Integrating Physical and Mental Health: SW Ohio Network Meeting Developing Policies for Integrating Care

1. Integrating Physical and Mental Health: SW Ohio Network MeetingDeveloping Policies for Integrating Care Ohio Coordinating Center for Integrating Care Health Foundation of Greater Cincinnati April 28, 2009

2. Support Health Foundation of Greater Cincinnati Margret Clark Morgan Foundation ODMH Ohio Coordinating Center for ACT Barbara J. Mauer

3. Resources Handouts Library/“Pass Arounds” INTERFACE/Website Each Other

4. Agenda OCCIC Overview of Integrated Healthcare Panels LUNCH National policy and Initiative “Action Areas” Medical Home Networking

5. We understand that you want…. Rapid action Opportunities for collaboration Structural models Clinical best practices Billing clarity and opportunity Business models Decrease of “regulatory burden” Coordinated leadership Attendance to psychosocial/educational

6. We understand that you want…. Today:

7. Ohio Morbidity and Mortality Research Study • Ohio Wellness Colloquium • Ohio Coordinating Center for Integrating Care History of this Initiative

8. OCCIC Infrastructure Development Hunt/Gather----Agrarian

9. OCCIC Network----Learning Community Resources----- “Toolkits” Policy Plan------Action/Participation

10. Overview Morbidity and Mortality Health Care Reform National Efforts Ohio Efforts Literature Medical Home for SMD

12. Focus: Quadrants II and IV

13. Morbidity and Mortality in People with Serious Mental Illness Persons with serious mental illness (SMI) are dying 25 years earlier than the general population While suicide and injury account for about 30-40% of excess mortality, 60% of premature deaths in persons with schizophrenia are due to medical conditions such as cardiovascular, pulmonary and infectious diseases (NASMHPD, 2006)

14. Massachusetts Study: Deaths from Heart Disease by Age Group/DMH Enrollees with SMI Compared to Massachusetts 1998-2000 2.2RR 4.9RR 1.5RR 3.5 RR

15. Maine Study: Comparison of Health Disorders Between SMI & Non-SMI Groups

16. CATIE Study CATIE source for SMI data NHANESIII source for general population data Meyer et al., Presented at APA annual meeting, May 21-26, 2005. McEvoy JP et al. Schizophr Res. 2005;(August 29).

17. At CATIE baseline: 88% of subjects who had dyslipidemia 62.4% of subjects who had hypertension 30.2% of subjects who had diabetes WERE NOT RECEIVING TREATMENT FOR THESE CONDITIONS CATIE Study

18. Washington State General Assistance Population DSHS | GA-U Clients: Challenges and OpportunitiesAugust 2006

19. What’s going on around integration of primary and mental health? Health Care Reform Nationally? In Ohio? In the “literature”?

20. Themes:General Issues for Health Care Reform in America Spending Quality Coverage Fragmentation

21. Emerging Themes for Healthcare Reform for People with SMI State and Federal Access Availability/ Coverage Quality Models/Efficacy Fiscal Payment structure Wellness Prevention/Person Centered

22. Chronic Disease Management Chronic Care Model Payment/system redesign Medical Home Quality Outcomes PAC

23. Overall Model for Improving Primary Care

24. Implementing the Chronic Care Model • Developing a Prepared, Proactive Practice Team • For persons with SMI, this “team” will typically need to span multiple agencies: MH, SA, medical, and social services • Need strategies for linking these services • Developing an Informed, Activated Patient: • Self-management : ability to understand and manage one’s health and medical problems • Activation: ability to act effectively in managing one’s own healthcare • Developing strategies for Reorganizing Healthcare: • Need to work across multiple stakeholders and agencies

25. IMPACT • Depression Treatment in Primary Care • Adapted to other ages and conditions • 5 “most” essential elements: • Collaborative Care team in PC • Collaborative Care Manager • Designated Psychiatrist • Outcome Measurement/Registry • Stepped Care

26. IMPACT

27. Collaborative Depression CareGilbody, et al, Archives of Internal Medicine (2006) • A meta-analysis of the evidence for collaborative depression care was published by. They examined 37 randomized controlled trials with 12,355 total patients. • “Sufficient randomized evidence had emerged by 2000 to demonstrate the effectiveness of collaborative care beyond conventional levels of statistical significance. Further and subsequent randomized trials have only sought to increase the precision of existing estimates of effectiveness, and it is unlikely that further randomized evidence will overturn this result.”

28. The Role of the Care Manager • Primary Point of Contact • Clinician • Advocate • Liaison • Educator • Coach/Cheerleader • Translator

29. Development of Medical Home Concept for people with SMI General Elements (Informed by Chronic Care Model) • Relationship with a personal physician • Team based coordinated care • Treat the whole person • Enhanced access/linkage • Payment Add expanded Care Management • IMPACT: Care Mgt./Stepped Care • Registry Will cover in detail this afternoon

30. National • Federal Efforts • Foundations • National Organizations • States

31. CMHS/SAMHSA • 10 by 10 Pledge (2007) • We envision a future in which people with mental illnesses pursue optimal health, happiness, recovery, and a full and satisfying life in the community via access to a range of effective services, supports, and resources  • We pledge to promote wellness for people with mental illnesses by taking action to prevent and reduce early mortality by 10 years over the next 10 year time period • SAMHSA Grants • 11 Grants/ 1 National TA • Medical Home for SMD…with IMPACT elements • ID programs/practice considerations

32. Foundations • Health Foundation of Greater Cincinnati • Margret Clark Morgan Foundation • California Endowment • Hogg Foundation • Maine Access Foundation • Robert Wood Johnson Foundation • Robert Graham Foundation • Others…..

