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					Central Ohio Integrating Care Network Meeting:

Integrating Primary and Behavioral Healthcare
    for Persons with Severe Mental Illness



                  June 3, 2010
                                           1
Central Ohio Integrating Care Network
               Meeting

        Networking Exercise :

              Report!


                                        2
                   Welcome!
          Dr. Radu Saveanu, M.D.
Chairman, Department of Psychiatry, & Executive Director,
                OSU Harding Hospital

                          and

        Dr. Marion Sherman, M.D.
Medical Director, Ohio Department of Mental Health

                                                       3
           3 areas of responsibility:
•Tools
•Infrastructure
•Advocacy

                  www.occic.org
                                        4
   Integrated Care Overview:

       Need and Solutions


(Thanks to Dr Svendsen for the data slides!)




                                               5
   Why Should we be Concerned About
        Morbidity and Mortality?

• Data from several states have found that
  people with serious mental illness served by
  our public mental health systems die, on
  average, at least 25 years earlier than the
  general population!



                                                 6
   Multi-State Study Mortality Data: Years of
               Potential Life Lost
             Year    AZ     MO     OK     RI     TX     UT     VA (IP
                                                                only)

             1997           26.3   25.1          28.5
             1998           27.3   25.1          28.8   29.3    15.5
             1999    32.2   26.8   26.3          29.3   26.9    14.0
             2000    31.8   27.9          24.9                  13.5



 • Compared to the general population, persons with
   major mental illness typically lose more than 25
   years of normal life span

Colton CW, Manderscheid RW. Prev Chronic Dis [serial online] 2006 Apr [date
cited]. Available from: URL:http://www.cdc.gov/pcd/issues/2006/apr/05_0180.htm
                                                                             7
           Ohio Study-1998-2002
   Mean Years of Potential Life lost              20,018
persons discharged from an Ohio State Hospital-- 608 deaths
 Cause                                     M       F      N
 All                                     31.8   32.5   32.0
 Intentional self-harm (suicide)         41.4   42.7   41.7
 Assault (homicide)                      42.3   35.8   41.6
 Accidents (unintentional injuries)      39.5   43.1   40.4
 Symptoms, signs, & abnormal             32.8   35.0   33.4
   clinical & laboratory findings, NEC
 Diabetes mellitus                       25.8   37.2   30.2
 Pneumonia & Influenza                   29.4   25.0   28.3
 Diseases of heart                       27.7   26.6   27.3
 Cerebrovascular diseases                20.7   32.8   25.5
 Malignant neoplasms (cancers)           24.3   26.9   25.3
 Chronic lower respiratory diseases      18.6   24.1   21.1   8
 What are the Causes of Morbidity and Mortality in
       People with Serious Mental Illness?


• While suicide and accidents account for 30-40% of
  excess mortality, about 60% of premature deaths
  in persons with schizophrenia are due to “natural
  causes”
   –   Cardiovascular disease
   –   Diabetes
   –   Respiratory diseases
   –   Infectious diseases

                                                      9
Massachusetts Study: Deaths from Heart Disease
by Age Group/DMH Enrollees with SMI Compared
          to Massachusetts 1998-2000

                    40
                                            2.2RR
                          DMH
                    35
                          MA                         1.5RR
Rates per 100,000




                    30
                                  4.9RR
                    25
                    20
                    15
                    10   3.5 RR
                     5
                     0
                          25-34     35-44    45-54   55-64

                                                             10
                        Mortality from Pneumonia/Influenza
                             DMH clients, ages 25-64


                   25
                         21.2                             DMH
                                                          Mass
                   20
Rate per 100,000




                   15                 13.9


                   10                               9.2


                    5           4.2
                                             3.5          3.1


                    0
                           1998         1999         2000

                                                                 11
                        Mortality from Lower Respiratory Disease
                                DMH clients, ages 25-64


                   60
                                                             DMH
                                         50.9
                                                             Mass
                   50
Rate per 100,000




                   40
                            31.8
                   30
                                                      18.5
                   20

                                   7.8          8.1          8.4
                   10

                    0
                              1998         1999        2000



                                                                    12
                        Deaths from Liver Disease and Diabetes
                               DMH and Massachusetts


                   20
                              17.6                            DMH
                   18
                                                              MASS
                   16                            14.6
Rate per 100,000




                   14
                   12
                   10                 9.3
                                                        8.2
                    8
                    6
                    4
                    2
                    0
                             Liver disease        Diabetes

                                                                     13
   Maine Study Results: Comparison of Health
   Disorders Between SMI & Non-SMI Groups
                  80
                                                                                                               SMI (N=9224)
                  70                                                                                           Non-SMI (N=7352)
                       59.4
Percent Members




                  60
                  50
                  40            33.9
                                            30       28.6       28.4
                  30                                                       22.8      21.7
                  20                                                                           16.5
                                                                                                          11.5       11.1
                  10                                                                                                            6.3       5.9

                   0
                          Sk           Ga          Ob         CO        Inf         Hy         De        Di                                   Liv
                               ele        st          es        PD          ec         pe         nt       ab Can         He
                                                                                                                            ar
                                                                                                                                    Pn
                                                                                                                                       eu         er
                                   tal       ro          ity                   tio        rte        al        ete   ce        tD          mo          Di
                                      -C        -In                                us         ns        Di         s    r         ise                     se
                                         on         tes /Dys                          Di         ion      so                          as
                                                                                                                                              nia           as
                                            ne         tin       lip                     se                  rd                          e        /In          e
                                                cti        al        id                     as                  er                                    flu
                                                                                               e                  s                                       en
                                                    ve                                                                                                       za

