Daryl Sharp Associate Professor of Clinical Nursing & in the Center for Community Health

1. Integrating Physical & Behavioral Health:Measuring Key Cardiometabolic Indicators in Community Mental Health Settings Daryl Sharp Associate Professor of Clinical Nursing & in the Center for Community Health Director, Doctor of Nursing Practice Program December 3, 2010

2. Objectives • To discuss the evidence supporting the responsibility of clinicians to monitor cardiometabolic health indicators in community mental health treatment settings • To identify key cardiometabolic indicators to measure & monitor among those cared for in community mental health treatment settings • To discuss essential interventions that can significantly decrease health risk & improve well-being among those receiving care in community mental health treatment settings

3. Troubling data • In comparison to the general population, people with serious mental illness: • Lose 25 years of life • Average age of death for men: 53 years; women: 59 years • Cardiac events alone account for more deaths than suicide • We routinely assess for suicide and develop suicide response plans • We do little to screen for or respond to the more prevalent causes of premature death (Colton and Manderscheid, 2006; NASMHPD, 2006)

4. Cardiovascular Disease Risk • Cardiovascular disease (CVD) including coronary heart disease (CHD), stroke, & peripheral vascular disease: • Leading cause of death in the US & most developed countries • Expected to remain so in 21st century • Although morality rates due to CVD have declined in the general population, not so with the SMI population Newcomer & Hennekens, 2007

5. Cardiovascular Disease Risk • In general US population within the last decade, reduced CVD morality primarily due to 1) better treatment for acute events & 2) long-term secondary prevention • Contrasting SMI population: • Less likely to receive drug therapies post-MI • Less likely to receive cardiac catheterizations/emergency surgeries Newcomer & Hennekens, 2007

6. The Metabolic Syndrome • A constellation of at least 3 of 5 risk factors: • Abdominal obesity • Low high-density lipoprotein • High triglycerides • Increased blood pressure • Elevated blood glucose (Grundy et al., 2005) • Increasingly common in US population (> 25% of population;50-60% for those with BMI >30) • Confers 10 year risk of CHD event of about 16-18% (Park, Zhu, et al., 2003) • CATIE trial: Prevalence about twice that of age-matched controls • Accounted for by increased prevalence of all individual metabolic syndrome criteria (above) (McEvoy, Myer, Goff et al., 2005; Newcomer& Hennekens, 2007)

7. Relative risk • Metabolic syndrome results in a: • @ 2-fold increase in risk for ASCVD events • @5-fold increase in risk for developing diabetes THUS: THE METABOLIC SYNDROME IMPARTS A RELATIVELY HIGH LONG-TERM RISK FOR BOTH ASCVD AND DIABETES (Grundy et al., 2005)

8. Diagnostic Criteria for Metabolic Syndrome (any 3 of 5 criteria) • Elevated waist circumference • ≥ 102 cm (≥ 40 in) men • ≥ 88 cm (≥ 35 in) women • Elevated TG • ≥ 150 mg/dL or drug treatment for elevated TG • Reduced HDL-C • < 40 mg/dL in men • < 50 mg/dL in women • Or drug treatment for reduced HDL-C • Elevated BP • ≥ 130 mm Hg systolic BP OR • ≥ 85 mm Hg diastolic BP OR • Drug treatment for hypertension • Elevated Fasting Glucose • ≥ 100 mg/dL or drug treatment for elevated glucose (Grudy et al., 2005)

9. Those with Serious Mental Illness Appropriate medical treatment not received (CATIE) • 30.2 % of those with diabetes • 62.4% of those with hypertension • 88.0% of those with dyslipidemia (Casey & Carson,2003; Druss, 2007)

10. “Prevention of metabolic syndrome should be a treatment priority…all steps should be taken to avoid the development of this syndrome” Carpenter & Buchanan, 2008, p. 524

11. Causes of Health Disparities • Medications, especially the atypical antipsychotic drugs, effects on: • Weight gain • Dyslipidemia (unhealthy cholesterol profiles) • Glucose (sugar) metabolism • High rates of smoking • Lack of weight management/poor nutrition • Physical inactivity (NASMHPD, 2006)

12. Causes of Health Disparities • Lack of access to & utilization of preventive community healthcare, including health promotion services/resources • Poverty • Social isolation • Separation of health & mental health systems at the federal, state, local level • Lack of coordinated infrastructure, policy, planning, quality improvement strategies, regulation or reimbursement (NASMHPD, 2006)

