The Interdependence of Mental Health and Physical Health

1. The Interdependence of Mental Health and Physical Health The case for creating integrated systems of care James Yoe PhD; Elsie Freeman MD Maine Department of Health and Human Services SAMHSA National Grantee Conference Washington, DC June 19, 2009

2. WHO Global Burden of Disease2000 Chronic Diseases are a major cause of death and disability accounting for 25% of all disability worldwide Arthritis – Musculoskeletal Diseases Respiratory Diseases Cardiovascular Diabetes

3. Behavioral Disorders Account for Even More Disability than Chronic Medical Conditions WHO: 2000 Global Burden of Disease – In the developed world, behavioral disorders account for almost half of burden of disability • Mental Illnesses – 24% • Substance Use Disorders – 12% • Alzheimer’s Disease/Dementias – 8%

4. And In Addition…. • Persons with mental ill health have higher rates of health risk (smoking, obesity, physical inactivity) • Persons with mental ill health have higher rates of diabetes, arthritis, asthma, heart disease • Persons with both chronic disease and mental illness have higher costs and poorer outcomes Mental illnesses and chronic medical diseases interact:

5. Negative Impact of Depression on the Outcome of Cardiovascular Disease

6. Negative Impact of Chronic Medical Conditions on Recovery from Severe Mental Illness • On average persons with Serious Mental Illness die 25 years earlier than their age mates in the general population • Persons with SMI are not dying from their mental illness but from heart disease, diabetes and other medical conditions • Death is the ultimate impediment to recovery

7. The Gaps – disease and program specific structures are not person centered • Most data and management systems focus on one or the other (and separate mental illness from substance abuse or from cognitive impairments) • Most systems of care (and regulation and reimbursement) focus on one only • Institutional systems (federal, state, academic) are also separate from each other

8. The Goal The goal of a transformed health system that integrates mental health and physical health promotion should be to put the head and body back together so that policies and programs are “person-centered” or more holistic rather than our present system of carving out body parts (i.e., oral health, reproductive health, mental health etc.) or specific diseases (i.e., diabetes, heart disease, stroke, cancer, etc.).

9. Maine Data: The Impact of Mental Illness on Physical Health in the General Population Expanding focus of SMHA, Medicaid and Public Health to mental health issues in the general population

10. Maine Examples of Integrated Data Analysis • Integrated analysis of Mental Health Modules in BRFSS • Integrated analysis of Medicaid data – the Maine/SC Emergency Room Usage study

11. Maine BRFSS Mental Illness Modules Frequent Mental Distress (FMD):≥ 14 days mental ill health 10.7% Depression and Anxiety Module • Moderate/Severe Current Depression – 7.4% • Past history of depression – 20% • Past history anxiety disorder – 16% K-6 Module • Serious Psychological Distress (K6 ≥ 13) - 3.8% • Moderate Psychological Distress (K6 – 8-12) - 7.8% • History of Mental Health Treatment -15% • Miss Most Days Activities - 3.1% Miss Some Days - 6.8% No one definition includes all persons – overlapping, but non-identical populations

12. Conclusion from Integrated Analysis of Maine BRFSS Data • Mental ill health affects one in five Mainers, touching every social network • Mental ill health is associated with higher rates of health risk, chronic disease and poor self care in the general population • Attention to mental health issues critical for systems that target chronic disease

13. Maine DHHS /South Carolina ER Study Integrated Analysis Medicaid Services Data

14. Population Studied Medicaid only, 11 or 12 months eligibility, 19-64 years old Group placement is dependent on whether there was any SA or MH diagnosis for any claim in the fiscal year Four groups: MH, SA, MH & SA, no MH/SA ER visit diagnoses are primary diagnosis given for the ER visit ER utilization is # of visits per 1000 members in each specific group

15. ER Utilization Rates Increase with Complexity of Group

16. Overall ER Usage Increases with Complexity of Underlying Population ER utilization rates 2 times higher for MH or SA only groups compared to Medicaid members with no behavioral health diagnoses ER rates are 4 times higher for Co-morbid MH/SA

17. What is primary reason for going to the ER?

18. Percent Maine ER Visits by Diagnosis by Group

19. Highest Usage of ER: Visits for Medical Conditions per Thousand Members by Group

20. ER Rates for Medical Dx Increase with Complexity of Group Members In both states, ER rates for medical reasons, compared to group with no underlying behavioral health diagnoses are: 1.9-1.7 times higher for MH group 1.8-2.1 times higher for SA group 3.5-4.0 times higher for the Co-occurring group.

