Physical Health – Behavioral Health Integration 04/25/12 - Pocono Medical Center Richard Silbert, M.D. Senior Medical Director Community Care A Non-profit Behavioral Health Managed Care Company In partnership with

2 AHEC Area Health Education Center Enhancing access to health care through education Community experiences for health professions’ students Promoting Health Careers Preceptor / health practitioner support Support of community partners

About Community Care Incorporated in 1996 primarily to support HealthChoices. Part of the UPMC Insurance Services Division. 501(c)(3) nonprofit behavioral health managed care organization. Licensed as risk bearing PPO. Implemented HealthChoices in: – Allegheny County (1999). – York, Adams, and Berks Counties (2001). – Chester County (2004). – Lackawanna, Luzerne, Susquehanna, and Wyoming Counties (2006). – 23-County North Central Region (2007). – Carbon, Monroe, and Pike Counties (2007). – Erie County (2011) Implemented a Care Monitoring Initiative in New York City (2009). 3

About Community Care Experience with full-risk, shared-risk, and Administrative Services Only (ASO) contracts. – 6 contracts with 9 counties, 1 contract with a consortium (representing 4 counties), 1 contract directly with DPW (representing 23 counties), and 1 contract with the New York State Office of Mental Health/New York City Department of Health and Mental Hygiene. “Full” NCQA accreditation for Medicaid product (Perfect score). Recipient of the Moffic Ethics Award from the American Association of Community Psychiatrists. 4

5 PA Counties Served by Community Care County Served by Community Care Community Care Office

6 Community Care Mission and Vision To improve the health and well- being of the community through the delivery of effective and accessible behavioral health services. To improve the quality of services for members through a stakeholder partnership focused on outcomes. To support high quality service delivery through a not-for-profit partnership with public agencies, experienced local providers, and involved members and families.

Our Objectives 1. Review interactions between medical and mental disorders 2. identify why morbidity and mortality are greater in Serious Mental Illness (SPMI), even excluding suicide attempts and completions. 3. Show improved outcomes when both Physical Health and Behavioral Health efforts are coordinated. 4. Several examples of initiatives aimed at earlier identification of individuals at high risk with both physical health and behavioral health disorders will be presented together with description of efforts to promote wellness 5. Participants will be able to better identify resources to utilize when their patients are in need of case management for coordinated care

Collaboration with APS Developing methods to identify members with serious mental illnesses who have concurrent physical health problems Process for joint care management services for members who need integrated physical and behavioral health services Joint educational efforts to insure behavioral and physical health providers are aware of resources and how to access them 8 BH MCO Goals

- 9 - Moving Towards PH/BH Coordination © 2011 Community Care Include PH in Recovery Goals Educate Consumers/Providers about risk for having PH and BH problems WHY? Lack of collaboration for PH and BH clients Need for better quality of life BH providers & clients not usually focused on PH factors ACES exposure leads to BH and PH problems Need to include substance abuse in PH & BH healthcare

What Do We Know about PH in SMI population? People with serious behavioral illness die earlier than the general population. People without SMI who have risk factors common to SMI (i.e. smoking, poverty, homelessness, obesity) also die much earlier than the general population Our behavioral and physical health systems have failed to systematically address and support prevention and wellness across all populations, especially those which suffer from socioeconomic disadvantages National Association of State Mental Health Program Directors (NASMHPD) Medical Directors Council. (2006). Morbidity and Mortality in People with Serious Mental Illness. Alexandria, VA.

Inadequate Access to Physical Health Care Lack of capacity Stigma and discrimination Poor quality and poor provision of services in some areas and/or less efficacious use Lack of adequate health care coverage (in some areas) Monitoring and treatment guidelines are underutilized with the SMI population (as they are in most populations) National Association of State Mental Health Program Directors (NASMHPD) Medical Directors Council. (2006). Morbidity and Mortality in People with Serious Mental Illness. Alexandria, VA.

58% of Adults: People with Medical Problems 25% of Adults: People with Mental D/O 68% of adults with Mental d/o have medical conditions 29% of adults with Medical D/O have mental disorders National Comorbidity Survey Replication

Mental Health-Physical Health 2 nd Report on Health Care Quality 50% see PCP 1/3 make 1 visit Higher risk for PH disease 17% NO visits 13% Both PCP & MH 5% MH Only

Major Depression Chronic Pain % Stroke % Multiple PH problems 23% Heart Disease 15-20% DM %

Impact of Medications Overweight and obesity Insulin resistance Diabetes and hyperglycemia Dyslipidemia Modifiable risk factors affected by psychotropics include: National Association of State Mental Health Program Directors (NASMHPD) Medical Directors Council. (2006). Morbidity and Mortality in People with Serious Mental Illness. Alexandria, VA.

