The Interdependence of Mental Health and Physical Health

1
The Interdependence of Mental Health and Physical
Health

• The case for creating integrated
• systems of care

James Yoe PhD Elsie Freeman MD Maine Department
of Health and Human Services SAMHSA National
Grantee Conference Washington, DC June 19, 2009
2
WHO Global Burden of Disease2000

• Chronic Diseases are a major cause of death and
  disability accounting for 25 of all disability
  worldwide
• Arthritis Musculoskeletal Diseases
• Respiratory Diseases
• Cardiovascular
• Diabetes

3
Behavioral Disorders Account for Even More
Disability than Chronic Medical Conditions

• WHO 2000 Global Burden of Disease In the
  developed world, behavioral disorders account for
  almost half of burden of disability
• Mental Illnesses 24
• Substance Use Disorders 12
• Alzheimers Disease/Dementias 8

4
And In Addition.
Mental illnesses and chronic medical diseases
interact

• Persons with mental ill health have higher rates
  of health risk (smoking, obesity, physical
  inactivity)
• Persons with mental ill health have higher rates
  of diabetes, arthritis, asthma, heart disease
• Persons with both chronic disease and mental
  illness have higher costs and poorer outcomes

5
Negative Impact of Depression on the Outcome of
Cardiovascular Disease
Cardiovascular Illness Impact of Depression
Coronary artery disease 40 ? risk of cardiac events
Unstable angina 3x ?of cardiac death at 1 year
Post-MI ? mortality 4-6x
Congestive heart failure 50 survival vs. 78 survival
6
Negative Impact of Chronic Medical Conditions on
Recovery from Severe Mental Illness

• On average persons with Serious Mental Illness
  die 25 years earlier than their age mates in the
  general population
• Persons with SMI are not dying from their mental
  illness but from heart disease, diabetes and
  other medical conditions
• Death is the ultimate impediment to recovery

7
The Gaps disease and program specific
structures are not person centered

• Most data and management systems focus on one or
  the other (and separate mental illness from
  substance abuse or from cognitive impairments)
• Most systems of care (and regulation and
  reimbursement) focus on one only
• Institutional systems (federal, state, academic)
  are also separate from each other

8
The Goal

• The goal of a transformed health system that
  integrates mental health and physical health
  promotion should be to put the head and body back
  together so that policies and programs are
  person-centered or more holistic rather than
  our present system of carving out body parts
  (i.e., oral health, reproductive health, mental
  health etc.) or specific diseases (i.e.,
  diabetes, heart disease, stroke, cancer, etc.).

9
Maine Data The Impact of Mental Illness on
Physical Health in the General Population

• Expanding focus of SMHA, Medicaid and Public
  Health to mental health issues in the general
  population

10
Maine Examples of Integrated Data Analysis

• Integrated analysis of Mental Health Modules in
  BRFSS
• Integrated analysis of Medicaid data the
  Maine/SC Emergency Room Usage study

11
Maine BRFSS Mental Illness Modules

• Frequent Mental Distress (FMD) 14 days mental
  ill health 10.7
• Depression and Anxiety Module
• Moderate/Severe Current Depression 7.4
• Past history of depression 20
• Past history anxiety disorder 16
• K-6 Module
• Serious Psychological Distress (K6 13) - 3.8
• Moderate Psychological Distress (K6 8-12) -
  7.8
• History of Mental Health Treatment -15
• Miss Most Days Activities - 3.1 Miss Some Days
  - 6.8
• No one definition includes all persons
  overlapping,
• but non-identical populations

12
Conclusion from Integrated Analysis of Maine
BRFSS Data

• Mental ill health affects one in five Mainers,
  touching every social network
• Mental ill health is associated with higher rates
  of health risk, chronic disease and poor self
  care in the general population
• Attention to mental health issues critical for
  systems that target chronic disease

13
Maine DHHS /South Carolina ER Study
Integrated Analysis Medicaid Services Data
14
Population Studied

• Medicaid only, 11 or 12 months eligibility, 19-64
  years old
• Group placement is dependent on whether there was
  any SA or MH diagnosis for any claim in the
  fiscal year
• Four groups MH, SA, MH SA, no MH/SA
• ER visit diagnoses are primary diagnosis given
  for the ER visit
• ER utilization is of visits per 1000 members in
  each specific group

15
ER Utilization Rates Increase with Complexity of
Group
16
Overall ER Usage Increases with Complexity of
Underlying Population

• ER utilization rates 2 times higher for MH or SA
  only groups compared to Medicaid members with no
  behavioral health diagnoses
• ER rates are 4 times higher for Co-morbid MH/SA

17

• What is primary reason
• for going to the ER?

