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

2. 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

3. National Prevalence of Behavioral Illness 25% CDC; 2011

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

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

6. 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

8. REGIONAL PREVALENCE OF MENTAL ILLNESS

9. 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.

14. ADOLESCENT MENTAL HEALTH

15. Data Source: Monroe County Youth Risk Behavior Survey, 2011

16. HEALTH CARE UTILIZATION AMONG INDIVIDUALS WITH BEHAVIORAL HEALTH ISSUES

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

22. Data Source: Regional Multi-payer claims database

23. 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

26. EVIDENCE OF SUBOPTIMAL CARE

27. 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)

28. 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; 2007 2.DHHS; 1999 3.Wang, et al; 2006 4.Levit, et al; 2008

29. 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

30. 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

31. Number of Visits with a 60 Day Readmit % of All Visits with a Readmission 1 Heart Disease 284214.6 2 Mental Disorders 15788.1 3 COPD 10615.4 4 Symptoms (i.e.- Chest pain) 9594.9 5 Bacterial Disease (i.e.- Septicemia) 9564.9 6 Pneumonia/Flu 8474.3 7 Other Diseases Of Digestive System 8154.2 8 Complications Of Surgical And Medical Care, Not Elsewhere Classified 7944.1 9 Other Diseases Of Urinary System (UTI) 6863.5 10 Diseases Of Other Endocrine Glands (Diabetes) 6693.4 Leading Diagnosis Clusters Associated with a Readmission within 60 Days Finger Lakes Region, 2011 Data Source: NYS Dept. of Health, SPARCS Inpatient file

36. Multivariate Regression: Effect of a Behavioral Health Comorbidity on Risk for Hospital Readmission Finger Lakes Region, 2011 30 Day Readmission60 Day Readmission AORp-value95% CIAORp-value95% CI No Behavioral Health ComorbidityREF Mental Health Condition 1.110.0011.041.18 1.09<0.0011.051.14 Substance Abuse Only 1.050.3640.951.16 1.060.2170.971.17 Serious Mental Health Condition 1.41<0.0011.171.70 1.32<0.0011.131.54 Data Source: NYS Dept. of Health, SPARCS Inpatient file

37. 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

38. 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)99,27529.94 2Mental Disorders23,4167.07 3Acute Respiratory Infections22,1076.67 4Back Pain21,8146.58 5Urinary System Diseases (UTI)14,5414.39 6COPD11,6023.5 7Ear Infections10,4253.14 8 Diseases Of Oral Cavity, Salivary Glands, And Jaws 10,0683.04 9Skin Infection8,6722.62 10Headache/Migraine8,3632.52 Data Source: NYS Dept. of Health, SPARCS Inpatient file

39. * 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

42. 30 Day Repeat Visit60 Day Repeat Visit AORp-value95% CIAORp-value95% CI No Behavioral Health Diagnosis REF Behavioral Health Comorbidity 1.38<0.0011.341.421.39<0.0011.361.43 Behavioral Health Primary Diagnosis 1.66<0.0011.611.711.66<0.0011.611.71 Multivariate Regression: Effect of a Behavioral Health Diagnosis on Risk for a Repeat ED Treat and Release Visit

43. 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

44. 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

45. Questions

46. Data Source: Monroe County Youth Risk Behavior Survey

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

55. Healthcare Spending Roehrig, Miller, Lake, Bryant; 2009