21. Second Highest Usage of ER: Injury Visits per Thousand Members by Group for Year

22. The Smallest Percentage of Overall ER Usage is for Behavioral Health Overall --- 5.2% Maine ER visits are for MH 3.3% South Carolina ER visits are for MH Overall --- 2.1% Maine ER visits are for SA 1.0% South Carolina ER visits are for SA

23. Conclusions of ER Study • Majority of ER visits are for injuries and medical conditions for all groups • Rates of ER utilization for medical issues and injuries are increased in populations with behavioral disorders • Effective care for these complex populations will depend on development of integrated systems of care

24. Persons with Serious Mental Illness Impact on physical health is same as for persons with any mental illness in the general population, only more so

25. Biggest Impediment to Recovery • Compared to the general population, persons with serious mental illness on average lose 25 years of normal life span • People are dying, not from their schizophrenia, but from chronic medical conditions

26. For Persons with SMI Chronic Health Conditions Are an Expectation Not an Exception

27. High Rate of Health Disorders of Persons with SMI Compared to Non-SMI Groups in Maine Medicaid – 2004

28. Burden of Medical Illness: Maine Medicaid 2004

29. Another Approach: BRFSS Questions Added to Consumer Satisfaction Survey • Height and Weight (translated into Body Mass Index) • Have you ever been told by a doctor or health professional that you have…(coronary artery disease, heart attack, diabetes, high blood pressure, high cholesterol)? • Do you smoke cigarettes? • Now thinking about your physical health, which includes physical illness and injury, how many days during the past 30 days was your physical health not good? • Now thinking about your mental health, which includes stress, depression, and problems with emotions, how many days during the past 30 days was your mental health not good? • During the past 30 days, about how many days did poor physical or mental health keep you from doing usual activities, such as self-care, school, or recreation? • Would you say that your general health is…(excellent, very good, good, fair, poor)? March 14-18, 2009

30. Health RiskMaine DIG Surveys (Age 18-64 Years) March 14-18, 2009

31. Chronic Health ConditionsMaine DIG Surveys (Age 18-64 Years) ** Cardiovascular Disease (CVD) = reported angina or heart attack March 14-18, 2009

32. Metabolic Risk Among persons with no diabetes: obesity, high blood pressure, or high cholesterol Percent Reporting 2 or More Risks March 14-18. 2009

33. Satisfaction Related to Physical Health Status(…how many days during the past 30 days was your physical health not good?) Percent Reporting March 14-18, 2009

34. Costs to Maine Medicaid Persons with co-morbid medical and behavioral health disorders cost more both for medical and for psychiatric services

35. Medical Expenditures for Persons with MH/SA Conditions Compared to General Maine Care 2002

36. Impact of Increasing Number of Medical Co-morbidities on Maine Mental Health Expenditures for Persons with Serious Mental Illness

37. Summary of Integrated Analysis of Maine Data • Mental ill health is associated with higher rates of chronic disease, poor outcome and higher medical costs in the general population • Persons with Serious Mental Illness have even higher rates of health risk, chronic disease, poor outcomes and higher costs

38. Bringing The Data to Key Policy Discussions Governor’s Office Commissioner of DHHS Medicaid Public Health Mental Health

39. Maine State Health Plan:Support from the Governor • Integration of mental health, public health and primary care • Ongoing surveillance of mental health issues in health surveillance • Person centered health care home • Health Info Net - interoperable electronic health information systems and a statewide health information exchange system

40. DHHS Policy Changes • Integration of previously separate agencies into one state health and human services agency, with an integrated management structure • Commissioner’s Policy on Integrated Care • DHHS Strategic Plan has as a focus integration of services to meet the complex needs of persons served

41. The Maine Patient Centered Medical Home Project • Includes behavioral health provider on health care team • Care management to integrate medical and behavioral health issues • Patient self management support to include both medical and behavioral health issues

42. Integration of Mental Health into Maine Medicaid Initiatives • Financial support for Medical Home Pilot • New policies for reimbursement of mental health providers in primary care settings • Medicaid funded medical care management system routinely screens for depression • Medical care managers to coordinate with mental health case managers for persons with SMI

43. Integration of Mental Health into Maine Public Health Initiatives • Ongoing inclusion and integrated analysis of mental health modules in BRFSS will permit county level and special population data for local needs assessment • Universal Web Based Health Screen includes depression screening, education and treatment resources

44. Office of Adult Mental Health • Ongoing inclusion of BRFSS health questions in DIG Consumer Satisfaction Survey • Inclusion of health questions in launch of new Outcome Tool • Partnerships with Medicaid, Elder Services, Public Health to expand role of SMHA to include attention to mental health of whole population

45. December 2008 – DHHS Partners with Local Funder to Launch SMI Health Project • Link every consumer with SMI to a welcoming medical home • Coordinate medical and mental health care/case management • Track health issues in mental health system workflow • Develop consumer led health programming

46. Maine SMI Health Project Will… • Develop information sharing systems between consumers, mental health and health care systems • Educate workforce/consumers: health literacy, health advocacy, chronic disease care, self management • Inform development of policy, contracts, regulation and system design at the state level

47. Integration: Making the Case in Maine • Surveillance and data gathering are key first steps • Maine specific data is necessary to drive policy, programming and quality improvement • Analyses concurrently addresses physical and behavioral health issues

48. Dissemination is a Critical Part of Surveillance Present , present, present to many different audiences (not just a report that sits on a shelf)

49. Dissemination Strategies: ONE SIZE REPORTING ONLY USEFUL TO ONE SIZE STAKEHOLDER Tailor presentation to each audience, showing how attention to integration is not an add on but will serve their specific aims • MH audience – how chronic disease impacts Recovery • Health audience –impact of mental illness on chronic disease and population health • Legislature – impact of siloed approach on total costs of care

50. Tie Data and Dissemination to State Program and Policy Issues Give non mental health partners concrete suggestions for what they can do to integrate mental health into their regular programming