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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. WHO Global Burden of Disease 2000.

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the interdependence of mental health and physical health
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

who global burden of disease 2000
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



behavioral disorders account for even more disability than chronic medical conditions
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%
  • Alzheimer’s Disease/Dementias – 8%
and in addition
And In Addition….
  • 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

Mental illnesses and chronic medical diseases interact:

negative impact of chronic medical conditions on recovery from severe mental illness
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
the gaps disease and program specific structures are not person centered
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
the goal
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.).

maine data the impact of mental illness on physical health in the general population

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

maine examples of integrated data analysis
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
maine brfss mental illness modules
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

conclusion from integrated analysis of maine brfss data
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
maine dhhs south carolina er study

Maine DHHS /South Carolina ER Study

Integrated Analysis

Medicaid Services Data

population studied
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

overall er usage increases with complexity of underlying population
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

what is primary reason for going to the er
What is primary reason

for going to the ER?

er rates for medical dx increase with complexity of group members
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.

the smallest percentage of overall er usage is for behavioral health
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

conclusions of er study
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
persons with serious mental illness

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

biggest impediment to recovery
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
For Persons with SMI

Chronic Health Conditions Are an


Not an Exception

high rate of health disorders of persons with smi compared to non smi groups in maine medicaid 2004
High Rate of Health Disorders of Persons with SMI Compared to Non-SMI Groups in Maine Medicaid – 2004
another approach brfss questions added to consumer satisfaction survey
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)?

March 14-18, 2009

chronic health conditions maine dig surveys age 18 64 years
Chronic Health ConditionsMaine DIG Surveys (Age 18-64 Years)

** Cardiovascular Disease (CVD) = reported angina or heart attack

March 14-18, 2009

metabolic risk
Metabolic Risk

Among persons with no diabetes: obesity, high blood pressure,

or high cholesterol

Percent Reporting 2 or More Risks

March 14-18. 2009

Satisfaction Related to Physical Health Status(…how many days during the past 30 days was your physical health not good?)

Percent Reporting

March 14-18, 2009

costs to maine medicaid

Costs to Maine Medicaid

Persons with co-morbid medical and behavioral health disorders cost more both for medical and for psychiatric services

medical expenditures for persons with mh sa conditions compared to general maine care 2002
Medical Expenditures for Persons with MH/SA Conditions Compared to General Maine Care 2002
Impact of Increasing Number of Medical Co-morbidities on Maine Mental Health Expenditures for Persons with Serious Mental Illness
summary of integrated analysis of maine data
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
bringing the data to key policy discussions

Bringing The Data to Key Policy Discussions

Governor’s Office

Commissioner of DHHS


Public Health

Mental Health

maine state health plan support from the governor
Maine State Health Plan:Support 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
dhhs policy changes
DHHS Policy Changes
  • Integration of previously separate agencies into one state health and human services agency, with an integrated management structure
  • Commissioner’s Policy on Integrated Care
  • DHHS Strategic Plan has as a focus integration of services to meet the complex needs of persons served
the maine patient centered medical home project
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
integration of mental health into maine medicaid initiatives
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
integration of mental health into maine public health initiatives
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
office of adult mental health
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
december 2008 dhhs partners with local funder to launch smi health project
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
maine smi health project will
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
integration making the case in maine
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
dissemination is a critical part of surveillance

Dissemination is a Critical Part of Surveillance

Present , present, present

to many different audiences (not just a report that sits on a shelf)

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
tie data and dissemination to state program and policy issues

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

implications for health policy for general population
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
implications for medicaid
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

implications for medicaid53
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
implications for public health
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
implications for smha
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
attending to health and wellness for persons with smi
Attending to health and wellness for persons with SMI
  • Start with surveillance – if you don’t measure it, you won’t 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

Elsie Freeman, MD, MPH

Medical Director, Behavioral Health

DHHS Office of Quality Improvement Services


Jay Yoe, PhD


DHHS Office of Quality Improvement Services