                                                                                                                                                           14
                 Change in US General Population Age-
                    Adjusted Mortality (1979-1995)
                                                    Noncardiovascular Disease
                10
                 0
  Decline (%)




                -10                                  Coronary Heart Disease (CHD)

                -20
                                                     Stroke
                -30
                -40
                -50
                -60
                      79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95
                                                                  Year
Morbidity and Mortality Weekly Report. 1999; 48(30):649-656.                        15
                                 Mortality Risk From All Causes and From Cardiovascular
                                                 Disease Increased Among
                                   Patients With Schizophrenia Between 1970-2003
                                                            Men                                                                                        Women
Standardized Mortality Ratio




                                3                                                                                            2.5




                                                                                                  Standardized Mortality Ratio
                               2.5                                                                                               2
     Relative Risk for




                                                                                                       Relative Risk for
                                2
                                                                                                                             1.5
                               1.5
                                                                                                                                 1
                                1

                               0.5                                                                                           0.5

                                0                                                                                                0
                                     1970-   1975-   1980-     1985-     1990-    1995-   2000-                                      1970-   1975-   1980-     1985-     1990-    1995-    2000-
                                     1974    1979    1984      1989      1994     1999    2003                                       1974    1979    1984      1989      1994     1999     2003
                                               All Causes    Cardiovascular Disease                                                            All Causes    Cardiovascular Disease




                  Test for time trends of excess relative risks for SMRs were statistically significant (P<0.001)
                  for all cause mortality and mortality due to cardiovascular disease.

                  Ösby U et al. BMJ. 2000;321:483-484, and unpublished data courtesy of Urban Osby.
                                                                                                                                                                                          16
                                     Diabetes and Obesity:
                                    The Continuing Epidemic
                                                    Diabetes
                                                    Mean body weight
                                    7.5                                   78
                   Prevalence (%)



                                    7.0                                   77
                                    6.5                                   76




                                                                               kg
                                    6.0
                                                                          75
                                    5.5
                                                                          74
                                    5.0
                                    4.5                                   73
                                    4.0                                   72
                                      1990   1992   1994 1996   1998   2000
                                                       Year
Mokdad et al. Diabetes Care. 2000;23:1278.
Mokdad et al. JAMA. 1999;282:1519.                                                  17
Mokdad et al. JAMA. 2001;286:1195.
18
BMI Distributions for General Population and
     Those With Schizophrenia (1999)
            30
                 Under-            Acceptable               Overweight      Obese
                 weight


            20




            10




             0
                 < 18.5 18.5-20 20-22 22-24 24-26 26-28 28-30 30-32 32-34 > 34
                                                        BMI Range
                                                                         No schizophrenia
Allison DB et al. J Clin Psychiatry. 1999;60:215-220.
                                                                         Schizophrenia      19
        Prevalence of Diagnosed Diabetes in
            General Population Versus
             Schizophrenic Population
                                     Diagnosed Diabetes, General Population
                                     Diagnosed Diabetes, Schizophrenic Patients


                                30
        Percent of              25
        population              20
                                15
                                10
                       5
                       0
       Schizophrenic: 50-59 y
           General: 50-59 y                             60-69 y
                                                        60-74 y      70-74 y
                                                                      75+ y
Harris et al. Diabetes Care. 1998; 21:518.
Mukherjee et al. Compr Psychiatry. 1996; 37(1):68-73.                             20
Hypothesized Reasons Why There May Be
  More Type 2 Diabetes in People With
             Schizophrenia
• Genetic link between schizophrenia and
  diabetes
• Impact of lifestyle (e.g., smoking)
• Medication effect increasing insulin
  resistance by impacting insulin receptor or
  post receptor function
• Drug effect on caloric intake, expenditure
  (obesity, activity)
                                                21
          Effects of Some Psychotropic
                   Medications
• Weight gain/obesity

• Insulin resistance by impacting insulin receptor or post-
  receptor function

• Antipsychotic use associated with 2X the risk of sudden
  cardiac death*

• Diabetes and hyperglycemia

• Dyslipidemia
   –   Correll.MD et al, “Cardiometabolic Risk of Second-Generation Antipsychotic Medications During
       First-Time Use in Children and Adolescents”, JAMA, Oct., 2009
   –   *Ray et al, Atypical antipsychotic drugs and the Risk of Sudden Cardiac Death NEJM, Jan., 2009

                                                                                                        22
       ADA/APA/AACE/NAASO Consensus on
   Antipsychotic Drugs and Obesity and Diabetes:
               Monitoring Protocol*
                         Start     4 wks    8 wks     12 wk        qtrly   12 mos.   5 yrs.

