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The Interdependence of Mental Health and Physical Health

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Title: The Interdependence of Mental Health and Physical Health


1
The Interdependence of Mental Health and Physical
Health
  • The case for creating integrated
  • systems of care

James Yoe PhD Elsie Freeman MD Maine Department
of Health and Human Services SAMHSA National
Grantee Conference Washington, DC June 19, 2009
2
WHO Global Burden of Disease2000
  • Chronic Diseases are a major cause of death and
    disability accounting for 25 of all disability
    worldwide
  • Arthritis Musculoskeletal Diseases
  • Respiratory Diseases
  • Cardiovascular
  • Diabetes

3
Behavioral Disorders Account for Even More
Disability than Chronic Medical Conditions
  • WHO 2000 Global Burden of Disease In the
    developed world, behavioral disorders account for
    almost half of burden of disability
  • Mental Illnesses 24
  • Substance Use Disorders 12
  • Alzheimers Disease/Dementias 8

4
And In Addition.
Mental illnesses and chronic medical diseases
interact
  • Persons with mental ill health have higher rates
    of health risk (smoking, obesity, physical
    inactivity)
  • Persons with mental ill health have higher rates
    of diabetes, arthritis, asthma, heart disease
  • Persons with both chronic disease and mental
    illness have higher costs and poorer outcomes

5
Negative Impact of Depression on the Outcome of
Cardiovascular Disease
6
Negative Impact of Chronic Medical Conditions on
Recovery from Severe Mental Illness
  • On average persons with Serious Mental Illness
    die 25 years earlier than their age mates in the
    general population
  • Persons with SMI are not dying from their mental
    illness but from heart disease, diabetes and
    other medical conditions
  • Death is the ultimate impediment to recovery

7
The Gaps disease and program specific
structures are not person centered
  • Most data and management systems focus on one or
    the other (and separate mental illness from
    substance abuse or from cognitive impairments)
  • Most systems of care (and regulation and
    reimbursement) focus on one only
  • Institutional systems (federal, state, academic)
    are also separate from each other

8
The Goal
  • The goal of a transformed health system that
    integrates mental health and physical health
    promotion should be to put the head and body back
    together so that policies and programs are
    person-centered or more holistic rather than
    our present system of carving out body parts
    (i.e., oral health, reproductive health, mental
    health etc.) or specific diseases (i.e.,
    diabetes, heart disease, stroke, cancer, etc.).

9
Maine Data The Impact of Mental Illness on
Physical Health in the General Population
  • Expanding focus of SMHA, Medicaid and Public
    Health to mental health issues in the general
    population

10
Maine Examples of Integrated Data Analysis
  • Integrated analysis of Mental Health Modules in
    BRFSS
  • Integrated analysis of Medicaid data the
    Maine/SC Emergency Room Usage study

11
Maine BRFSS Mental Illness Modules
  • Frequent Mental Distress (FMD) 14 days mental
    ill health 10.7
  • Depression and Anxiety Module
  • Moderate/Severe Current Depression 7.4
  • Past history of depression 20
  • Past history anxiety disorder 16
  • K-6 Module
  • Serious Psychological Distress (K6 13) - 3.8
  • Moderate Psychological Distress (K6 8-12) -
    7.8
  • History of Mental Health Treatment -15
  • Miss Most Days Activities - 3.1 Miss Some Days
    - 6.8
  • No one definition includes all persons
    overlapping,
  • but non-identical populations

12
Conclusion from Integrated Analysis of Maine
BRFSS Data
  • Mental ill health affects one in five Mainers,
    touching every social network
  • Mental ill health is associated with higher rates
    of health risk, chronic disease and poor self
    care in the general population
  • Attention to mental health issues critical for
    systems that target chronic disease

13
Maine DHHS /South Carolina ER Study
Integrated Analysis Medicaid Services Data
14
Population Studied
  • Medicaid only, 11 or 12 months eligibility, 19-64
    years old
  • Group placement is dependent on whether there was
    any SA or MH diagnosis for any claim in the
    fiscal year
  • Four groups MH, SA, MH SA, no MH/SA
  • ER visit diagnoses are primary diagnosis given
    for the ER visit
  • ER utilization is of visits per 1000 members in
    each specific group

15
ER Utilization Rates Increase with Complexity of
Group
16
Overall ER Usage Increases with Complexity of
Underlying Population
  • ER utilization rates 2 times higher for MH or SA
    only groups compared to Medicaid members with no
    behavioral health diagnoses
  • ER rates are 4 times higher for Co-morbid MH/SA

17
  • What is primary reason
  • for going to the ER?