18
Percent Maine ER Visits by Diagnosis by Group
19
Highest Usage of ER Visits for Medical
Conditions per Thousand Members by Group
20
ER Rates for Medical Dx Increase with Complexity
of Group Members

• In both states, ER rates for medical reasons,
  compared to group with no underlying behavioral
  health diagnoses are
• 1.9-1.7 times higher for MH group
• 1.8-2.1 times higher for SA group
• 3.5-4.0 times higher for the Co-occurring group.

21
Second Highest Usage of ER Injury Visits per
Thousand Members by Group for Year
22
The Smallest Percentage of Overall ER Usage is
for Behavioral Health

• Overall --- 5.2 Maine ER visits are for MH
• 3.3 South Carolina ER visits are for MH
• Overall --- 2.1 Maine ER visits are for SA
• 1.0 South Carolina ER visits are
  for SA

23
Conclusions of ER Study

• Majority of ER visits are for injuries and
  medical conditions for all groups
• Rates of ER utilization for medical issues and
  injuries are increased in populations with
  behavioral disorders
• Effective care for these complex populations will
  depend on development of integrated systems of
  care

24
Persons with Serious Mental Illness

• Impact on physical health is same as for persons
  with any mental illness in the general
  population, only more so

25
Biggest Impediment to Recovery

• Compared to the general population, persons with
  serious mental illness on average lose 25 years
  of normal life span
• People are dying, not from their schizophrenia,
  but from chronic medical conditions

26

• For Persons with SMI
• Chronic Health Conditions Are an
• Expectation
• Not an Exception

27
High Rate of Health Disorders of Persons with SMI
Compared to Non-SMI Groups in Maine Medicaid
2004
28
Burden of Medical Illness Maine Medicaid 2004
29
Another Approach BRFSS Questions Added to
Consumer Satisfaction Survey

• Height and Weight (translated into Body Mass
  Index)
• Have you ever been told by a doctor or health
  professional that you have(coronary artery
  disease, heart attack, diabetes, high blood
  pressure, high cholesterol)?
• Do you smoke cigarettes?
• Now thinking about your physical health, which
  includes physical illness and injury, how many
  days during the past 30 days was your physical
  health not good?
• Now thinking about your mental health, which
  includes stress, depression, and problems with
  emotions, how many days during the past 30 days
  was your mental health not good?
• During the past 30 days, about how many days did
  poor physical or mental health keep you from
  doing usual activities, such as self-care,
  school, or recreation?
• Would you say that your general health
  is(excellent, very good, good, fair, poor)?

30
Health RiskMaine DIG Surveys (Age 18-64 Years)
Health Risk Age Group 2007 DIG Survey (n731) 2007 Maine BRFSS
Smoking 18-44 45-64 46.1 49.5 26.3 18.8
Obesity 18-44 45-64 49.4 49.6 26.0 27.6
High Cholesterol 18-44 45-64 40.5 38.6 23.2 46.0
High Blood Pressure 18-44 45-64 34.0 34.7 13.5 34.0
31
Chronic Health ConditionsMaine DIG Surveys (Age
18-64 Years)
Health Risk Age Group 2007 DIG Survey (n731) 2008 DIG Survey (n1190) 2007 Maine BRFSS
Cardiovascular Disease 18-44 45-64 11.3 9.7 5.3 14.3 1.3 7.7
Diabetes 18-44 45-64 23.0 25.5 15.1 29.2 2.7 9.4
Cardiovascular Disease (CVD) reported
angina or heart attack
32
Metabolic Risk
Among persons with no diabetes obesity, high
blood pressure, or high cholesterol
Percent Reporting 2 or More Risks
33
Satisfaction Related to Physical Health
Status(how many days during the past 30 days
was your physical health not good?)
Percent Reporting
34
Costs to Maine Medicaid

• Persons with co-morbid medical and behavioral
  health disorders cost more both for medical and
  for psychiatric services

35
Medical Expenditures for Persons with MH/SA
Conditions Compared to General Maine Care 2002
MH/SA Behavioral Services MH/SA Medical Services General MaineCareMedical Services
359 PUPM 422 PUPM 163 PUPM
36
Impact of Increasing Number of Medical
Co-morbidities on Maine Mental Health
Expenditures for Persons with Serious Mental
Illness
37
Summary of Integrated Analysis of Maine Data

• Mental ill health is associated with higher rates
  of chronic disease, poor outcome and higher
  medical costs in the general population
• Persons with Serious Mental Illness have even
  higher rates of health risk, chronic disease,
  poor outcomes and higher costs

38
Bringing The Data to Key Policy Discussions

• Governors Office
• Commissioner of DHHS
• Medicaid
• Public Health
• Mental Health

39
Maine State Health PlanSupport from the Governor

• Integration of mental health, public health and
  primary care
• Ongoing surveillance of mental health issues in
  health surveillance
• Person centered health care home
• Health Info Net - interoperable electronic health
  information systems and a statewide health
  information exchange system

