SAMHSA Standard Title Slide

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SAMHSA Standard Title Slide
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• The Case for
• Physical-Behavioral Health Integration
•  Tami Mark, Ph.D.
• Thomson Reuters Healthcare
• April 14, 2011

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Outline of Material to be Presented

• Behavioral disorders are common, costly,
  disabling and deadly
• Behavioral and physical disorders commonly
  co-occur
• Reasons for co-occurrence are complex
• Co-occurrence leads to higher costs worse
  outcomes
• Currently US healthcare addresses co-occurrence
  poorly
• Research suggests integration improves outcomes
• Research suggests integration is cost effective

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Outline

• Behavioral disorders are common, costly,
  disabling and deadly
• Behavioral and physical disorders commonly
  co-occur
• Reasons for co-occurrence are complex
• Co-occurrence leads to higher costs worse
  outcomes
• Currently US healthcare addresses co-occurrence
  poorly
• Research suggests integration improves outcomes
• Research suggests integration is cost effective

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Behavioral Health Disorders are Common, Costly,
Disabling, and Deadly

• Almost 50 of Medicaid beneficiaries will have
  diagnosable mental health or substance abuse
  disorder in given year.1
• 11.5 of Medicaid expenditures go to treating
  behavioral health disorders (10 mental health,
  1.5 substance use disorders)2
• The World Health Organization ranks depression,
  alcohol, and tobacco use as among the top causes
  of disability.3
• Persons with mental illness die, on average, 25
  years earlier than the general population and
  much of this gap can be attributable to medical
  conditions such as cardiovascular disease.4

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Outline

• Behavioral disorders are common, costly,
  disabling and deadly
• Behavioral and physical disorders commonly
  co-occur
• Reasons for co-occurrence are complex
• Co-occurrence leads to higher costs worse
  outcomes
• Currently US healthcare addresses co-occurrence
  poorly
• Research suggests integration improves outcomes
• Research suggests integration is cost effective

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Percentages of Adults with Mental Disorders
and/or Medical Conditions5

• National Comorbidity Survey Replication,
  2001-2003 as Reported in Druss and Walker, 2011

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Medical Comorbidities are Higher Among Persons
with Mental Illness6

• Diabetes2-3 times higher
• Cardiovascular Disease2-3 times higher
• HIVhigher but varies
• Hepatitis5-11 times higher
• Chronic Obstructive Pulmonary Diseasehigher
  

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Physical Disorders Associated with Chronic
Alcohol Use

• Adapted from Schuckit MA. In Harrisons
  Principles of Internal Medicine. New York
  McGraw-Hill 20012561-2566.

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Outline

• Behavioral disorders are common, costly,
  disabling and deadly
• Behavioral and physical disorders commonly
  co-occur
• Reasons for co-occurrence are complex
• Co-occurrence leads to higher costs worse
  outcomes
• Currently US healthcare addresses co-occurrence
  poorly
• Research suggests integration improves outcomes
• Research suggests integration is cost effective

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Medical and Behavioral Illness Interact in
Complex and Important Ways

• Modified from Katon, 2003, by Druss and Walker,
  2011

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Outline

• Behavioral disorders are common, costly,
  disabling and deadly
• Behavioral and physical disorders commonly
  co-occur
• Reasons for co-occurrence are complex
• Co-occurrence leads to higher costs worse
  outcomes
• Currently US healthcare addresses co-occurrence
  poorly
• Research suggests integration improves outcomes
• Research suggests integration is cost effective

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Average Monthly Expenditures for Medicaid
Beneficiaries With and Without Co-Occurring
Costly Physical Conditions (2003)

• Source Medicaid Analytic eXtract (MAX), 2003
• Substance Abuse and Mental Health Services
  Administration. (2010). Mental health and
  substance abuse services in Medicaid , 2003
  Charts and state tables. HHS Publication No.
  (SMA) 10-XXXX. Rockville, MD Center for Mental
  Health Services, Substance Abuse and Mental
  Health Services Administration.