18
Percent Maine ER Visits by Diagnosis by Group
19
Highest Usage of ER Visits for Medical
Conditions per Thousand Members by Group
20
ER Rates for Medical Dx Increase with Complexity
of Group Members
  • In both states, ER rates for medical reasons,
    compared to group with no underlying behavioral
    health diagnoses are
  • 1.9-1.7 times higher for MH group
  • 1.8-2.1 times higher for SA group
  • 3.5-4.0 times higher for the Co-occurring group.


21
Second Highest Usage of ER Injury Visits per
Thousand Members by Group for Year
22
The Smallest Percentage of Overall ER Usage is
for Behavioral Health
  • Overall --- 5.2 Maine ER visits are for MH
  • 3.3 South Carolina ER visits are for MH
  • Overall --- 2.1 Maine ER visits are for SA
  • 1.0 South Carolina ER visits are
    for SA

23
Conclusions of ER Study
  • Majority of ER visits are for injuries and
    medical conditions for all groups
  • Rates of ER utilization for medical issues and
    injuries are increased in populations with
    behavioral disorders
  • Effective care for these complex populations will
    depend on development of integrated systems of
    care

24
Persons with Serious Mental Illness
  • Impact on physical health is same as for persons
    with any mental illness in the general
    population, only more so

25
Biggest Impediment to Recovery
  • Compared to the general population, persons with
    serious mental illness on average lose 25 years
    of normal life span
  • People are dying, not from their schizophrenia,
    but from chronic medical conditions

26
  • For Persons with SMI
  • Chronic Health Conditions Are an
  • Expectation
  • Not an Exception

27
High Rate of Health Disorders of Persons with SMI
Compared to Non-SMI Groups in Maine Medicaid
2004
28
Burden of Medical Illness Maine Medicaid 2004
29
Another Approach BRFSS Questions Added to
Consumer Satisfaction Survey
  • Height and Weight (translated into Body Mass
    Index)
  • Have you ever been told by a doctor or health
    professional that you have(coronary artery
    disease, heart attack, diabetes, high blood
    pressure, high cholesterol)?
  • Do you smoke cigarettes?
  • Now thinking about your physical health, which
    includes physical illness and injury, how many
    days during the past 30 days was your physical
    health not good?
  • Now thinking about your mental health, which
    includes stress, depression, and problems with
    emotions, how many days during the past 30 days
    was your mental health not good?
  • During the past 30 days, about how many days did
    poor physical or mental health keep you from
    doing usual activities, such as self-care,
    school, or recreation?
  • Would you say that your general health
    is(excellent, very good, good, fair, poor)?

30
Health RiskMaine DIG Surveys (Age 18-64 Years)
31
Chronic Health ConditionsMaine DIG Surveys (Age
18-64 Years)
Cardiovascular Disease (CVD) reported
angina or heart attack
32
Metabolic Risk
Among persons with no diabetes obesity, high
blood pressure, or high cholesterol
Percent Reporting 2 or More Risks
33
Satisfaction Related to Physical Health
Status(how many days during the past 30 days
was your physical health not good?)
Percent Reporting
34
Costs to Maine Medicaid
  • Persons with co-morbid medical and behavioral
    health disorders cost more both for medical and
    for psychiatric services

35
Medical Expenditures for Persons with MH/SA
Conditions Compared to General Maine Care 2002
36
Impact of Increasing Number of Medical
Co-morbidities on Maine Mental Health
Expenditures for Persons with Serious Mental
Illness
37
Summary of Integrated Analysis of Maine Data
  • Mental ill health is associated with higher rates
    of chronic disease, poor outcome and higher
    medical costs in the general population
  • Persons with Serious Mental Illness have even
    higher rates of health risk, chronic disease,
    poor outcomes and higher costs

38
Bringing The Data to Key Policy Discussions
  • Governors Office
  • Commissioner of DHHS
  • Medicaid
  • Public Health
  • Mental Health

39
Maine State Health PlanSupport from the Governor
  • Integration of mental health, public health and
    primary care
  • Ongoing surveillance of mental health issues in
    health surveillance
  • Person centered health care home
  • Health Info Net - interoperable electronic health
    information systems and a statewide health
    information exchange system

40
DHHS Policy Changes
  • Integration of previously separate agencies into
    one state health and human services agency, with
    an integrated management structure
  • Commissioners Policy on Integrated Care
  • DHHS Strategic Plan has as a focus integration of
    services to meet the complex needs of persons
    served