Personal/family Hx         X                                                   X
Weight (BMI)               X         X         X        X             X
Waist circumference        X                                                   X
Blood pressure             X                            X                      X
Fasting glucose            X                            X                      X
Fasting lipid profile      X                            X                                 X
                                                                           X
 *More frequent assessments may be warranted based on clinical status

                                 Diabetes Care. 27:596-601, 2004                     23
“Metabolic Syndrome”


Special Consideration




                        24
        Comparison of Metabolic Syndrome and Individual
        Criterion Prevalence in Fasting CATIE Subjects and
                   Matched NHANES III Subjects
                                                Males                   Females
                                            CATIE NHANES      p      CATIE NHANES    p
                                            N=509   N=509            N=180  N=180
 Metabolic Syndrome                          36.0%   19.7%   .0001   51.6%   25.1%   .0001
 Prevalence
 Waist Circumference Criterion               35.5%   24.8%   .0001   76.3%   57.0%   .0001

 Triglyceride Criterion                      50.7%   32.1%   .0001   42.3%   19.6%   .0001

 HDL Criterion                               48.9%   31.9%   .0001   63.3%   36.3%   .0001

 BP Criterion                                47.2%   31.1%   .0001   46.9%   26.8%   .0001

 Glucose Criterion                           14.1%   14.2%   .9635   21.7%   11.2%   .0075




Meyer et al., Presented at APA annual meeting, May 21-26, 2005.
McEvoy JP et al. Schizophr Res. 2005;(August 29).
                                                                                         25
   Identification of the Metabolic Syndrome

                                 ≥3 Risk Factors Required for Diagnosis

                                 Risk Factor               Defining Level
                          Abdominal obesity                Waist circumference
                            Men                              >40 in (>102 cm)
                            Women                            >35 in (>88 cm)
                                                               150 mg/dL
                          Triglycerides
                                                            (1.69mmol/L)

                          HDL cholesterol
                                                                <40 mg/dL
                            Men
                                                       (1.03mmol/L)      <50
                            Women
                                                         mg/dL (1.29mmol/L)
                         Blood pressure                     130/85 mm Hg

                         Fasting blood glucose          110 mg/dL (6.1mmol/L)
HDL = high-density lipoprotein.                                                  26
NCEP III. Circulation. 2002;106:3143-3421.
                       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!


Nasrallah HA, et al. Schizophr Res. 2006;86:15-22.
                                                     27
     Many Risk Factors are Modifiable
•   Smoking
•   Alcohol and drug use
•   Poor nutrition / obesity
•   Lack of exercise
•   Medication side effects (Metabolic syndrome)
•   Unsafe sexual behavior
•   IV drug use
•   Inadequate physical healthcare
•   Poverty, homelessness, victimization,
    unemployment, incarceration, social isolation, etc.

                                                          28
                    Cardiovascular risk factors –
                             overview
                                  The Framingham Study                                        5
         14

         12                                               Multiple Risk
                                                            Factors
  Odds ratios




         10                                                                         4

                8

                6         Single Risk Factors                             3
                4                                              2
                2

                0
                    BMI >27 Smoking TC >220 DM      HTN      Smoking   Smoking Smoking        Smoking
                                                              + BMI      + BMI     + BMI        + BMI
                                                                       + TC >220 + TC >220    + TC >220
                                                                                   + DM      + DM + HTN
BMI = body mass index; TC = total cholesterol; DM = diabetes mellitus; HTN = hypertension.
                                                                                      29
Wilson PWF et al. Circulation. 1998;97:1837–1847.
Complete Reversal of CVD Risks is not necessary:
       Partial control has great benefit
• Blood cholesterol
   – 10%  = 30%  in CVD (200-180)
• High blood pressure (> 140 SBP or 90 DBP)
   – 4-6 mm Hg  = 16%  in ; 42%  in stroke
• Cigarette smoking cessation
   – 50%-70%  in CHD
• Maintenance of ideal body weight (BMI = 25)
   – 35%-55%  in CHD
• Maintenance of active lifestyle (20-min walk daily)
   – 35%-55%  in CHD

Hennekens CH. Circulation. 1998;97:1095-1102.
                                                        30
     Mental Disorders and Smoking
• Higher prevalence (56-88% for patients with
  schizophrenia) of cigarette smoking (overall
  U.S. prevalence 20%)
• More toxic exposure for patients who
  smoke (more cigarettes, larger portion
  consumed)
• Smoking is associated with increased
  insulin resistance
• Similar prevalence in bipolar disorder
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;
                                                                                     31
Ziedonis D, Williams JM, Smelson D. Am J Med Sci. 2003(Oct);326(4):223-330
Healthcare for Persons with SMI is Poor
• CATIE Findings

• Fewer preventive services…PAP Smears and
  Colonoscopies (Ohio Medicaid)

• Higher rate of emergency department visits and
  Hospital Admissions (Kaiser, 2004)

• Fewer cardiac diagnostic procedures and less likely to
  receive post MI Rx (Druss BG et al. Arch Gen Psychiatry.
  2001;58:565-572.)


• Worse diabetes care (Desai 2002, Frayne 2006)        32
    Why not just do it? Provide better physical
        healthcare for persons with SMI.