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Mental Illness Worsens Diabetes Outcomes7

• Persons with diabetes who are depressed have
  increased rates of adverse health outcomes
  relative to persons with diabetes who are not
  depressed
• Mortality
• Cardiac events
• Hospitalizations
• Diabetes-related complications
• Functional impairment
• Quality of life

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Mental Illness Worsens Prognosis from AMI

• The occurrence of depression in patients with
  coronary heart disease substantially increases
  the likelihood of poor cardiovascular prognosis.
• Patients with post-heart attack depression are
  about three times more likely to die from a
  future attack or other heart problem.

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Outline

• Behavioral disorders are common, costly,
  disabling and deadly
• Behavioral and physical disorders commonly
  co-occur
• Reasons for co-occurrence are complex
• Co-occurrence leads to higher costs worse
  outcomes
• Currently US healthcare addresses co-occurrence
  poorly
• Research suggests integration improves outcomes
• Research suggests integration is cost effective

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Institute of Medicine8

• Multiple clinicians and health care organizations
  serving patients in the American health care
  system typically fail to coordinate their care.
• The resulting gaps in care, miscommunication, and
  redundancy are sources of significant patient
  suffering.

• IOM Improving the Quality of Health Care for
  Mental Health and Substance-Use Conditions
  Quality Chasm Series (2005)

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IOM Report Improving the Quality of Health Care
for Mental Health and Substance-Use Conditions
Quality Chasm Services (2006)

• Overarching Recommendation 1
• Health care for general, mental, and
  substance-use problems and illnesses must be
  delivered with an understanding of the inherent
  interactions between the mind/brain and the rest
  of the body.

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Presidents New Freedom Commission9

• Consumers often feel overwhelmed and bewildered
  when they must access and integrate mental health
  care and other services across multiple,
  disconnected providers in the public and private
  sectors. (2003)

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Reasons for Readmission in Medicaid (age 21
64)10
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Medicaid - Follow-up after Discharge for Mental
Illness in Reporting HMOs11

• Source HEDIS (National Committee for Quality
  Assurance, 2010)

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Medicaid - Initiation and Engagement of SUD
Treatment 11

• Source HEDIS (National Committee for Quality
  Assurance, 2010)

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Percent of Adolescents who Received
Antidepressants and Therapy12
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PCPs Unable to Get MH Services13
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Provision of Medical Services by Community Mental
Health Centers14
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What Does Integration Mean?

• Communication Sharing of information among
  providers
• Comprehensiveness Meeting all health care needs
• Continuity of care Timely, uninterrupted
  delivery of appropriate services over time
• (IOM, 200162)

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How Can We Better Integrate Care for Medical and
Behavioral Conditions?

• Train behavioral health providers in screening,
  preventive care, and routine medical services
• Train medical providers in behavioral health
• Increase communication between behavioral health
  and medical care providers with
• Co-location
• Enhanced referral
• Team meetings
• Verbal/Written consults
• Coordinated treatment plan

• Integrated medical record
• Telemedicine
• Case management
• Outreach and follow-up

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Outline

• Behavioral disorders are common, costly,
  disabling and deadly
• Behavioral and physical disorders commonly
  co-occur
• Reasons for co-occurrence are complex
• Co-occurrence leads to higher costs worse
  outcomes
• Currently US healthcare addresses co-occurrence
  poorly
• Research suggests integration improves outcomes
• Research suggests integration is cost effective

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AHQR Technology Assessment Integration of MHSA
with Primary Care15

• Intervention Integrating mental health
  specialists into primary care.
• Analysis 33 RCTs examined (26 studies address
  depression)
• Conclusions
• There is reasonably strong evidence to encourage
  use of integrated services.
• The major obstacles to encouraging the use of
  integrated services appear to be financial and
  organizational.

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Meta-analysis Collaborative Care for
Depression16

• Intervention Collaborative care for Depression
• A multifaceted intervention.
• Three distinct professionals working
  collaboratively within the primary care setting
  a case manager, a primary care practitioner, and
  a mental health specialist.
• Analysis 37 RCTs include 12,355 patients
  receiving collaborative care.
• Conclusion Depression outcomes were improved at
  6 months and evidence of longer term benefit was
  found for up to 5 years.

