persons with SMIpersons with SMI

Expanded pool of insurance likely to Expanded pool of insurance likely to stretch safety net workforce.stretch safety net workforce.Garfield et al Psychiatr Serv. 2010 Nov;61(11):1081-6

Medical Home Medical Home Demonstration ProjectsDemonstration Projects

Medicare: Center for Medicare and Medicare: Center for Medicare and Medicaid Innovation will test new Medicaid Innovation will test new models including the medical home models including the medical home within Medicare. within Medicare.

Medicaid: State plan option to permit Medicaid: State plan option to permit Medicaid enrollees designate a Medicaid enrollees designate a medical home; explicitly includes medical home; explicitly includes persons with SMI in target population persons with SMI in target population and CMHCs as potential sites.and CMHCs as potential sites.

SAMHSA PBHCI GrantsSAMHSA PBHCI Grants

56 community mental health providers 56 community mental health providers have been funded to provide health care have been funded to provide health care and wellness servicesand wellness services

Funds primary care services, referral Funds primary care services, referral costs, information technology and facility costs, information technology and facility modificationsmodifications

NCCBH is leading a national technical NCCBH is leading a national technical assistance center to help grantees and assistance center to help grantees and other sites improve care on the primary other sites improve care on the primary care/BH interfacecare/BH interface

Improving Prevention and Improving Prevention and Wellness Wellness

Health reform includes a national Health reform includes a national strategy, including appropriation of strategy, including appropriation of substantial Federal funding, to support substantial Federal funding, to support and expand health prevention and and expand health prevention and wellness programs. wellness programs.

Particularly given the importance of Particularly given the importance of primary prevention in addressing the primary prevention in addressing the problem of excess mortality, we must problem of excess mortality, we must lobby to ensure that funding for this lobby to ensure that funding for this portion of the legislation is preserved.portion of the legislation is preserved.

ConclusionsConclusions

The long history and complex causes The long history and complex causes of morbidity and mortality in of morbidity and mortality in persons with SMI indicates what a persons with SMI indicates what a challenging task it will be to challenging task it will be to remediate it.remediate it.

However, a confluence of events However, a confluence of events now provide a window for change to now provide a window for change to improve health and healthcare in improve health and healthcare in this vulnerable population.this vulnerable population.