13. Impact of Poor Physical Health • Adversely affects an individual’s • Quality of life • Relationships • Employability • Integration into community life (Hogan, 2008)

14. Impact of Poor Physical Health • Enrollees who reported a high number of physically unhealthy days were significantly more negative re: • Perceptions of access & social connectedness • Perceptions of functioning • Less likely to report feeling they belonged in their community • Less likely to report support of family/friends (NASMHPD, 2006)

15. Impact of Poor Physical Health • Less likely to feel in control of their lives & daily problems including things that could go wrong or things they want to do e.g. school, work, housing • More likely to report psychiatrists and/or mental health staff were not willing to see them as often as necessary • Unable to get services they thought they needed (NASMHPD, 2006)

16. What is known about the physical health of individuals we serve? Results from the 2008 WNYCCP Physical Health Survey

17. WNYCCP Physical Health Survey • 41% of enrollees rate their physical health fair to poor • This is comparable to results of the 2004 physical health survey results

18. WNYCCP Physical Health Survey

19. WNYCCP Physical Health Survey • As in 2004, high blood pressure was the most frequently reported health problem with 33% of all 2008 respondents identifying it as such (as compared to 31% in 2004). Also as in 2004, diabetes remained in second place with 19% of 2008 respondents reporting it as a health problem (in comparison to 20% in 2004). Heart problems ranked 3rd (13% vs. 10% in 2004, a statistically significant increase, p = .047) and emphysema 4th (12% vs. 13% in 2004).

20. WNYCCP Physical Health Survey

21. WNYCCP Physical Health Survey

22. WNYCCP: Physical Health Survey

23. WNYCCP Physical Health Survey

24. WNYCCP Physical Health Survey

25. WNYCCP Physical Health Survey

26. WNYCCP Physical Health Survey

27. Integrated care “The systematic coordination of physical and behavioral health care” The question is not whether to integrate, but how? The Hogg Foundation for Mental Health

28. The importance of monitoring • “What gets measured gets done” • Low levels of screening likely contribute to low levels of diagnosis and treatment for modifiable CVD risk factors • Permits us to establish baseline data & measure the future impact of initiatives Parks, Radke, & Mazade, 2008

29. What should we be monitoring? • Smoking status* • Body Mass Index (BMI)* • Waist circumference • Blood pressure* • Fasting blood glucose/Hemoglobin A1c • Fasting lipid profile *OMH cardiometabolic measurement initiative in NY state hospital outpatient clinics

30. Smoking status • Ask at baseline & every medical visit (at least every 3 months)* • Advise to stop smoking • Assess willingness to stop • Assist in reducing and/or quitting with pharmacotherapy & counseling • Arrange follow-up *Even very low levels of tobacco use are harmful to health as is any level of environmental tobacco smoke (Fiore et al., 2008)

31. Body Mass Index • Assess at baseline & every 3 months • More frequently if taking antipsychotic medication; especially with med initiation, change or significant weight gain (1 point increase in BMI) • Measures weight in relation to height • Closely associated with body fat • Healthy range: 18.5-24.9 • Overweight: 25-29.9 • Obese: 30-39.9 • Extreme obesity: 40+ • Does not distinguish between fat & muscle • e.g. athletes can have higher BMI & have little risk of developing diabetes or heart disease; elderly lose muscle mass over time

32. Waist Circumference • Assess at baseline & every 3 months • More frequently if taking antipsychotic medication; especially with med initiation, change or significant weight gain (1 point increase in BMI) • Where fat is located predicts health problems: • Central adiposity more troublesome than fat in hips/thighs even with healthy BMI • Higher disease risk: • Women: waist measurement > 35 inches • Men: waist measurement > 40 inches

33. Blood Pressure Assess at baseline & every 3 months Measurement: 2 readings, 5 minutes apart, sitting in chair. Confirm elevated reading in contralateral arm. Ensure proper cuff size and measurement at heart level Monroe County Medical Society, 2010

34. Blood Glucose • Assess at baseline AND… • Every 3 years If blood glucose levels are within normal range • HgbA1c < 5.7 or 2 FBS <100 • Annually if blood glucose levels are elevated • HgbA1c 5.7-6.4 or 2 FBS between 100-125 (Pre-diabetes) • Every 3-6 months if diabetic or if taking antipsychotic medication; especially with med initiation, change or significant weight gain (1 point increase in BMI) • HgbA1c > 6.5 or 2 FBS > 126 (Diabetes Care, Vol 33, Supplement 1, January 2010)

