Physical Health Integration in a Behavioral Health Setting Robin Reed, MD, MPH Rupal Yu, MD, MPH Acknowledgements The Duke Endowment Piedmont Health Services Carolina Advanced Health Community Care of Wake and Johnston Co. Community Care of North Carolina UNC Family Medicine UNC Internal Medicine Carolina Data Warehouse UNC Sheps Center Cardinal Innovations Lori Raney, MD AIMS Center Outline Overview of the Issue Program Overview Program Components Program Implementation Key steps Data 1
Overview of the Issue Physical health conditions are more common among individuals with mental illness when compared to the rest of the population Physical health conditions are often undiagnosed and undertreated in individuals with mental illness Untreated mental illness leads to more time in the hospital Individuals with mental illness often die earlier from common physical health conditions when compared to the general population. Overview of the Issue Smoking and low levels of physical activity are more common in individuals with mental illness when compared to the general population Individuals with mental illness often have limited means to allow access to healthier lifestyle choices, for food and physical activity. Primary care and mental health providers struggle to deliver whole person care for the individuals that they serve. Mortality Excess mortality from: poor quality of care, socioeconomic disadvantage, health behaviors, adherence 2
Chronic Conditions are Undertreated Prevalence of Non Treatment: CATIE Study Data Diabetes: 30% Hypertension 62% Hyperlipidemia 88% Nasrallah Ha et al, 2006 Parks J et al, Morbidity and Mortality of People with Mental Illness. 3
Integrated Care Strategies National Efforts 4
Behavioral Health Home For patients with Severe and Persistent Mental Illness primarily cared for in mental health setting Organize around the Mental Health setting Apply evidence based strategies to improve chronic disease care Track chronic disease outcomes Co-location of primary care provider Lots of new activities tested, no solid health home model developed 5
Orange/Chatham ACT Wake ACT Critical Time Intervention & Hospital Transition Community Resource & Outreach Courts Psychiatric Street Medicine Psychiatric Residency Community Psychiatry Fellowship Social Work Psychology Medical Students Allied Health (OT, Rehab Counseling) Nursing STEP Community Clinics UNC Carr Mill, Carrboro Wake STEP, Raleigh OASIS 3NS Psychotic Disorders Unit Health Home Primary Care Population Health Monitoring, Care Management, Transitional Care Health and Wellness Program Co-localization/Consultation Piedmont Health Clinic UNC Internal Med/Family Med UNC/BCBS Clinic Mental Health Services Community Services Integrated Care Programs Education & Training UNC Center for Excellence In Community Mental Health Recovery & Rehabilitation Programs Technical Assistance, External Training & Support Research IPS Supported Employment The Farm at Penny Lane Brushes with Life UNC PAWS Program NC ACT Coalition ACT Technical Assistance Center NC Medical Directors Network AHEC Community Services & Outcomes, Clinical Trials NC Psychiatric Research Center Community Outcomes Research and Evaluation Center (COREC) SHEPs Center CECMH Integrated Care Program Overview High Risk Care Management Transitional Care CECMH Integrated Care Program Clinic-Level Monitoring Psychiatric Consultation Wellness Groups Primary Care Clinic Center Demographics Total Active STEP Patients = 696 Male= 402 Female= 287 Other= 7 Counties Served = 34 Alamance = 30 Chatham = 44 Durham = 67 Orange = 389 Person = 5 Wake = 58 Other = 58 Race African American = 24.5% Caucasian = 53.5% Other = 22% Age Range 0-20 yrs = 8 21-30 yrs = 148 31-40 yrs = 147 41-50 yrs = 139 51-60 yrs = 137 61-70 yrs = 69 71+ yrs = 11 6
Our Population Primary Diagnoses: Psychotic Disorders Planning Hiring Key Positions Need flexible staff, bought into integrated care Need leadership engagement Existing Data: What is our Baseline? Population characteristics, physical health status Feasible Metrics: Local, State, and National Examples Established physical health metrics & outcomes Key Partners: See Acknowledgements Doing Themes: Continuous training needs Data-driven decision-making Translating operational and clinical needs between diverse disciplines and organizations Adjust processes to meet data and real-time feedback 7
Key Health Home Services Community Support Team -Focused on adults with SMI with multiple chronic conditions Add 1 FTE Nurse and 0.1 FTE Primary Care Provider Expand focus to meet physical & mental health goals Community-Based TOOLS: Integrated Care Plan, Symptom Scales, Self- Management Kits Physical Health Care--CST Continued Medication Reconciliation Compare patient report (in home) with provider intent and pharmacy records Comprehensive Chart Review Performed by primary care provider Use Tool from CCNC Focus on prevalent chronic conditions & preventive care Diabetes, CAD, COPD, Asthma, CHF CAD prevention, Smoking, Weight Management, Cancer Screening, Drug monitoring, Vaccination Team works with the consumer to set goals to address any gaps in care. Physical Health Provision on CST & ACT Continued Disease education/health coaching-promotion Empowering consumers Self-Management Toolkit, Strategies Organize questions for health care professionals Keep list of important health information Appointments, medications, provider contact information 8
Integrated CST Data Diabetes: Improvement in all measures 30% reduction in diabetics in need of eye examination 20% reduction in diabetics on ACE/ARB Cardiovascular Disease: Improvement in all measures 30% Improvement in ASA use Heart Failure: Improvement in all measures 40% Improvement in ACE/ARB use 20% Improvement in B-blocker use 60% Improvement in LV-EF monitoring Key Health Home Service Components Transitional Care Support for Care Transitions (hospital discharge, ED visit, etc) Key Goals: Focused, time-limited Organize medications Help individuals attend appointments after the hospital Improve inpatient-outpatient communication* Provide important information to hospital providers Phone, Electronic Medical Record, and eventual face-toface visits in hospital & community Collaborate with other Care Management Efforts CECMH Transitional Care Data Most recent 6 month period 146 ED visits Slightly more than ½ for Physical Health Concerns 1 Pain (29% overall) 2 Infection 3 Pulmonary 9
Physical Health Monitoring All Center Consumers Identify any potential gaps in care across our population Diabetes, Heart Failure, Heart Disease, Lung disease, Cancer screening etc. Work with the consumer and health care providers to close the gaps in care Track our efforts to close gaps in care Do more consumers suffer less? Adjust our outreach to have fewer gaps in care Population Health Data Primary Care Clinic Primary Care provider at mental health clinic Consumer can see their mental health and primary care provider in the same location. Consumer s providers can communicate better More time for consumer to talk with their primary care provider 10
CECMH Primary Care Clinic Low no-show rate (~10-15%) High Provider Satisfaction Minimal wait time After hours coverage not overburdened Most Common Diagnoses (in order): Pain, tobacco abuse, hyperlipidemia, chest pain, anemia, URI, prediabetes, UTI, drug monitoring, Post-concussion, vaginitis, HTN, annual physical, skin, dyspepsia Lab Draw (Clinic-Wide) Full service since 8/2014: 2.5/week (August)-> 5/week-(September)->15/week (October) Weight Management Groups Weight monitoring Healthy eating- meal preparation and planning Exercise- YMCA membership, group walking, light strength training and yoga Farm workday- growing and cooking with food from The Farm at Penny Lane Links to smoking cessation programs, physical health education, and primary care 11
Questions? 12