• Through policy and “evolution” behavioral healthcare is
  separated from physical healthcare
   –   Systemic- institutionalized separations
   –   Program- new administrative/clinical resources
   –   Person-level- stigma/access/training


• Fiscal barriers – separate billing/benefits/ new services/ rates/
  infrastructure/ start-up


• The likelihood of people with SMI successfully seeking
  coordinated physical healthcare in another location is low
                                                                 33
34
  What’s Ohio Doing?
•ODMH/OCCIC
•Foundations
•Policy Work
•Program Examples



                       35
     Integrating Primary Care and
           Behavioral Health
• Ohio Behavioral Health Providers are developing
  integrated care initiatives (from 8 to 50+)

• High healthcare cost of people with a serious mental
  illness and another physical health condition will
  drive integration

• Behavioral Health is becoming part of healthcare
  (operational/fiscally)
                                                     36
   Ohio is Embracing the Medical
           Home Concept
• Governor’s Ohio Health Care Coverage and Quality
  Council task forces:
   – Patient Centered Medical Homes
   – Informed and Activated Patients
   – Health IT
   – Payment Reform

• Benefits package/redefinition of SMD/SED

                                                     37
       What is a “Medical Home” ?
Joint Principles of the Patient-Centered Medical Home
(American Academy of Family Physicians, American Academy of Pediatrics, American
            College of Physicians, and American Osteopathic Association)


1. Personal physician: “…ongoing relationship
   ..continuous and comprehensive care…"

2. Physician directed medical practice: " leads a team
   take responsibility for the ongoing care ..."

3. Whole person orientation: "responsible for all the
   patient’s healthcare needs or arranging care..."
                                                                               38
 Joint Principles of the Patient-Centered Medical
                    Home, cont.
4. Care is coordinated and/or integrated “…across
   specialists, hospitals, home health, and nursing
   homes...”

5. Quality and safety “are assured by evidence-based
   medicine, …tools, measurement, …information
   technology, a, quality improvement activities...”

6. Enhanced access “to care is available …”

7. Payment "appropriately recognize…."
                                                       39
         NCQA Certification Standards:
        Patient Centered Medical Home
          PPC-PCMH Content and Scoring
Standard 1: Access and Communication                        Pts   Standard 5: Electronic Prescribing                      Pts
A.   Has written standards for patient access and patient         A.   Uses electronic system to write prescriptions      3
     communication**                                        4     B.   Has electronic prescription writer with safety     3
B.   Uses data to show it meets its standards for patient   5          checks
     access and communication**                                   C.   Has electronic prescription writer with cost       2
                                                            9          checks
                                                                                                                          8
Standard 2: Patient Tracking and Registry Functions         Pts
A.   Uses data system for basic patient information               Standard 6: Test Tracking                               Pts
     (mostly non-clinical data)                             2     A.   Tracks tests and identifies abnormal results       7
B.   Has clinical data system with clinical data in                    systematically**
     searchable data fields                                 3     B.   Uses electronic systems to order and retrieve      6
C.   Uses the clinical data system                          3          tests and flag duplicate tests
D.   Uses paper or electronic-based charting tools to                                                                     13
     organize clinical information**                        6     Standard 7: Referral Tracking                           PT
E.   Uses data to identify important diagnoses and          4     A.   Tracks referrals using paper-based or electronic   4
     conditions in practice**                                          system**
F.   Generates lists of patients and reminds patients and   3                                                             4
     clinicians of services needed (population                    Standard 8: Performance Reporting and                   Pts
     management)                                            21
                                                                       Improvement
Standard 3: Care Management                                 Pts   A.   Measures clinical and/or service performance       3
A.   Adopts and implements evidence-based guidelines        3          by physician or across the practice**
     for three conditions **                                      B.   Survey of patients’ care experience                3
B.   Generates reminders about preventive services for      4     C.   Reports performance across the practice or by      3
     clinicians                                                        physician **
C.   Uses non-physician staff to manage patient care        3     D.   Sets goals and takes action to improve             3
D.   Conducts care management, including care plans,        5          performance
     assessing progress, addressing barriers                      E.   Produces reports using standardized measures       2
E.   Coordinates care//follow-up for patients who           5     F.   Transmits reports with standardized measures       1
     receive care in inpatient and outpatient facilities               electronically to external entities
                                                            20                                                            15

Standard 4: Patient Self-Management Support                 Pts   Standard 9: Advanced Electronic Communications          Pts
A.   Assesses language preference and other                 2     A.   Availability of Interactive Website                1
     communication barriers                                 4     B.   Electronic Patient Identification                  2
B.   Actively supports patient self-management**                  C.   Electronic Care Management Support                 1
                                                            6
                                                                                                                          4
                                                                                               **Must Pass Elements
                                                                                                                                40
How can Behavioral Health Providers
      be a Medical Home”?


 Person-Centered Healthcare Home:

Integrated Care with Behavioral Health
   Provider as part of Medical Home

         www.thenationalcouncil.org
                                      41
                                                   The Four Quadrant Clinical Integration Model

                                                                   Quadrant II                                                 Quadrant IV
                                                                  BH PH                                                 BH PH 

                                                         Behavioral health clinician/case                         PCP (with standard screening tools
                                                          manager w/ responsibility for                             and guidelines)
                                                          coordination w/ PCP                                      Outstationed medical nurse
                                                         PCP (with standard screening                              practitioner/physician at
High
                                                          tools and guidelines)                                     behavioral health site
                                                         Outstationed medical nurse                               Nurse care manager at behavioral
                                                          practitioner/physician at                                 health site
       Behavioral Health (MH/SA) Risk/Complexity

                                                          behavioral health site                                   Behavioral health clinician/case
                                                         Specialty behavioral health                               manager
                                                         Residential behavioral health                            External care manager
                                                         Crisis/ED                                                Specialty medical/surgical
                                                         Behavioral health inpatient                              Specialty behavioral health
                                                         Other community supports                                 Residential behavioral health
                                                                                                                   Crisis/ ED
                                                                                                                   Behavioral health and
                                                                                                                    medical/surgical inpatient
                                                                                                                   Other community supports
                                                         Persons with serious mental illnesses could be served in all settings. Plan for and deliver
                                                                                                              
                                                         services based upon the needs of the individual, personal choice and the specifics of the
                                                         community and collaboration.

