1 How far we’ve come Integrating Primary & Behavioral Healthcare

My Background  Medicaid Director  Previously DMH Medical Director – 20 years –Practicing Psychiatrist –CMHCs – 10 years –FQHC – 18 years  Distinguished Professor, Missouri Institute of Mental Health, University of Missouri St. Louis 2

Life Expectancy 3 Bar 1 & 2: Druss BG, Zhao L, Von Esenwein S, Morrato EH, Marcus SC. Understanding excess mortality in persons with mental illness: 17-year follow up of a nationally representative US survey. Med Care June;49(6): Bar 3; Daumit GL, Anthony CB, Ford DE, Fahey M, Skinner EA, Lehman AF, Hwang W, Steinwachs DM. Pattern of mortality in a sample of Maryland residents with severe mental illness. Psychiatry Res Apr 30;176(2-3):242-5

What are the Causes of Morbidity and Mortality in People with Serious Mental Illness?  88% of the deaths and 83% of premature years of life lost in persons with serious mental illness are due to “natural causes” –Cardiovascular disease –Diabetes –Respiratory diseases –Infectious diseases

Decline (%) Noncardiovascular Disease Coronary Heart Disease (CHD) Stroke Morbidity and Mortality Weekly Report. 1999; 48(30): Change in US General Population Age- Adjusted Mortality ( ) 5 Year

Mortality Risk From all causes and cardiovascular disease increased in patients with schizophrenia between Test for time trends of excess relative risks for SMRs were statistically significant (P<0.001) for all causes of mortality due to cardiovascular disease. Men Women Ösby U et al. BMJ. 2000;321: , and unpublished data courtesy of Urban Osby. All causes Cardiovascular Disease

Maine Study Results Comparison of health disorders between SMI & Non-SMI groups 7

Comparison Metabolic syndrome prevalence in fasting CATIE & matched NHANES III subjects 8 Meyer et al., Presented at APA annual meeting, May 21-26, McEvoy JP et al. Schizophr Res. 2005;80:19-32.

The CATIE Study At baseline investigators found that:  88.0% of subjects who had dyslipidemia  62.4% of subjects who had hypertension  30.2% of subjects who had diabetes were NOT receiving treatment. 9

Causes of Excess Mortality Smoking Obesity Inactivity Polypharmacy Under-diagnosis of medical conditions Inadequate medical treatment 10

Per Member Per Month Costs 11 Melek et. al, Milliman, Inc., 2013

MH/SU costs in NY state’s Medicaid program 12

Recovery for persons with serious mental illness (SMI) CMHC Mission 13

CMHC Problem 14 Early death from physical illness prevents recovery from SMI

Big Trends  Increased coverage  Increased demand  Focus of high utilizers  Increased desire for integration by payers  Shrinking psychiatric workforce 17

Drivers of Increased Demand  ACA requires newly covered populations meet the parity requirements of Wellstone Domenici Parity Act  Multiple parts of ACA require or incentivize integration of Behavioral Health and general medical care  ACA insurance reforms and coverage expansions provide new coverage many people need and want BH services  Stigma continues to drop releasing pent up demand  In responding to recent press coverage of mass shootings increasing mental health services is more popular than gun control 18

So, what to do…  There is NO one magic bullet  Integration of behavioral health and primary care  Team care with everyone working at the top of their training  Population health management  Health care delivery based on deep partnerships 19

4 Strategies 1.Coordination of care –EHR, CyberAccess, PROACT, and Missouri Health Connection –Care management – CMHC & FQHC as Health Homes 2.Co-Location/Integration of primary and behavioral healthcare – CMHC/FQHC partnering and Health Homes 3.Medical disease management including for persons with mental illness 4.BH interventions for medical risks –Obesity/activity –Smoking –Screening for prevention and treatment 20

CMHC Health Home Performance Progress 21 LDL, A1C, and Blood Pressure

Outcomes | LDL Levels  10% ↓ in LDL level  30% ↓ in cardiovascular disease

Outcomes | A1C Levels 1 point drop in A1c  21% ↓ in diabetes-related deaths  14% ↓ in heart attack  31% ↓ in microvascular complications

Outcomes | Hypertension and Cardio 34% 41%

Outcomes | Diabetes 37%42% 46%

Outcomes | Metabolic Syndrome Screening 74%

Outcomes | Reducing Hospitalization % of patients with at least 1 hospitalization (non-duals, 9+ attestations)

CMHC Hospital Days Per 1000 Member Month

CMHC ER Visits Per 1000 Member Month (attestation method)

Initial Estimated Cost Savings After 18 Months 30  PC Health Homes –23,354 persons total served (includes Dual Eligibles) –Cost decreased by $30.79 PMPM –Total cost reduction $7.4 M  CMHC Health Homes –20,031 persons total served (includes Dual Eligibles) –Cost decreased by $76.33 PMPM –Total cost reduction $15.7 M

What Makes it Possible?  A Relationship of basic trust between: –Department of Mental Health –MO HealthNet (Medicaid) –State Budget Office –MO Coalition of CMHCs –MO Primary Care Association  Transparent use of data instead of anecdotes to explore and discuss issues  Willingness of all partners to tolerate and share risk  Principled negotiation and Motivational Interviewing

Partnership Principles DO  Ask about their needs first  Give something  Assist wherever you can  Make it about the next 10  Pursue common interest  Reveal anything helpful  Take one for the team DON’T  Talk about your need first  Expect to get something  Limit assistance to a project  Make it about this deal  Push a specific position  Withhold information  Let them take their lumps

 Character –Talk Straight –Demonstrate Respect –Create Transparency –Right Wrongs –Show Loyalty  Competence –Deliver Results –Get Better –Confront Reality –Clarify Expectations –Practice Accountability  Character & Competence –Listen First –Keep Commitments –Extend Trust S.M.R. Covey, The Speed of Trust Behaviors that Promote Trust

Resources NASMHPD Technical Reports Healthcare Home Source documents page Missouri CMHC Healthcare Homes