33. State example • Missouri’s legislature provided seed funding for six pairs of CHCs and CMHCs to partner in improving care • Partners include state DMH,(Parks) FQHC and CMHC trade organizations • Evaluation will include primary care and behavioral performance measures, staff attitudes, and access and cost indicators

34. In Ohio • Governor's Office(s) • State Agencies • FQHCs • MH Advocacy Groups • Health Care Reform • Health Plans • Business Roundtable • ……

35. In Ohio • Services • Wellness/Recovery • Direct Service Programs • Psychoeducational Programs • Agency Practices • Workforce Development • OCCIC • Networking • Tools • Policy Agenda • EVERYONE CAN DO SOMETHING!

36. What’s going on around integration of primary and mental health? Themes in Literature and Experiential Not “one size fits all” No specific EBPs for SMD Consider both structure and content Consider both “medical” and psychosocial Design with clients (and staff) Multiple (simultaneous) approaches are happening Local needs & resources determine course Medical Home with Care Management emerging EVERYONE CAN DO SOMETHING

37. Examples of (current) researched approaches for improving Primary Care for Mental Health Consumers • Team Based Approaches • Consumer Driven Approaches

38. Team-Based Models of Care: Integrated Care Clinic1 • A medical clinic was established to manage routine medical problems of patients with SMI at a VA • Nurse practitioner provided the bulk of medical services; a care manager provided patient education and referrals to mental health and medical specialists • Study randomized 120 veterans to either the integrated care clinic or usual care, followed for one year 1. Druss BG, et al. Arch Gen Psychiatry. 2001;58(9):861-868.

39. Integrated Care Clinic: Results • Access: Significantly increased the rates and number of visits to medical providers, reduced likelihood of ER use • Quality: Significantly improved quality of most routine preventive services (15/17) • Outcomes: Significantly improved scores on SF-36 Health Related Quality of Life • Costs: Program cost-neutral from a VA perspective (primary care costs offset by reduction in inpatient costs)

40. Team-Based Models of Care: Medical Care Management1 • PCARE (Primary Care Access, Referral, and Evaluation) study • 400 persons with SMI randomized to either care management or usual care • Study setting: inner-city, academically affiliated CMHC in Atlanta, GA. Population largely poor, African American, with SMI 1Funded by NIMH R01MH070437

41. PCARE Intervention • 2 nurse care managers (one psychiatric, one public health) help patients get access to and follow-up with regular medical care but do not provide any direct medical services • Examples of services include patient education; scheduling appointments, advocacy (e.g., accompanying patients to appointments, communicating with PCPs)

42. Consumer Based Approaches 1: HARP (Health and Recovery Peer) Project1 • Adapting Stanford’s Chronic Disease Self-Management Program (CDSMP), for MH Consumers • Peer-led, manualized program designed to improve individuals’ self-management of chronic illnesses • In general populations with chronic illnesses, the CDSMP has been shown to improve self-efficacy and reduce unnecessary health service use2 1. Funded by NIMH R34MH078583\ 2. Lorig K et al. Med Care. 2001 Nov;39(11):1217-23.

43. Improving Self-Efficacy through Action Plans • Set short and long-term goals • Identify the specific steps and actions to be taken in order to pursue those goals • Rank confidence, on a scale of 1-10, in achieving these objectives; if the confidence is less than 7 reexamine the barriers

44. The HARP Program • Much of the CDSMP was retained • Six session format focuses on promoting self-efficacy through goal setting and action plans • Sessions focus on health and nutrition, exercise, and being a more effective patient • Changes • Addition of content on MH and general health interaction symptoms and systems was added • MH certified peer leaders trained to become master CDSMP trainers • Diet and exercise recommendations tailored for socioeconomic status (SES) of public sector population

46. Shared Care Plan • Perhaps the best established community-based Electronic Personal Health Record; developed at Peace Health in Seattle, WA • Microsoft worked closely with the Shared Care developers in establishing Health Vault, its new platform for PHRs

48. Adapting the Shared Care Plan • Working with Shared Care developers (Pierson), MH consumer leaders (Fricks, Jenkins), integration experts (Mauer) • Focus groups with consumers, MH and medical providers • Enormous excitement from consumers • Providers: some concerns about TMI, trustworthiness of information

49. Enhancements for My Health Record • Advanced MH directives • Personal recovery plan • Notifications about upcoming visits and preventive services

50. The Role of the Care Manager My Health Record Differs from PCARE in distinct and important ways: • Incorporating a personal health record • Promoting an informed and activated patient as the focus of person-centered health care • Connecting patients with community-based peer centers for training, web access and supportive networking • Enlisting the help of a patient-identified health buddy who is already a supportive person in the patient’s life