                                                                   Quadrant I                                                  Quadrant III
                                                                  BH PH                                                 BH PH 

                                                         PCP (with standard screening                             PCP (with standard screening tools
                                                          tools and behavioral health                               and behavioral health practice
                                                          practice guidelines)                                      guidelines)
                                                         PCP-based behavioral health                              PCP-based behavioral health
                                                          consultant/care manager                                   consultant/care manager (or in
                                                         Psychiatric consultation                                  specific specialties)
                                                                                                                   Specialty medical/surgical
                                                                                                                   Psychiatric consultation
                                                                                                                   ED
                                                                                                                   Medical/surgical inpatient
                                                                                                                   Nursing home/home based care
                                                                                                               
Low




                                                                                                                    Other community supports

                                                                               Physical Health Risk/Complexity                                                42
                                Low                                                                                                                    High
     Person-Centered Healthcare Home
3 points along a “continuum”:
Least complex:
•Coordination/Collaboration: Behavioral Health
Provider as specialty care and linkage

•Partnership: Behavioral Health Provider in
structured partnership

Most Complex:
•“Single Provider”: Behavioral Health Provider as
“vertically integrated” medical home                43
PCHCH for People with SMI: Coordination

• Identified PCP
• Clear communication/coordination
  mechanisms
• Regular screening
• A registry tracking/outcome system
• Education, provision and linking with
  prevention and wellness                 44
 PCHCH for People with SMI: Partnership

• Locus is either/both PC/BH
• A PC Physician/Nurse Practitioner within the
  full scope healthcare home in clinic
• Nurse care managers to
  support/coordinate/collaborate
• Regular screening and a registry
• Use of evidence based practices
• Education, provision and linking with
  prevention and wellness                   45
The Person-Centered Healthcare Home for
     People with SMI: Single Provider

 • Full range of Primary and Behavioral
   healthcare services
 • Strong links with Specialty Care
 • Identified as PCHCH
 • Prevention and Wellness programs

                                          46
     Behavioral Health Provider as Person-
         Centered Healthcare Home


3 “kinds” of services make up “integrated care”

1. Clinical Services
2. Coordination/Collaboration/Consultation
3. Prevention and Wellness



                                                  47
       Behavioral Health Provider as Person-
           Centered Healthcare Home

3 “kinds” of services: Clinical Services

• Direct health interventions

• Full access

• Behavioral and other healthcare: Psychiatry,
  Primary Care, EBPs, etc.

                                                 48
      Behavioral Health Provider as Person-
          Centered Healthcare Home

3 “kinds” of services: Coordination

• Collaboration among providers

• Coordination of intervention and information
  (EHR)

• Consultation as needed

• Inclusion of family and person served          49
  Behavioral Health Provider as Person-
      Centered Healthcare Home

3 “kinds” of services: Prevention and Wellness
• Education and “Activation”

  – Education: illness and treatment options

  – Activation: Skills, support and empowerment



                                                 50
                  Solutions
“Everyone can do something”!!!!

Hope
• Consumers
• Providers
• Institutions
• Policy
• OCCIC
• You


                                  51
Central Ohio Integrating Care Network Meeting:

                      Panels
•Data and Resources for Identification of Need,
Advocacy

•“Local” Integrated Care Program Descriptions and
Lessons Learned

•Behavioral Health and Managed Care: Working
Together                                          52
                   Panel:
Data and Resources for Identification of Need,
                 Advocacy

Alicia D. Smith (Health Management Associates)
asmith@healthmanagement.com

Kraig Knudsen (Ohio Department of Mental Health)
Kraig.Knudsen@mh.ohio.gov

                                                 53
Supporting Integration of Primary
 Care and Mental Health Services
  through Data and Information
           Technology


                            Alicia D. Smith, MHA
                                Senior Consultant
                    Health Management Associates
                   asmith@healthmanagement.com


                                               54
                Three Key Uses of Data

 State-level data
   ─ Document the business case
   ─ Provide baseline utilization information
 Provider-level data to measure improvements




                                                55
              The Medi-Cal Business Case

Disabled Medi-Cal members have multiple and costly chronic
conditions
Medi-Cal members with chronic health conditions represent 74% of program costs
70% with disabilities have two or more chronic conditions
16% with disabilities have diabetes (compared to 7% nationally)
30% disabilities receive treatment for a mental health condition
9% receiving mental health treatment diagnosed with schizophrenia
Members with mental health conditions are more costly than those without
Individuals with SMI represent 10% of Medi-Cal members and 37% of total payments




                                                                               56
           Medi-Cal Business Case (cont’d)

Individuals with SMI are at higher risk of death from preventable
conditions
Roughly 75% of individuals with serious mental illness are tobacco dependent
compared with 22% of the general population
SMI served by the public mental health systems die, on average, at least 25 years
earlier than the general population
60% of premature deaths in persons with schizophrenia are due to medical
conditions such as cardiovascular, pulmonary and infectious diseases
Severe mental illness is associated with a 31.2% increase in the odds of being
hospitalized in a given year
In CY ‘07 the prevalence of diabetes, ischemic heart disease, cerebrovascular disease,
arthritis and heart failure was three times higher among the SMI Medi-Cal population
compared to the general Medi-Cal population