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Effectiveness of Brief Alcohol Interventions in
Primary Care17

• Intervention Feedback on alcohol use and harms,
  identification of high risk situations for
  drinking and coping strategies, increased
  motivation and the development of a personal plan
  to reduce drinking. 5 to 15 minutes.
• Analysis Cochrane Collaboration Systematic
  Meta-Analysis of 29 RCTs in general practice (24)
  or emergency department (5), 7000 patients.
• Conclusion Significantly reductions in alcohol
  consumption

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Assertive Community Treatment (ACT)18

• Intervention Multidisciplinary team approach to
  provide aimed at keeping people with severe
  mental illness in contact with services by using
  integrated and outreach-oriented services.
• Analysis Cochran Collaboration review 17 RCTs
  that compared ACT to standard community care.
• Conclusion
• Reduces hospital days
• Improves employment
• Increases independent living
• Improves quality of life

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Discharge Planning19

• Interventions Done while an inpatient to
  facilitate transition to outpatient treatment
• Analysis Steffen et al. (2009) Systematic Review
  and Meta-Analysis of 11 studies of inpatient
  discharge planning
• Conclusions
• Reduced the relative risk of readmissions by 35
• Increased probability of adherence to outpatient
  treatment increased by 25

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Outline

• Behavioral disorders are common, costly,
  disabling and deadly
• Behavioral and physical disorders commonly
  co-occur
• Reasons for co-occurrence are complex
• Co-occurrence leads to higher costs worse
  outcomes
• Currently US healthcare addresses co-occurrence
  poorly
• Research suggests integration improves outcomes
• Research suggests integration is cost effective

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Example Weisner et al.. JAMA Study of
Co-Location Medical Provider within SA
Providers20,21

• Study Location Kaiser Permanentes Chemical
  Dependency Recovery Program
• Intervention Patients in integrated care model
  received primary medical care within the
  substance abuse program (3 MDs, 2 nurses, 1
  medical assistant).
• Analysis Compared findings among patients in
  integrated and independent groups for patients
  with and without substance abuse-related medical
  conditions.

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Results Weisner et al, JAMA, 2003

• Integrated larger decline in
• Hospitalization rates
• Inpatient Days
• ED Use

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Example IMPACT Trial22

• Intervention Collaborative program for
  depression (applied to other conditions)
• Screening tool
• Patient monitoring and follow-up
• Case manager who coordinates, educates, trouble
  shoots
• Evidence based guidelines and stepped care.
• Psychiatric Consultations
• Analysis RCT of1801 depressed older primary care
  patients from 8 healthcare systems.
• Findings Effective in reducing depression,
  improving physical functioning, improving social
  functioning

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Results IMPACT TRIAL
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Need for Future Research23

• Most models integrate mental health care into
  primary care, few do opposite
• Who is most likely to benefit from treatment?
• More examination of conditions other than
  depression and older adults those with SMI,
  SUD, children
• More models of integrated payment needed

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Summary

• Behavioral and physical conditions are closely
  intertwined.
• Having a separate, fragmented system to address
  behavioral and physical illnesses is a bad idea.
• Evidence has identified some effective and cost
  effective integration approaches.
• More research and experimentation needs to be
  done.

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References

1. Adelmann PK. Mental and substance use disorders
   among Medicaid recipients prevalence estimates
   from two national surveys. Adm Policy Ment
   Health. 2003 Nov31(2)111-29.
2. Mark TL, Levit KR, Vandivort-Warren R, Buck JA,
   Coffey RM. Changes In US spending on Mental
   Health And Substance Abuse Treatment, 1986-2005,
   and implications for policy. Health Aff
   (Millwood). 2011 Feb30(2)284-92.
3. World Health Organization http//www.who.int/menta
   l_health/management/depression/definition/en/
4. National Association of State Mental Health
   Program Directors (NASMHPD) Morbidity and
   Mortality in People with Serious Mental Illness,
   2006.
5. Druss BG and Walker ER. Mental Disorders and
   Medical Comorbidity. Robert Wood Johnson
   Foundation, Research Synthesis Report No 21,
   February 2011. www.policysynthesis.org
6. DE Hert M, Correll CU, Bobes J, Cetkovich-Bakmas
   M, Cohen D, Asai I, Detraux J, Gautam S, Möller
   HJ, Ndetei DM, Newcomer JW, Uwakwe R, Leucht S.
   Physical illness in patients with severe mental
   disorders. I. Prevalence, impact of medications
   and disparities in health care. World Psychiatry.
   2011 Feb10(1)52-77.

