Improving Health and Healthcare for Persons With SMI: A Public Health Perspective

1. Improving Health and Healthcare for Persons With SMI: A Public Health Perspective Benjamin Druss MD, MPH January 12, 2011 ACHMA

2. Overview Defining the problem A public health approach to addressing it Some examples of ongoing research Opportunities under health reform

3. The Problem: Medical Illness and Premature Mortality in the Public Mental Health Sector

4. An Historical Perspective 1. Malzberg B. Journal of the American Statistical Association. Mar 1932;27(177A):160-174. 1928-1931: Malzberg found that patients in NY State’s Psychiatric Hospitals die 15 years earlier than other NY state residents1 Most of this excess mortality was due to “natural” rather than “unnatural” causes:heart disease (33%); pneumonia (10.1%), tuberculosis (9.5%), and peripheral artery disease (8.9%)

5. A Widening Disparity 1. Saha S et al Arch Gen Psychiatry. Oct 2007;64(10):1123-1131 The 20th century saw public health victories such as reduced rates of smoking and development of new health technologies. As health and life expectancy improved in the general population, persons with SMI lagged behind and disparities widened still further. 1

6. What Accounts for Excess Morbidity and Mortality in Mental Disorders? • 1989 Mental Health Supplement to the NHIS • Mortality data collected for subsequent 17-18 years to assess • All-cause mortality • Relative contribution of • Socioeconomic factors • Health system factors • Clinical characteristics In driving that mortality *Medical Care, in press 2011

7. Age at Death

8. Factors Contributing to Mortality

9. Hypothesized Causes of Premature Death in the General Population1 1.N Engl J Med. 2007 Sep 20;357(12):1221-8.

10. A Public Health Approach to Improving Health and Healthcare in Persons with SMI

11. A Public Health Approach To Reducing Mortality Tertiary Prevention Primary Prevention Secondary Prevention Chronic Medical Illnesses Risk Factors Lifestyle Medications Wellness programs Environmental Policies Screening Treatment

12. 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).

13. Secondary Prevention 1. Arch Gen Psychiatry. 2010 Jan;67(1):17-24. 2. Psychiatr Serv. 2008 Aug;59(8):917-20. Rates of screening among persons on second generation antipsychotics have remained low even after 2003 ADA/APA guidelines Even when providers do screen, few sites can follow-up for persons who screen positive either onsite or via referrals.

14. Tertiary Prevention: Effective Treatment of Chronic Illness

15. Applying the Chronic Care Model for persons with SMI • Developing an Informed, Activated Patient: • Using Information Technology • Developing a Prepared, Proactive Practice Team • Reorganizing Healthcare:

16. Activating Patients: The Role of Peers Certified peer specialists may play a key role in helping consumers become more engaged in self-management and more effective in working within the health system Peers may work in partnership with providers in the formal medical system or separately through existing recovery networks.

17. Examples The HARP program has adapted the Chronic Disease Self-Management Program (CDSMP), for MH Consumers. Sessions involve action planning and feedback, modeling of behaviors, training in specific disease management techniques. Pilot test suggested improvement in activation, primary care visit, and trends towards improvement in other health outcomes. Full multisite trial to follow. HARP helped inspire “Whole Health” program developed by Larry Fricks to train certified peers nationwide. 1. Schizophr Res. 2010 May;118(1-3):264-70.

18. Using Information Technology • Funded by AHRQ R18HS017829 Need to harness IT to help coordinate care and activate patients Promising techniques include shared/common electronic records (with appropriate privacy protections), personal health records, handheld devices/smartphones Example: My Health Record study developing a medical PHR for MH consumers, and in a randomized trial, is studying the impact on activation and quality of care

19. Care Delivery: Building a Medical Home for People with SMI Collocated Models: Bring care onsite Facilitated Referral: Link to community medical providers Partnership: Develop a relationship between a CMHC and medical provider

20. Providing Care Onsite Advantages: Potential for maximal integration of services, control over services provided Disadvantages: Requires substantial economies of scale, financing may be difficult Sites to implement: Large, quasi integrated systems such as the VA or HMOs.

21. Collocated Care Example: Integrated Care Clinic • Medical care for a VA mental health clinic provided • onsite through a multidisciplinary team • Randomized trial showed improved quality of • preventive care, better health outcomes, and that the • program was cost-neutral from the VA perspective Archives of General Psychiatry 2001; 58: 861-8

22. Referral Model Advantages: Easy to implement, inexpensive, can retrain existing care management staff Disadvantages: Care is only as good as available community resources

23. PCARE PCARE (Primary Care Access, Referral, and Evaluation) studying a medical nurse-care manager to improve primary care for persons with SMI (n=407). One year f/u data found greater improvements in quality of preventive services, cardiometabolic care, mental health quality of life, and cardiovascular risk among those with lab values Two year f/u analyses (in progress) indicate persistent clinical improvements and favorable cost findings Am J Psychiatry. 2010 Feb;167(2):151-9. Epub 2009 Dec 15.

24. Partnership-Based Models Advantages: Access both to onsite staff and full resources of partner site for more complex problems. Disadvantages: Need to identify and develop relationship with partner This is the predominant model now being used in the SAMHSA PBHCI grant program and by states developing integration collaboratives.

25. The HOME study 2R01MH070437-06A1 HOME study (Health Outcomes, Monitoring and Evaluation) has established partnership-based medical home for persons with SMI. West End FQHC established a satellite clinic onsite at Cobb County CMHC Electronic health records are being used to a “virtual medical home spanning the two systems. The partners have now received SAMHSA funding to implement a similar model in two other clinic sites.

26. How might Healthcare Reform Affect Health and Healthcare for Persons with SMI? Expansion of Insurance Medical Home Demonstrations Expansion of SAMHSA integration program Addressing prevention and promotion

27. Medicaid Expansion Garfield et al Psychiatr Serv. 2010 Nov;61(11):1081-6 Expansion of insurance, Medicaid in particular, will ensure that more people with SMI have access to health and mental health services Will need adequate scope of benefits to cover full range of services for persons with SMI Expanded pool of insurance likely to stretch safety net workforce.

28. Medical Home Demonstration Projects Medicare: Center for Medicare and Medicaid Innovation will test new models including the medical home within Medicare. Medicaid: State plan option to permit Medicaid enrollees designate a medical home; explicitly includes persons with SMI in target population and CMHCs as potential sites.

29. SAMHSA PBHCI Grants 56 community mental health providers have been funded to provide health care and wellness services Funds primary care services, referral costs, information technology and facility modifications NCCBH is leading a national technical assistance center to help grantees and other sites improve care on the primary care/BH interface

30. Improving Prevention and Wellness Health reform includes a national strategy, including appropriation of substantial Federal funding, to support and expand health prevention and wellness programs. Particularly given the importance of primary prevention in addressing the problem of excess mortality, we must lobby to ensure that funding for this portion of the legislation is preserved.

31. Conclusions The long history and complex causes of morbidity and mortality in persons with SMI indicates what a challenging task it will be to remediate it. However, a confluence of events now provide a window for change to improve health and healthcare in this vulnerable population.