The Psychiatric Medical The Psychiatric Medical Home and Chronic Home and Chronic Psychiatric IllnessPsychiatric Illness

Edward Kim, MD, MBAEdward Kim, MD, MBAAssociate Director, Health Economics and Associate Director, Health Economics and Outcomes Research Outcomes Research Bristol-Myers Squibb CompanyBristol-Myers Squibb Company

OverviewOverview

The challenge of chronic The challenge of chronic psychiatric illnesspsychiatric illness

Structural barriers to effective Structural barriers to effective managementmanagement

Psychiatric medical home case Psychiatric medical home case studystudy

Lessons learned/future directionsLessons learned/future directions

The ProblemThe Problem

People with serious mental illness People with serious mental illness die approximately 25 years die approximately 25 years earlier than the general earlier than the general population.population.

Medical co-morbidity is common Medical co-morbidity is common in this populationin this population

Care coordination is complexCare coordination is complex

SMR = standardized mortality ratio (observed/expected deaths).1. Harris et al. Br J Psychiatry. 1998;173:11. Newman SC, Bland RC. Can J Psych. 1991;36:239-245.

2. Osby et al. Arch Gen Psychiatry. 2001;58:844-850.3. Osby et al. BMJ. 2000;321:483-484.

Increased Mortality From Increased Mortality From Medical Causes in Mental Medical Causes in Mental IllnessIllness

Increased risk of death from medical Increased risk of death from medical causes in schizophrenia and 20% (10-15 causes in schizophrenia and 20% (10-15 yrs) shorter lifespanyrs) shorter lifespan11

Bipolar and unipolar affective disorders Bipolar and unipolar affective disorders also associated with higher SMRs from also associated with higher SMRs from medical causesmedical causes22 – 1.9 males/2.1 females in bipolar disorder1.9 males/2.1 females in bipolar disorder– 1.5 males/1.6 females in unipolar disorder1.5 males/1.6 females in unipolar disorder

Cardiovascular mortality in schizophrenia Cardiovascular mortality in schizophrenia increased from 1976-1995, with greatest increased from 1976-1995, with greatest increase in SMRs in men from 1991-1995increase in SMRs in men from 1991-199533

Multi-State Study Mortality Multi-State Study Mortality Data: Years of Potential Life Data: Years of Potential Life LostLost

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

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

Colton CW, Manderscheid RW. Prev Chronic Dis [serial online] 2006 Apr [date 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.htmcited]. Available from: URL:http://www.cdc.gov/pcd/issues/2006/apr/05_0180.htm

Osby U et al. Schizophr Res. 2000;45:21-28.

Schizophrenia: Schizophrenia: Natural Causes of DeathNatural Causes of Death

Higher standardized mortality rates Higher standardized mortality rates than the general population from:than the general population from:– Diabetes Diabetes 2.7x2.7x– Cardiovascular diseaseCardiovascular disease 2.3x2.3x– Respiratory diseaseRespiratory disease 3.2x3.2x– Infectious diseases Infectious diseases 3.4x3.4x

Cardiovascular disease associated with Cardiovascular disease associated with the largest number of deaths the largest number of deaths – 2.3 X the largest cause of death in the 2.3 X the largest cause of death in the

general population general population

Contributory FactorsContributory Factors

LifestyleLifestyle MedicationsMedications SurveillanceSurveillance

Cardiovascular Disease (CVD) Cardiovascular Disease (CVD) Risk FactorsRisk Factors

Modifiable Risk Modifiable Risk FactorsFactors

Estimated Prevalence and Relative Risk Estimated Prevalence and Relative Risk (RR)(RR)

SchizophreniaSchizophrenia Bipolar Bipolar DisorderDisorder

ObesityObesity 45–55%, 1.5-2X 45–55%, 1.5-2X RRRR11 26%26%55

SmokingSmoking 50–80%, 2-3X 50–80%, 2-3X

RRRR22 55%55%66

DiabetesDiabetes 10–14%, 2X RR10–14%, 2X RR33 10%10%77

HypertensionHypertension ≥≥18%18%44 15%15%55

DyslipidemiaDyslipidemia Up to 5X RRUp to 5X RR88

1. Davidson S, et al. Aust N Z J Psychiatry. 2001;35:196-202. 2. Allison DB, et al. J Clin Psychiatry. 1999; 60:215-220. 3. Dixon L, et al. J Nerv Ment Dis. 1999;187:496-502. 4. Herran A, et al. Schizophr Res. 2000;41:373-381. 5. MeElroy SL, et al. J Clin Psychiatry. 2002;63:207-213. 6. Ucok A, et al. Psychiatry Clin Neurosci. 2004;58:434-437. 7. Cassidy F, et al. Am J Psychiatry. 1999;156:1417-1420. 8. Allebeck. Schizophr Bull. 1999;15(1)81-89.