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References, Continued

• Markowitz SM, Gonzalez JS, Wilkinson JL, Safren
  SA. A review of treating depression in diabetes
  emerging findings. Psychosomatics. 2011
  Jan-Feb52(1)1-18.
• Institute of Medicine. Improving the Quality of
  Health Care for Mental and SubstanceUse
  Conditions. National Academies Press, Washington,
  DC. 2006.
• Presidents New Freedom on Commission on Mental
  Health. Achieving the Promise. Transforming
  Mental Health Care in America. July 2003.3
• Jiang, JH and Wier LH. All-Cause Hospital
  Readmissions for Non-Elderly Medicaid Patients.
  2007. HCUP Statistical Brief 89. April 2010.
  Agency for Healthcare Research and Quality,
  Rockville, MD. http//.hcup.us.ahrq.gov/reports/sta
  tbriefs/sb89.pdf
• National Center for Quality Assurance. The State
  of Health Care Quality 2010. http//www.ncqa.org/P
  ortals/0/State20of20Health20Care/2010/SOHC2020
  1020-20Full2.pdf
• Mark TL. Receipt of psychotherapy by adolescents
  taking antidepressants. Psychiatr Serv. 2008
  Sep59(9)963
• Cunningham PJ. Beyond Parity. Primary Care
  Physicians Perspectives on Access to Mental
  Health Affairs. 2009 490 501.

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References, Continued

1. Druss BG, Marcus SC, Campbell J, Cuffel B,
   Harnett J, Ingoglia C, Mauer B. Medical services
   for clients in community mental health centers
   results from a national survey. Psychiatr Serv.
   2008 Aug59(8)917-20.
2. Butler M, Kane RL, McAlpine D, et al. Rockville
   (MD) Agency for Healthcare Research and Quality
   (http//www.ahrq.gov/ ) (US) 2008 Oct.
   Integration of Mental Health/Substance Abuse and
   Primary Care. Evidence Reports/Technology
   Assessments, No. 173.
3. Gilbody S, Bower P, Fletcher J, et al.
   Collaborative Care for Depression A Cumulative
   Meta-analysis and Review of Longer-term Outcomes.
   Arch Intern Med. 20061662314-2321
4. Kaner EF.S., Dickinson HO, Beyer FR, Campbell F,
   Schlesinger C, Heather N, Saunders JB, Burnand B,
   Pienaar ED. Effectiveness of brief alcohol
   interventions in primary care populations.
   Cochrane Database of Systematic Reviews 2007,
   Issue 2. Art. No. CD004148. DOI
   10.1002/14651858.CD004148.pub3
5. Marshall M, Lockwood A. Assertive community
   treatment for people with severe mental
   disorders. Cochrane Database of Systematic
   Reviews. 2002.
6. Steffen S, Kösters M, Becker T, Puschner B.
   Discharge planning in mental healthcare a
   systematic review of the recent literature. Acta
   Psychiatr Scand. 2009 Jul120(1)1-9. Epub 2009
   Apr 8. Review. PubMed PMID 19486329.

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References, Continued

• Weisner C, Mertens J, Parthasarathy S, Moore C,
  Lu Y. Integrating primary medical care with
  addiction treatment a randomized controlled
  trial. JAMA. 2001 Oct 10286(14)1715-23.
• Parthasarathy S, Mertens J, Moore C, Weisner C.
  Utilization and cost impact of integrating
  substance abuse treatment and primary care. Med
  Care. 2003 Mar41(3)357-67.
• Unutzered J, Katon WJ, Fan MY, Schoenbaum MC, Lin
  EH, Della Penna RD, Powers D. Long-term cost
  effects of collaborative care for late-life
  depression. Am J Manag Care. 2008
  Feb14(2)95-100.
• Carey TS, Crotty KA, Morrissey JP, Jonas DE,
  Viswanathan M, Thaker S, Ellis AR, Woodell C,
  Wines C. Future Needs for Integration of Mental
  Health/Substance Abuse and Primary Care. Future
  Research Needs Paper No. 3. (Prepared by the RTI
  International University of North Caroline at
  Chapel Hill Evidence-based Practice Center under
  Contract No. 290-2007-10056-I.). AHRQ Publication
  No. 10-EHC0690EF. Rockville, MD Agency for
  Healthcare Research and Quality. September 2010.

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• QUESTIONS?

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