1. Chronic Mental Illness & Chronic Disease: A Problem of Unmet Need Jacqueline Mosley, MPH, MSN, ACNP-BC

2. Case Study 42 year-old, AA male presents to ED with c/o SOB, fever, cough, purulent sputum production x 6 days.  PMHx: NIDDM, HTN, HLD, Obesity, Schizophrenia, Tobacco Dependence  Social Hx: Construction worker (unemployed past 3 months), single, lives alone, 30 pyh.  Family Hx: DM, HTN, CAD, Stroke, Cancer  Destination: Medical ICU, Mechanical Ventilation d/t CAP, complicated by ARDS, ARF, ICU Delirium  LOS 24 days (19 days ICU, 5 days Med-Surg)  Post-hospital discharge and aftercare??????

3. Background & Significance  Disproportionate Chronic Disease Burden  Higher prevalence of leading chronic disease  Higher mortality rates 2/2 chronic disease  Premature death and years of lost productivity  Inadequate Healthcare Service Utilization  Not enough primary and preventative care  Too much acute care => ED visits & hospitalizations  Costs, Costs, Costs $$$$$$$$$$$$$$$$$$$$$$$  Actual healthcare dollars  Patient quality of life  Societal

4. Empirical Model  Health it = β 0 + β 1 unmet need it + β 2 age it + β 3 utilization it + β 4 lifestyle factors i + β 5 SES i + β 6 race i + β 7 gender i +ε it

5. Paper #1: Epidemiologic Analysis  Aim: To generate national estimates of physical disease prevalence, related mortality, & the consequences of both  Analytic Approach  Data Source: National Health Interview Survey  Methods: Epidemiologic calculations, e.g., Odds Ratio of T2DM in persons w/chronic mental illness compared to general population; leading causes of death among minority SMI patients; YPLL due to untreated chronic disease  Significance: We DO NOT have NATIONAL estimates, so truly, what is the MAGNITUDE of this problem?  How are minority populations who are predisposed to higher rates of certain chronic diseases impacted by comorbid mental and physical illness?

6. Paper #2: Healthcare Utilization Patterns  Aim: To illustrate utilization patterns in a national sample of persons with SMI  Analytic Approach  Data: (a) patient interviews => perceived need, HRQoL, (b) National Hospital Discharge Survey => hospitalization rates r/t chronic disease in persons with SMI compared to non-SMI  Methods: (a) structured interviews, (b) rate calculations (c) probit regression analysis  Significance: We do NOT have NATIONAL estimates of utilization patterns & we have not documented challenges around access & quality that incorporate patients’ perspectives

7. Paper #3: Health Determinants & Cost Analysis  Aim: To estimate costs associated with inadequate care & to estimate potential program costs associated with integrated care delivery  Analytic Approach  Data: Existing annual cost estimates for T2DM in the US  Predictors of healthcare service utilization  Logistic Regression Analysis  Using epidemiologic rates from Paper #1, extrapolate excess costs attributable to comorbid SMI & T2DM  Cost-Outcome Tables  Simulate cost & potential benefits/savings derived from integrated health delivery program  Markov State-Transitions Model  Significance: Translate Research to PRACTICE…

8. Pulling It All Together (I hope…)

9. Why Bother? 1.What do “we” really know about this problem? 2.How do we make the best use of existing data and make a case for collecting better data? 3.How do we translate clinical insight that we gain in our organizations and communities to language that decision-makers understand? 4.In other words, how to move beyond research for the sake of research????

10. Theoretical Framework  Andersen’s “Determinants of Medical Care Utilization”  i.e., what are the forces/factors that motivate an individual to seek medical care?  What forces/factors prohibit an individual from seeking care???  Grossman’s Model of Health Production  How do individuals “produce” health, or fail to produce health, as a commodity that allows them to participate in the exchange of healthcare services for health?  What is the value of “health” to society as a whole, i.e., what are we losing by not providing adequate care and treatment to vulnerable populations?

11. Questions…Comments???