                                                                                     57
           Medi-Cal Business Case (cont’d)

The case for integrated primary care and mental health services
The Medi-Cal program does not provide most disabled Medi-Cal members care
coordination services
Individuals with SMI face significant barriers accessing primary care services
Roughly 40% of initial treatment of mental health conditions occurs in primary care
settings




                         For more information, please visit
           http://www.dhcs.ca.gov/provgovpart/pages/waiverrenewal.aspx




                                                                                       58
      State-Level Data to Understand Baseline
                 Service Utilization
  Top Medical Diagnoses            Top SMI Diagnoses          Top Prescribed Drugs
MISSING DIAGNOSIS             DEPRESSIVE DISORDER NEC      ASPIRIN

LABORATORY EXAMINATION        ANXIETY STATE, UNSPECIFIED   LORAZEPAM
UNSPECIFIED ESSENTIAL
HYPERTENSION                  UNSPECIFIED PSYCHOSIS        ACETAMINOPHEN
DB W/O COMP TYPE II/UNS NOT   SCHIZOAFFECTIVE DISORDER     HYDROCODONE
UNCNTRL                       UNSPEC                       BIT/ACETAMINOPHEN
ESSENTIAL HYPERTENSION,       PARANOID SCHIZOPHRENIA
BENIGN                        UNSPEC COND                  IBUPROFEN

CHEST PAIN UNSPECIFIED        DYSTHYMIC DISORDER           QUETIAPINE FUMARATE
                              MJR DEPRESS D/O RECUR
LUMBAGO                       EPIS-SEVERE                  BLOOD SUGAR DIAGNOSTIC


            Based on 2009 Medi-Cal date of service data from 8 California counties




                                                                                     59
Provider-level data to measure
        improvements




                                 60
     Identification of Clients At Risk
 Name of Measure                           Description
1)   Count of Clients   A count of the SMI clients shared by MH and PC

2)   Risk Behavior      The percentage of SMI clients who have been recently
     Screening          screened for risk behaviors (e.g., CAGE, audit)


3)   CVD/DM Risk        The percentage of SMI clients who have been recently
     Screening          screened for CVD/DM risk (BP, BMI, and waist
                        circumference)




                                                    61
Core CVD Measures, Health Risk &
           Control
Name of Measure                              Description
4)   Screening for DM The percentage of “at-risk” SMI clients who have been
     (&               screened for CVD/DM risk (BP, BMI, and waist
     hyperlipidemia)  circumference)
5)   CVD with Blood      The percentage of SMI clients with established CVD
     Pressure in         whose last BP < 130/80
     Control
6)   Statin Use          The percentage of SMI clients with DM and > 40 yrs
                         or with CAD risk factors, (#4) HTN or CAD & are on a
                         statin
7)   ACE Inhibitor Use   The percentage of SMI clients with DM and CAD, HTN,
                         or albuminuria who are on an ACE Inhibitor (or ARB)
8)   Aspirin Use         The percentage of SMI clients with DM and a > 10%
                         10-year risk for CAD or MI on an antithrombotic (ASA)




                                                    62
              Additional Measures

9)   Smoking Cessation Counseling   13) Referrals for Primary Care
10) Self-Management Goal Setting    14) Referred Clients to Primary Care
11) Shared Care Plan                15) Percent Referred to Mental
                                        Health Services
12) Receive Ongoing Primary Care    16) Percent Referred to Mental
                                        Health and Kept Appointment




                                                 63
       How will information be organized and
                      shared?
Through a patient registry that will:
   Identify client/patient populations and sub-populations in need of care
   Organize data from disparate information sources (EMR, paper record, client/patient visit,
    claims data)
   Measure care of individuals and populations of clients/patients
   Provide client summaries at time of visit
   Produce exception reports for population care planning
   Enable feedback to team on population outcomes
   Automate care reminders
   Allow queries of data to target at risk sub-populations

    Considerations: Client Opt-In vs. Opt-Out? Consent for shared information?




                                                                                                 64
               2014 Begins Now!
“The exceptional
status of mental health
is going away.”
Linda Rosenberg, CEO of NCCBH
Behavioral Healthcare, April 2010




                                    65
    Central Ohio Integrating Care Network
                   Meeting

Data and resources for identification of need, advocacy and
           improvement efforts in integration

             Ohio Department of Mental Health

                    Kraig J. Knudsen, PhD
           Chief, Office of Research and Evaluation
       Ohio Fee-for-Service and Managed Care
           Medicaid Analysis – SFY 2009-
                        COST



                         All Medicaid     All Medicaid
                      Programs Total    Programs SMI                        Metric
Ohio Medicaid
Members*                    2,311,303         235,895 10% SMI % of total

Ohio Medicaid Costs   $13,226,440,824   $2,658,866,821 20% SMI % of total
Ohio Medicaid                                          2.0 times as much per
Cost/Member                   $5,723          $11,271 SMI member
Ohio Fee-for-Service and Managed Care Medicaid Analysis –
                         SFY 2009-
              PHYSICAL HEALTH CONDITIONS
                                       All
                                 Medicaid
                                 Programs   All Medicaid
                                     Total Programs SMI             Metric
                                                         2.4 times as
                                                        frequent for SMI
   Diabetes                           5%            12% members

