Finger Lakes Health Systems Agency Interface of the Physical and Mental Health Care Systems RCCHI Meeting December 18, 2013

Definitions Behavioral Health –Mental illness –Substance abuse –Exclude dementia and developmental disabilities Serious Mental Illness –Psychoses (i.e.- schizophrenia, bipolar disorder) –Major depression –PTSD Primary vs. Secondary Diagnoses Not Health Behaviors

National Prevalence of Behavioral Illness 25% CDC; 2011

Prevalence of Behavioral Illness Among General Medical Outpatients 25-40% Kathol et al; 2006

Prevalence of Behavioral Illness Among Medical Inpatients >40% Kathol et al; 2006

Mental Illness and Physical Health Mental illness increases risk for a variety of medical conditions –Obesity –Cardiovascular disease –Gastrointestinal disorders –Diabetes –HIV –Pulmonary Disease –Hypertension –Cancer Dickey, et al; 2002 Jones, et al; 2004 Pandiani, Boyd, Banks, Johnson; 2006

REGIONAL PREVALENCE OF MENTAL ILLNESS

Q3a. Percent of adults experiencing poor physical health 14 or more days in the past month. Data from NYS Dept. of Health, Expanded Behavioral Risk Factor Surveillance System Q4a. Percent of adults experiencing poor mental health 14 or more days in the past month.

ADOLESCENT MENTAL HEALTH

Data Source: Monroe County Youth Risk Behavior Survey, 2011

HEALTH CARE UTILIZATION AMONG INDIVIDUALS WITH BEHAVIORAL HEALTH ISSUES

Data Source: NYS Dept. of Health, SPARCS Inpatient file

Data Source: Regional Multi-payer claims database

Summary Behavioral health issues are prevalent –Especially among the inpatient population Not an issue limited to adults Mental illness, substance abuse, and physical illness do not occur in isolation The presence of behavioral health issues are associated with increased health care utilization

EVIDENCE OF SUBOPTIMAL CARE

Diagnosis of Behavioral Health Issues Primary care as gate-keeper –Evidence that behavioral health issues are often un- or misdiagnosed in a primary care setting (e.g.- Kroenke, et al. 2007; Vermani, et al. 2011)

Treatment of Behavioral Health Issues Unmet mental health needs: –60% of adults with a diagnosable conditions 1 –70% of children in need of treatment 2 54% of people with mental health issues receive no specialty treatment 3 90% of individuals over the age of 12 with a substance abuse condition do not receive specialty treatment 4 1.Druss, Wang, Sampson; DHHS; Wang, et al; Levit, et al; 2008

Treatment of Medical Conditions High rates of non-treatment for chronic conditions like diabetes, hypertension, high cholesterol, metabolic syndrome, and dental health issues for individuals with serious mental illness Nasrallah, et al; 2006 DeHert, et al; 2011

Hospital Readmissions “Avoidable readmissions are a strong indicator of a fragmented health care system that too often leaves discharged patients confused about how to care for themselves at home, and unable to follow instructions and get the necessary follow-up care.” - Ness and Kramer Health Affairs Blog, 2013

Number of Visits with a 60 Day Readmit % of All Visits with a Readmission 1 Heart Disease Mental Disorders COPD Symptoms (i.e.- Chest pain) Bacterial Disease (i.e.- Septicemia) Pneumonia/Flu Other Diseases Of Digestive System Complications Of Surgical And Medical Care, Not Elsewhere Classified Other Diseases Of Urinary System (UTI) Diseases Of Other Endocrine Glands (Diabetes) Leading Diagnosis Clusters Associated with a Readmission within 60 Days Finger Lakes Region, 2011 Data Source: NYS Dept. of Health, SPARCS Inpatient file

Multivariate Regression: Effect of a Behavioral Health Comorbidity on Risk for Hospital Readmission Finger Lakes Region, Day Readmission60 Day Readmission AORp-value95% CIAORp-value95% CI No Behavioral Health ComorbidityREF Mental Health Condition < Substance Abuse Only Serious Mental Health Condition 1.41< < Data Source: NYS Dept. of Health, SPARCS Inpatient file

Emergency Department Utilization Emergency Department –High cost –Not well suited to delivering continuous primary care Avoidable use of this care setting has been used as an indicator for inadequate access to primary care and poor care coordination Christakis, et al; 2001 Gill, Mainous, Nsereko; 2000 Sarver, Cydulka, Baker; 2002

Leading Causes of Non-Injury Related ED Treat and Release Visits Finger Lakes Region, 2011 RankDiagnosis Cluster# of Visits % of Total Non- Injury T&R Visits 1 Symptoms (chest pain, abdomen pain)99, Mental Disorders23, Acute Respiratory Infections22, Back Pain21, Urinary System Diseases (UTI)14, COPD11, Ear Infections10, Diseases Of Oral Cavity, Salivary Glands, And Jaws 10, Skin Infection8, Headache/Migraine8, Data Source: NYS Dept. of Health, SPARCS Inpatient file

* Indicates statistically significant difference from the No BH Diagnosis Group at the p<0.05 level Data Source: NYS Dept. of Health, SPARCS Inpatient file

30 Day Repeat Visit60 Day Repeat Visit AORp-value95% CIAORp-value95% CI No Behavioral Health Diagnosis REF Behavioral Health Comorbidity 1.38< < Behavioral Health Primary Diagnosis 1.66< < Multivariate Regression: Effect of a Behavioral Health Diagnosis on Risk for a Repeat ED Treat and Release Visit

Health Outcomes People with serious mental illness die, on average, 25 years earlier than their age cohorts in the general population The presence of comorbid mental illness increases the risk of mortality for individuals with a variety of chronic diseases Parks, et al; 2006 Phillips, et al; 2009 Williams, Ghose, Swindle; 2004

Conclusions Evidence that individuals with behavioral health issues are not being treated optimally –Bidirectional The local experience seems to be consistent with national findings Suboptimal care has real impacts –Health of the community –Efficiency of the health care system

Questions

Data Source: Monroe County Youth Risk Behavior Survey

Data Source: NYS Dept. of Health, SPARCS Inpatient file

Healthcare Spending Roehrig, Miller, Lake, Bryant; 2009