35. Lipid (Cholesterol) Profile • Assess at baseline and… • Every 5 years if at low risk (normal profile) • Annually if at moderate or high risk or if taking antipsychotic medication; especially with med initiation, change or significant weight gain (1 point increase in BMI)

36. ATP III Guidelines http://www.nhlbi.nih.gov/guidelines/cholesterol/atglance.pdf

37. ATP III Guidelines http://www.nhlbi.nih.gov/guidelines/cholesterol/atglance.pdf

38. Monitoring to what end? • To prevent co-morbidities & premature death • To improve quality of life, well-being, vitality & recovery outcomes • To improve coordination of care including • Education and support for the individual in becoming a partner in healthcare decision making • Promoting self-management strategies for health promotion & living well with chronic disease • Accessing community resources

39. In addition to monitoring… • Coordination & collaboration with primary care ESSENTIAL • Consumer education; preparing for medical visits • Person-centered approaches to lifestyle behavior change including medication interest (adherence): • This is our expertise!

40. In addition to monitoring… • Counseling re: LIFESTYLE THERAPIES: • Weight loss in those overweight or obese GOAL: 5-10% during first year with goal of continuing weight loss to extent possible • Diet modification GOAL: Reduced intakes of saturated fats, trans fat, cholesterol; high fiber; 5 servings fruits/vegetables daily • Increased physical activity GOAL: Regular moderate intensity physical activity at least 30 minutes of continuous/intermittent (preferably 60 minutes) at least 5 days/week (preferably daily)

41. Resources • Wellness Self-Management Program http://www.practiceinnovations.org/WellnessSelfManagementWSM/tabid/118/Default.aspx • Developed in 2006 by NYSOMH in partnership with the Urban Institute for Behavioral Health • Curriculum designed to provide information, knowledge, and skills that help people to make decisions that support recovery • Understanding the connection between physical and mental health is one of the topics addressed in detail

43. LifeSPAN: OMH Wellness Initiative • Smoking Cessation: Stop smoking • Prevention of illness: Practice prevention • Physical Activity: Increase activity • Good Nutrition: Improve nutrition LifeSPAN Toolkit: http://www.omh.state.ny.us/omhweb/ adults/wellness/lifespan/

44. Helping consumers prepare for medical visits Pre-Visit: • Review key areas to address • Make lists of questions www.ahrq.gov/questionsaretheanswer/questionBuilder.aspx • Rehearsal important! Post-visit: • Review recommendations including medications prescribed • Consider your interest in recommendations • Assess satisfaction with services • Insist on communication between multiple providers

45. New York Care Coordination website:http://www.carecoordination.org/Physical-behavioral health integration resources including new provider toolkit!

46. Billing From the clinic reform FAQ list regarding tobacco dependence treatment in Article 31 : Question: Can a full group session of smoking cessation counseling in an Article 31 be legitimately billed? Given that Group is defined as psychotherapy under Part 599, it seems like it could be very risky to run a smoking cessation group and bill it as psychotherapy, however clinically appropriate it may be. Answer: Group Psychotherapy encompasses multiple forms of treatment. Given that all patients admitted for treatment in an Article 31 clinic are in need of treatment for a mental health problem, and given that many if not most are dealing with some form of serious mental illness, any group therapy that focuses on issues pertinent to quitting smoking in the context of mental illness and/or emotional difficulties would clearly meet criteria for group psychotherapy. Often these groups use a cognitive behavioral approach. Such a group would meet the aims of integrated treatment for co-occurring mental and chemical dependence disorders.

47. Clinic Restructuring • If providing either physical exams and/or limited primary care, or if focused on health screening/ education services: • Both types of services are billable up to 5 % of total services provided in clinic reform • Go to: clinic restructuring link on the NYS OMH website where there are guidelines, Frequently Asked Questions (FAQ's) and explanations about how to implement the new policy: http://www.omh.ny.gov/omhweb/clinic_restructuring/default.html

48. Conclusion Stop smoking! Eat healthy! Get moving! Monitor cardiometabolic indicators to assess progress toward health & recovery goals!

49. Acknowledgements Valerie Way, LCSW-R, Senior Program Associate New York Care Coordination Program Geoffrey Williams, MD, PhD, Director Kacie Cook, RD, CDN Christine Nabinger, MS The Healthy Living Center in the Center for Community Health University of Rochester Medical Center Gregory Miller, MD, Medical Director for Adult Services New York State Office of Mental Health And thank you, too, for your attention!

50. Questions/Comments