41
The Maine Patient Centered Medical Home Project
  • Includes behavioral health provider on health
    care team
  • Care management to integrate medical and
    behavioral health issues
  • Patient self management support to include both
    medical and behavioral health issues

42
Integration of Mental Health into Maine Medicaid
Initiatives
  • Financial support for Medical Home Pilot
  • New policies for reimbursement of mental health
    providers in primary care settings
  • Medicaid funded medical care management system
    routinely screens for depression
  • Medical care managers to coordinate with mental
    health case managers for persons with SMI

43
Integration of Mental Health into Maine Public
Health Initiatives
  • Ongoing inclusion and integrated analysis of
    mental health modules in BRFSS will permit county
    level and special population data for local needs
    assessment
  • Universal Web Based Health Screen includes
    depression screening, education and treatment
    resources

44
Office of Adult Mental Health
  • Ongoing inclusion of BRFSS health questions in
    DIG Consumer Satisfaction Survey
  • Inclusion of health questions in launch of new
    Outcome Tool
  • Partnerships with Medicaid, Elder Services,
    Public Health to expand role of SMHA to include
    attention to mental health of whole population

45
December 2008 DHHS Partners with Local Funder
to Launch SMI Health Project
  • Link every consumer with SMI to a welcoming
    medical home
  • Coordinate medical and mental health care/case
    management
  • Track health issues in mental health system
    workflow
  • Develop consumer led health programming

46
Maine SMI Health Project Will
  • Develop information sharing systems between
    consumers, mental health and health care systems
  • Educate workforce/consumers health literacy,
    health advocacy, chronic disease care, self
    management
  • Inform development of policy, contracts,
    regulation and system design at the state level

47
Integration Making the Case in Maine
  • Surveillance and data gathering are key first
    steps
  • Maine specific data is necessary to drive policy,
    programming and quality improvement
  • Analyses concurrently addresses physical and
    behavioral health issues

48
Dissemination is a Critical Part of Surveillance
  • Present , present, present
  • to many different audiences (not just a report
    that sits on a shelf)

49
Dissemination Strategies ONE SIZE REPORTING ONLY
USEFUL TO ONE SIZE STAKEHOLDER
  • Tailor presentation to each audience, showing how
  • attention to integration is not an add on but
    will
  • serve their specific aims
  • MH audience how chronic disease impacts
    Recovery
  • Health audience impact of mental illness on
    chronic disease and population health
  • Legislature impact of siloed approach on total
    costs of care

50
Tie Data and Dissemination to State Program and
Policy Issues
  • Give non mental health partners concrete
    suggestions for what they can do to integrate
    mental health into their regular programming

51
Implications for Health Policy for General
Population
  • Many forms of mental illness are highly
    prevalent, under-recognized, less disabling than
    SMI but associated with poor health
  • Overall health depends on addressing both mental
    health and physical health in an integrated
    fashion
  • Publicly funded health systems should addresses
    mental illness in the general population
  • Start with depression

52
Implications for Medicaid
  • Medicaid/SMHA populations have high degree of
    complexity. Needs span multiple traditional
    service sectors. Need for integrated approach.
  • Integration needed at all levels of the public
    system surveillance, reimbursement, programming,
    workforce training

53
Implications for Medicaid
  • Support screening and integrated treatment of
    depression in traditional health care settings
  • Support screening and treatment of health
    conditions among persons treated by specialty
    mental health

54
Implications for Public Health
  • Support ongoing inclusion of MH modules in BRFSS
  • Develop depression screening and awareness tools
    linked to health risk and chronic disease
    programming
  • Include mental health objectives in Healthy Maine
    2020

55
Implications for SMHA
  • Expand programming to SMI population to include
    attention to health and wellness
  • Expand role of SMHA to include persons with less
    disabling forms of Mental Illness
  • Partner with state Public Health and Medicaid to
    support integration of mental health into health
    policy and programming

56
Attending to health and wellness for persons with
SMI
  • Start with surveillance if you dont measure
    it, you wont manage it
  • Keep it simple History of smoking, alcohol use,
    major chronic diseases
  • Track BMI, Blood Pressure, glucose and lipids
  • Integrate health surveillance into current
    activities ISP development, med management,
    consumer survey, outcome measures

57
Elsie Freeman, MD, MPH Medical Director,
Behavioral Health DHHS Office of Quality
Improvement Services E-mail elsie.freeman_at_maine.g
ov Jay Yoe, PhD Director DHHS Office of Quality
Improvement Services E-mail jay.yoe_at_maine.gov
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