   Ischemic Heart Disease             4%             8%    2.0

   Hypertension                       7%            15%    2.1

   Cerebrovascular Disease            2%             3%    1.5

   Chronic Respiratory Disease        8%            13%    1.6

   Arthritis                          4%            10%    2.5
   Ohio Fee-for-Service and Managed Care Medicaid Analysis – SFY 2009
                    HEALTH CARE SERVICE UTILIZATION

                                    All
                              Medicaid
                              Programs   All Medicaid
                                  Total Programs SMI                          Metric

                                                      1.7 times more often for SMI
Inpatient   Episodes/1,000+        247           429 patients



ER Visits/1,000                  2,249          4,289   1.9



Inpatient Acute Days/1,000       2,048          4,356   2.1



OP Physician Visits/1,000       13,827         23,846   1.7



Specialist^ Patients/1,000         225          1,245   5.5
              Background on OFHS
            Special Population Study
• The 2008 OFHS included a question concerning days of
  functional impairment related to mental health

• Special population analysis was conducted through
  collaboration between ODMH, Health Policy Institute of
  Ohio, and OSU School of Public Health

• This survey contains responses from almost 51,000 adults
  and proxy responses for over 13,000 children

• Survey design requires special statistical techniques and
  software to analyze.
     Mental Health Question:
   Serious Psychological Distress
“Now thinking about your mental health,
 which includes stress, depression, and
 problems with emotions or substance abuse,
 for how many days DURING THE PAST 30
 DAYS did your mental health condition or
 emotional problem keep you from doing your
 work or other usual activities?”
Persons with Serious Psychological Distress (SPD)
   20+ Days of Functional Impairment Due to Mental Health Condition




                                                   Ohio Citizens
          Persons with SPD Rate Overall Health Status Lower

40%
           35.42%
35%                              Excellent              32.84%
                29.23%           Very good                        29.7%
30%
                                 Good              25.56%
25%
                                 Fair
      19.72%
20%                              Poor

15%                  12.46%
10%                                            7.97%

5%                            3.17%        3.94%

0%
          Ohioans without SPD                  Ohioans with SPD
                                Table 20
          A Higher Percentage of Persons with SPD
               Report History of Hypertension
80%

70%              67.16%

60%
                                       52.53%             Yes
50%                                             47.47%
                                                          No
40%
       32.84%
30%

20%

10%

0%
      Ohioans without SPD              Ohioans with SPD
                            Table 21
             A Higher Percentage of Persons with SPD
                  Report History of Heart Attack
100%             95.18%
90%                                              85.59%
80%
70%
                                                           Yes
60%
                                                           No
50%
40%
30%
20%                                     14.41%
10%     4.82%
 0%
       Ohioans without SPD              Ohioans with SPD
                             Table 22
       A Higher Percentage of Persons with SPD
       Report History of Coronary Heart Disease
100%
                 94.17%
90%                                               84.80%
80%
70%
                                                           Yes
60%
                                                           No
50%
40%
30%
20%                                     15.20%
10%      5.83%
 0%
       Ohioans without SPD              Ohioans with SPD
                             Table 23
         A Higher Percentage of Persons with SPD
                 Report History of Stroke
100%             97.06%
                                                 88.79%
90%
80%
70%
                                                           Yes
60%                                                        No
50%
40%
30%
20%
                                        11.21%
10%
        2.94%
 0%
       Ohioans without SPD              Ohioans with SPD
                             Table 24
          A Higher Percentage of Persons with SPD
          ReportHistory of Congestive Heart Failure
100%             97.40%
                                                 90.49%
90%
80%
70%
                                                           Yes
60%
                                                           No
50%
40%
30%
20%
                                        9.51%
10%
        2.60%
 0%
       Ohioans without SPD              Ohioans with SPD
                             Table 25
           Persons with SPD More Likely to Report
              History of Cardiovascular Disease:
      Hypertension, heart attack, coronary heart disease,
              stroke or congestive heart failure
70%
                64.59%
60%                                    58.12%

50%                                                         Yes
                                                41.88%      No
40%    35.41%

30%

20%

10%

0%
      Ohioans without SPD              Ohioans with SPD
                            Table 26
             A Higher Percentage of Persons with SPD
                   Report History of Diabetes*
                      *Including Borderline
100%
                  88.36%
90%
80%                                              75.29%
                                                           Yes
70%
                                                           No
60%
50%
40%
30%                                     24.71%
20%
        11.64%
10%
 0%
       Ohioans without SPD              Ohioans with SPD
                             Table 26
          A Higher Percentage of Persons with SPD
             Report History of Cancer Diagnosis

100%
                  90.71%
90%                                              87.03%

80%
70%                                                        Yes
60%                                                        No
50%
40%
30%
20%
                                        12.97%
        9.29%
10%
 0%
       Ohioans without SPD              Ohioans with SPD
                             Table 27
    Care Access & Unmet Needs

• Medical Home

• Emergency Room Use

• Care Coordination

• Mental Health Care

• Physical Health Care
               Persons with and without SPD:
              Identification of a Medical Home
100%

90%     85.78%                          85.27%
80%
                                                     Yes, I have a
70%                                                  medical home
60%                                                  No, I don't have
                                                     a medical home
50%