Obesity Obesity among persons with serious mental disorders is greater than among the general population Increased incidence of Metabolic Syndrome in SMI population Obesity in individuals with mental disorders attributed to a number of factors: a sedentary lifestyle poor nutritional choices lack of access to healthy food (which is also associated with poverty) the effects of both the mental disorder itself and the medications used to treat it lack of access to adequate preventative medical care National Association of State Mental Health Program Directors (NASMHPD) Medical Directors Council. (2006). Morbidity and Mortality in People with Serious Mental Illness. Alexandria, VA. Citromea, L., Vreeland, B., Obesity and Mental Illness. Thakore J, Leonard BE (eds): Metabolic Effects of Psychotropic Drugs. Basel, Karger, 2009, vol 26, pp

Smoking Higher prevalence (56-88% for patients with schizophrenia) of cigarette smoking (up to 25% of all cigarettes sold in US) More toxic exposure for patients who smoke (more cigarettes, larger portion consumed) Smoking is associated with increased insulin resistance Similar prevalence in bipolar disorder Smoking cessation may be the modifiable risk factor that is likely to have the greatest impact on decreasing mortality George TP et al. Nicotine and Tobacco Use in Schizophrenia. In: Meyer JM, Nasrallah HA, eds. Medical Illness and Schizophrenia. American Psychiatric Publishing, Inc. 2003; Ziedonis D. Williams JM, Smelson D. Am J Med Sci (Oct); 326(4):

Medical Comorbidities Medical Harm of Hazardous Drinking Hazardous drinking is associated with an increased risk for: – All-cause mortality – Hypertension – Cardiomyopathy – Diabetes – Trauma – Stroke – More serious alcohol disorders – Cancers particularly upper GI and breast cancers Figured from Babor et al (World Health Organization), AUDIT Guidelines for Use in Primary Care, 2001

Childhood Adversity Loss Abuse & Neglect Household dysfunction Stress Adverse Life Events Chronic Stressors SES Poverty Neighborhood Social support Isolation Adverse Health Outcomes: Obesity, smoking, poor self care, disability Chronic Medical D/O Mental D/O RWJ Synthesis Project 2/2011

Types of Stress POSITIVE STRESS Part of normal development Brief increased HR, and hormone changes e.g. cramming for a test TOLERABLE STRESS Stress response may affect brain; stopped with good support Allows brain to recover e.g. death of a loved one or disaster TOXIC STRESS Prolonged activation of stress response Impact on brain and body e.g. recurrent physical, sexual, or emotional abuse

Health Consequences of Chronic Stress SAM   BP, heart rate HPA  immuno- suppression

Relationship Between Number of Adverse Childhood Experiences and Smoking Behaviors and Smoking-Related Lung Disease

Risk Factors for Adult Heart Disease are Embedded in Adverse Childhood Experiences ACEs Source: Dong et al, 2004 Odds Ratio ,67, JACK P. SHONKOFF, M.D. DIRECTOR, CENTER ON THE DEVELOPING CHILD HARVARD UNIVERSITY

CDC Study concluding comment “The mind-body dichotomy that persists in Western medical training may lead clinicians away from understanding the role that childhood trauma and stress has on the health of their adult patients.…understanding the role of these childhood experiences on adult health will become increasingly important in making decisions about prognosis, diagnosis and treatment.” CDC research group (2008) BMC Public Health 8:198.

Improving Care Delivery Behavioral Health Home to Foster Collaboration Supporting Coordination of BH, PH, and SA Prevention and Promotion Work on Primary Prevention by targeting risk factors Active Secondary Prevention with health screening in Mental, Medical, and Community Settings

© 2011 Community Care Role of the Behavioral Health Home Provide a person-centered system of care Development of a “virtual team” for each individual Enhance physical health competencies in the BH team Develop person-centered plan with the individual Coordination of physical, behavioral and supportive services Promote health, wellness, recovery, use of personal medicine and self-management

Planned Steps Steps of Hope Program – Enhances Members’ quality of life by providing guidance, assistance, and support for their recovery journey; fosters hope. – Provides a Member-centric focus (as opposed to disease-centric) to contacts, materials, and interventions. – Imparts knowledge about recovery, knowing that knowledge is accompanied by responsibility. Program materials are carefully prepared or selected to ensure that they are recovery-oriented and Member-centered. Includes strategies to help Members with communication skills for talking to: Psychiatrists and primary care physicians, other service providers. family, friends, and other supports.

Member Interventions Members in the highest stratification group (actively engaged in the program) are assigned a “Specialized Care Manager” who: – Ensures that a crisis plan is in effect after an inpatient stay. – Makes quarterly follow-up calls to Members in order to provide support and assistance for living in the community.

Goals of PH/BH Integration at the Provider Level Development of a true Clinical Home – BH treatment options in PH settings for non-SMI consumers. – PH monitoring/coordination for SMI consumers in MH settings. – Management of the same issues that obstruct coordination of other specialties. Inclusion of PH in Recovery Goals/WRAP plans – Need to improve PH of SMI consumers. – Not the usual focus of BH treatment (tobacco cessation, weight management).

Information Line for Practitioners Primary care physicians and other health care practitioners can call the information line with questions about diagnostic criteria and psychiatric medications. Community Care psychiatrists and pharmacists are available 24 hours a day, seven days a week. Answer questions about Community Care members related to medication effects, medication side effects, diagnostic criteria, and treatment resources. 35