40
DHHS Policy Changes

• Integration of previously separate agencies into
  one state health and human services agency, with
  an integrated management structure
• Commissioners Policy on Integrated Care
• DHHS Strategic Plan has as a focus integration of
  services to meet the complex needs of persons
  served

41
The Maine Patient Centered Medical Home Project

• Includes behavioral health provider on health
  care team
• Care management to integrate medical and
  behavioral health issues
• Patient self management support to include both
  medical and behavioral health issues

42
Integration of Mental Health into Maine Medicaid
Initiatives

• Financial support for Medical Home Pilot
• New policies for reimbursement of mental health
  providers in primary care settings
• Medicaid funded medical care management system
  routinely screens for depression
• Medical care managers to coordinate with mental
  health case managers for persons with SMI

43
Integration of Mental Health into Maine Public
Health Initiatives

• Ongoing inclusion and integrated analysis of
  mental health modules in BRFSS will permit county
  level and special population data for local needs
  assessment
• Universal Web Based Health Screen includes
  depression screening, education and treatment
  resources

44
Office of Adult Mental Health

• Ongoing inclusion of BRFSS health questions in
  DIG Consumer Satisfaction Survey
• Inclusion of health questions in launch of new
  Outcome Tool
• Partnerships with Medicaid, Elder Services,
  Public Health to expand role of SMHA to include
  attention to mental health of whole population

45
December 2008 DHHS Partners with Local Funder
to Launch SMI Health Project

• Link every consumer with SMI to a welcoming
  medical home
• Coordinate medical and mental health care/case
  management
• Track health issues in mental health system
  workflow
• Develop consumer led health programming

46
Maine SMI Health Project Will

• Develop information sharing systems between
  consumers, mental health and health care systems
• Educate workforce/consumers health literacy,
  health advocacy, chronic disease care, self
  management
• Inform development of policy, contracts,
  regulation and system design at the state level

47
Integration Making the Case in Maine

• Surveillance and data gathering are key first
  steps
• Maine specific data is necessary to drive policy,
  programming and quality improvement
• Analyses concurrently addresses physical and
  behavioral health issues

48
Dissemination is a Critical Part of Surveillance

• Present , present, present
• to many different audiences (not just a report
  that sits on a shelf)

49
Dissemination Strategies ONE SIZE REPORTING ONLY
USEFUL TO ONE SIZE STAKEHOLDER

• Tailor presentation to each audience, showing how
• attention to integration is not an add on but
  will
• serve their specific aims
• MH audience how chronic disease impacts
  Recovery
• Health audience impact of mental illness on
  chronic disease and population health
• Legislature impact of siloed approach on total
  costs of care

50
Tie Data and Dissemination to State Program and
Policy Issues

• Give non mental health partners concrete
  suggestions for what they can do to integrate
  mental health into their regular programming

51
Implications for Health Policy for General
Population

• Many forms of mental illness are highly
  prevalent, under-recognized, less disabling than
  SMI but associated with poor health
• Overall health depends on addressing both mental
  health and physical health in an integrated
  fashion
• Publicly funded health systems should addresses
  mental illness in the general population
• Start with depression

52
Implications for Medicaid

• Medicaid/SMHA populations have high degree of
  complexity. Needs span multiple traditional
  service sectors. Need for integrated approach.
• Integration needed at all levels of the public
  system surveillance, reimbursement, programming,
  workforce training

53
Implications for Medicaid

• Support screening and integrated treatment of
  depression in traditional health care settings
• Support screening and treatment of health
  conditions among persons treated by specialty
  mental health

54
Implications for Public Health

• Support ongoing inclusion of MH modules in BRFSS
• Develop depression screening and awareness tools
  linked to health risk and chronic disease
  programming
• Include mental health objectives in Healthy Maine
  2020

55
Implications for SMHA

• Expand programming to SMI population to include
  attention to health and wellness
• Expand role of SMHA to include persons with less
  disabling forms of Mental Illness
• Partner with state Public Health and Medicaid to
  support integration of mental health into health
  policy and programming

56
Attending to health and wellness for persons with
SMI

• Start with surveillance if you dont measure
  it, you wont manage it
• Keep it simple History of smoking, alcohol use,
  major chronic diseases
• Track BMI, Blood Pressure, glucose and lipids
• Integrate health surveillance into current
  activities ISP development, med management,
  consumer survey, outcome measures

57
Elsie Freeman, MD, MPH Medical Director,
Behavioral Health DHHS Office of Quality
Improvement Services E-mail elsie.freeman_at_maine.g
ov Jay Yoe, PhD Director DHHS Office of Quality
Improvement Services E-mail jay.yoe_at_maine.gov