40%

30%

20%               14.22%                         14.73%
10%

 0%
       Ohioans without SPD              Ohioans with SPD
                             Table 34
                    Persons with and without SPD:
                      Location of Medical Home
80%        74.93%                                              Clinic or Health
                                                               Center
70%                                                            Doctor's Office or
                                                               HMO
60%                                               55.80%       Hospital Emergency
                                                               Room
50%                                                            Hospital Outpatient
                                                               Dept
                                                               Other
40%

30%
                                             18.98%
20%                                                       15.84%
      12.82%
10%             5.19%           3.48%                           5.71%
                        3.57%                                            3.66%
0%
          Ohioans without SPD                         Ohioans with SPD
                                  Table 35
                     Persons with and without SPD:
                    Reasons for Emergency Room Use
40%                                                         Can't afford
                                                            elsewhere/Don't turn
35%                                               34.15%    away
                32.86%
           31.21%                                           Didn't know where else
30%                                                         to go
                                     24.95%
25%                                           23.33%        Convenience/Don't need
                                                            appointment
20%
                                                            Best place to get care
      14.43%
15%
                         11.85%
10%                                                        8.34%
                     4.43%
5%         2.27%             2.94%        3.03%        2.82% 3.38%

0%
          Ohioans without SPD                 Ohioans with SPD
                                  Table 36
                    Persons with and without SPD:
                   Reasons for Lack of Medical Home
60%


50%   48.10%            Seldom/Never get sick

                        Don't know where to go for
40%                     care
                        Don't like/use doctors/treat        34.22%
                        myself                                       29.31%
30%                     Too expensive

20%                16.40%
                        12.21%              10.64%                      11.66%
               9.75%         10.02%                  8.35%
10%
                                                 5.82%
           3.51%
0%
           Ohioans without SPD                       Ohioans with SPD
                                 Table 38
       A Higher Percentage of Persons with SPD
       Report Needing Help Coordinating Care
90%
                 79.74%
80%

70%
                                                60.46%
60%                                                       Yes

50%                                                       No
                                       39.54%
40%

30%
       20.26%
20%

10%

0%
      Ohioans without SPD              Ohioans with SPD
                            Table 39
                Persons with and without SPD:
           Frequency of Receiving Care Coordination

70%
                           62.80%
60%
                                           Never

50%                                        Rarely
                                           Sometimes
40%                                        Usually            35.52%
                                           Always
30%
                                                         24.36%
                      18.38%                       17.90%
20%
                                              12.31%
                  9.54%                   9.91%
10%   5.09%
          4.19%
0%
         Ohioans without SPD                   Ohioans with SPD
                               Table 40
           Data Resources Available
• ODJFS
   – Claims data for all services paid for through Medicaid

   – De-identified individual level data

   – Eligibility data
       • CRIS-E: demographic information including living arrangements, age,
         gender, race/ethnicity, county, Medicaid program plan (e.g., ADC, ABD,
         CHIPP)
• ODMH
   – MACSIS Claims data-only mental health services Medicaid claims.
     Provides name of provider.

• Ohio Family Health Survey (OFHS)
                        Data Needs
• Data with identifiers included for matching purposes with
  mental health data. Need new data sharing agreements that
  enable us to obtain data with identifiers

• We currently do not have access to demographic data through
  eligibility files.

• Can only track health care utilization while they are on Medicaid.

• Better coordination with community agencies to begin collecting
  data that will inform Integrated Care policy and programming at
  both the local and state level.
LUNCH




        92
Central Ohio Integrating Care Network
               Meeting

        Networking Exercise :

              Report!


                                        93
                      Panel:
“Local” Integrated Care Program Descriptions and
                 Lessons Learned

Mike Unger & Bev Phipps (Concord Counseling)
mikeu@concordcounseling.org
bevphipps@concordcounseling.org

Prasad Potaraju (North Central Mental Health)
ppotaraju@ncmhs.org

Jayn Devney (Southeast Inc.)
devneyj@southeastinc.com                        94
Central Ohio Integrating Care Network Meeting


                   Break!




                                            95
                  Panel :
   Behavioral Health and Managed Care:
            Working Together

Kelly Kopecky (CareSource)
kelly.kopecky@csmg-online.com

Lisa Werner & Kevin Smith (Molina)
Lisa.Werner@MolinaHealthCare.com
Kevin.Smith@MolinaHealthCare.Com
                                         96
Central Ohio Integrating Care Network Meeting
                  Next Steps:
         Central Ohio Leadership Group

•Forum for: Collaborating and problem solving

•Focus on Behavioral Health Provider’s role

•Diverse membership

                                                97
                        Thank You
         Panelists, Speakers, Planning Committee:
•   Jessica Auslander        •   Prasad Potaraju
•   Janie Bailey             •   Jon Ramos
•   Jayn Devney
                             •   Dale Svendson
•   Connie Emerson
•   Afet Kilinc              •   Lisa Werner
•   Kraig Knudsen            •   Radu Saveanu
•   Kelly Kopecky            •   Alicia D. Smith
•   Teresa Lampl             •   Kevin Smith
•   Marc Molea               •   Mike Unger
•   Joy Parker
                             •   Mike Witzky
•   Stephanie Patrick
•   Bev Phipps               •   Ken Yeager
                                                    98
        Thank You Attendees!


Please fill out an evaluation

Jonas Thom
513-458-6733
jthom@healthfoundation.org

Jon Ramos
513-458-6684
jramos@healthfoundation.org

                   www.occic.org   99

				
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