Impact of mental illness on diabetes Impact of mental illness on diabetes managementmanagement

313,586 Veteran Health Authority patients with diabetes76,799 (25%) had mental health conditions (1999)

Frayne et al. Arch Intern Med. 2005;165:2631-2638

Depression

Anxiety

Psychosis

Mania

Substance use disorder

Personality disorder

0.8 1.0 1.2 1.4 1.6

No HbA test done

0.8 1.0 1.2 1.4 1.6

No LDL test done

0.8 1.0 1.2 1.4 1.6

No Eye examination

done

0.8 1.0 1.2 1.4 1.6

No Monitoring

0.8 1.0 1.2 1.4 1.6

Poor glycemic control

0.8 1.0 1.2 1.4 1.6

Poor lipemic control

Odds ratio for:

““Every system is perfectly Every system is perfectly designed to achieve exactly the designed to achieve exactly the results it gets.”results it gets.”(Berwick, 1998)(Berwick, 1998)

SummarySummary

SPMI population is at high risk for SPMI population is at high risk for medical morbidity and mortalitymedical morbidity and mortality

Management is suboptimalManagement is suboptimal

Barriers to Effective Barriers to Effective ManagementManagement Healthcare SystemHealthcare System ProviderProvider PatientPatient

The MH/SA “System”The MH/SA “System”

Segregated from PH systemSegregated from PH system Diverse care settingsDiverse care settings Diverse provider baseDiverse provider base Lack of confidence/priority with Lack of confidence/priority with

medical conditionsmedical conditions

System Level BarriersSystem Level Barriers

Structural and functional differences between MH and PH systems reduce

effectiveness and quality of clinical management

MHPMHP PHPPHP

Patient

PCP-Patient Interactions

▪ PCP Awareness of needs

▪ Patient cognitive barriers

▪ Patient health literacy

▪ Stigma

▪ PCP knowledge of MH system

MHS-PHS Communication

▪ HIPAA

▪ Geographic/temporal separation

▪ Role definition

▪ Organizational culture

MHP-Patient Interactions

▪ Awareness of needs

▪ Role definition

▪ Patient cognitive barriers

▪ MHP health literacy

▪ MHP knowledge of PH system

AccessAccess to Medical Care of to Medical Care of People with SPMIPeople with SPMI

SPMI clients have difficulties accessing SPMI clients have difficulties accessing primary care providersprimary care providers– Less likely to report symptomsLess likely to report symptoms– Cognitive impairment, social isolation Cognitive impairment, social isolation

reduce help-seeking behaviorsreduce help-seeking behaviors– Cognitive, social impairment impedes Cognitive, social impairment impedes

effective navigation of health care systemeffective navigation of health care system Accessing and using primary care is Accessing and using primary care is

more difficultmore difficultJeste DV, Gladsjo JA, Landamer LA, Lacro JP. Medical comorbidity in schizophrenia. Schizophrenia Bull 1996;22:413-427

Goldman LS. Medical illness in patients with schizophrenia. J Clin Psych 1999;60 (suppl 21):10-15

Management Management StrategiesStrategies Care CoordinationCare Coordination Integrated CareIntegrated Care

Collaborative Care Collaborative Care ModelModel

Level 1 – Preventive/screeningLevel 1 – Preventive/screening Level 2 – PCP/extenders provide Level 2 – PCP/extenders provide

carecare Level 3 – Specialist consultationLevel 3 – Specialist consultation Level 4 – Specialist referralLevel 4 – Specialist referral

Katon et al (2001) Gen Hosp Psychiatry 23:138-144

UMDNJ PilotUMDNJ Pilot

Dually-trained psychiatrist/FPDually-trained psychiatrist/FP– Direct patient careDirect patient care– Physician of ProtocolPhysician of Protocol

Dually-trained nurse practitionersDually-trained nurse practitioners– Direct patient careDirect patient care– Education groupsEducation groups– Liaison with external providers (MH, Liaison with external providers (MH,

PH)PH)

UMDNJ PilotUMDNJ Pilot

Full cross-functional integration on-site facilitates optimal

management

MHPMHP PCP/NPPCP/NP

Patient

PCP-Patient Interactions

▪ Focused consultation

▪ NP follow-up

MHS-PHS Communication

▪ Collaboration in treatment team meetings

▪ Consultation for routine care

▪ Referral for complex cases

MHP-Patient Interactions

▪ Focus on MH management

▪ Integrate PH issues into care plan

ConclusionsConclusions

Co-morbidity and increased Co-morbidity and increased mortality are the normmortality are the norm

Multiple barriers prevent effective Multiple barriers prevent effective carecare

Integrated care is clinically, Integrated care is clinically, operationally feasibleoperationally feasible

Funding pathway is a major barrierFunding pathway is a major barrier