A Non-profit Behavioral Health Managed Care Company
Physical Health – Behavioral
Health Integration
04/25/12 - Pocono Medical Center
Richard Silbert, M.D.
Senior Medical Director
Community Care
570-496-1311
silbertrr@ccbh.com
In partnership with
AHEC
Area Health Education Center
• Enhancing access to health care through
education
• Community experiences for health
professions’ students
• Promoting Health Careers
• Preceptor / health practitioner support
• Support of community partners
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About Community Care
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Incorporated in 1996 primarily to support HealthChoices.
Part of the UPMC Insurance Services Division.
501(c)(3) nonprofit behavioral health managed care organization.
Licensed as risk bearing PPO.
Implemented HealthChoices in:
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Allegheny County (1999).
York, Adams, and Berks Counties (2001).
Chester County (2004).
Lackawanna, Luzerne, Susquehanna, and Wyoming
Counties (2006).
– 23-County North Central Region (2007).
– Carbon, Monroe, and Pike Counties (2007).
– Erie County (2011)
• Implemented a Care Monitoring Initiative in New York City (2009).
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•
About
Community
Care
Experience with full-risk, shared-risk, and
Administrative Services Only (ASO) contracts.
– 6 contracts with 9 counties, 1 contract with a
consortium (representing 4 counties), 1 contract
directly with DPW (representing 23 counties), and 1
contract with the New York State Office of Mental
Health/New York City Department of Health and
Mental Hygiene.
• “Full” NCQA accreditation for Medicaid product
(Perfect score).
• Recipient of the Moffic Ethics Award from the
American Association of Community Psychiatrists.
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PA Counties Served by Community Care
Erie
Warren
McKean
Tioga
Potter
Susquehanna
Bradford
Wayne
Crawford
Wyoming
Forest
Elk
Venango
Cameron
Mercer
Luzerne
Clearfield
Butler
Centre
Union
Columbia
Montour
Monroe
Carbon
Northumberland
Armstrong
Mifflin
Indiana
Allegheny
Snyder
Northampton
Schuylkill
Lehigh
Cambria
Juniata
Perry
Blair
Westmoreland
Dauphin
Huntingdon
Washington
Berks
Bucks
Lebanon
Cumberland
Montgomery
Lancaster
Bedford
Greene
Pike
Clinton
Jefferson
Clarion
Lycoming
Lackawanna
Sullivan
Fayette
Somerset
Fulton
Franklin
Adams
Chester
York
Philadelphia
Delaware
County Served by Community Care
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Community Care Office
Community Care Mission and Vision
• To improve the health and wellbeing of the community through
the delivery of effective and
accessible behavioral health
services.
• To improve the quality of services
for members through a
stakeholder partnership focused
on outcomes.
• To support high quality service
delivery through a not-for-profit
partnership with public agencies,
experienced local providers, and
involved members and families.
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Our Objectives
1. Review interactions between medical and mental disorders
2. identify why morbidity and mortality are greater in Serious
Mental Illness (SPMI), even excluding suicide attempts and
completions.
3. Show improved outcomes when both Physical Health and
Behavioral Health efforts are coordinated.
4. Several examples of initiatives aimed at earlier identification of
individuals at high risk with both physical health and behavioral
health disorders will be presented together with description of
efforts to promote wellness
5. Participants will be able to better identify resources to utilize
when their patients are in need of case management for
coordinated care
BH MCO Goals
Collaboration
with APS
• Developing methods to identify members with
serious mental illnesses who have concurrent
physical health problems
• Process for joint care management services
for members who need integrated physical
and behavioral health services
• Joint educational efforts to insure behavioral
and physical health providers are aware of
resources and how to access them
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Moving Towards PH/BH Coordination
Include PH in Recovery Goals
Educate Consumers/Providers about risk for
having PH and BH problems
• WHY?
• Lack of collaboration for PH and BH clients
• Need for better quality of life
• BH providers & clients not usually focused on PH factors
• ACES exposure leads to BH and PH problems
• Need to include substance abuse in PH & BH healthcare
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© 2011 Community Care
What Do We Know about PH in SMI
population?
People with serious behavioral illness die earlier than the general
population.
People without SMI who have risk factors common to SMI (i.e. smoking,
poverty, homelessness, obesity) also die much earlier than the general
population
Our behavioral and physical health systems have failed to systematically
address and support prevention and wellness across all populations,
especially those which suffer from socioeconomic disadvantages
National Association of State Mental Health Program Directors (NASMHPD) Medical Directors Council. (2006).
Morbidity and Mortality in People with Serious Mental Illness. Alexandria, VA.
Inadequate Access to Physical Health Care
Lack of capacity
Stigma and
discrimination
Lack of adequate health
care coverage (in some
areas)
Poor quality and poor
provision of services in
some areas and/or less
efficacious use
Monitoring and
treatment guidelines are
underutilized with the
SMI population (as they
are in most populations)
National Association of State Mental Health Program Directors (NASMHPD) Medical Directors Council. (2006).
Morbidity and Mortality in People with Serious Mental Illness. Alexandria, VA.
29% of adults with Medical D/O
have mental disorders
58% of
Adults:
People with
Medical
Problems
25% of
Adults:
People with
Mental D/O
68% of adults with Mental
d/o have medical conditions
National Comorbidity Survey Replication 2001-2003
Mental Health-Physical Health
2nd Report on Health Care Quality
50% see
PCP
17% NO
visits
13% Both
PCP & MH
5% MH
Only
1/3 make 1
visit
Higher risk
for PH
disease
Chronic
Pain 2040%
DM 1115%
Major
Depression
Heart
Disease
15-20%
Stroke 3050%
Multiple
PH
problems
23%
Impact of Medications
Modifiable
risk factors
affected by
psychotropics
include:
• Overweight and obesity
• Insulin resistance
• Diabetes and
hyperglycemia
• Dyslipidemia
National Association of State Mental Health Program Directors (NASMHPD) Medical Directors Council. (2006).
Morbidity and Mortality in People with Serious Mental Illness. Alexandria, VA.
Obesity
Obesity among persons with serious mental disorders is greater
than among the general population
Increased incidence of Metabolic Syndrome in SMI population
Obesity in individuals with mental disorders attributed to a
number of factors:
• a sedentary lifestyle
• poor nutritional choices
• lack of access to healthy food (which is also associated with poverty)
• the effects of both the mental disorder itself and the medications used to treat it
• lack of access to adequate preventative medical care
Citromea, L., Vreeland, B., Obesity and Mental Illness. Thakore J, Leonard BE (eds): Metabolic Effects of Psychotropic Drugs. Basel,
Karger, 2009, vol 26, pp 25-46.
National Association of State Mental Health Program Directors (NASMHPD) Medical Directors Council. (2006). Morbidity and
Mortality in People with Serious Mental Illness. Alexandria, VA.
Smoking
Higher prevalence (56-88% for patients with schizophrenia)
of cigarette smoking (up to 25% of all cigarettes sold in US)
More toxic exposure for patients who smoke (more
cigarettes, larger portion consumed)
Smoking is associated with increased insulin resistance
Similar prevalence in bipolar disorder
Smoking cessation may be the modifiable risk factor that is
likely to have the greatest impact on decreasing mortality
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; Ziedonis D. Williams JM, Smelson D. Am J Med Sci. 2003 (Oct); 326(4): 223-330
Medical Harm of Hazardous Drinking
• Hazardous drinking is
associated with an increased
risk for:
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All-cause mortality
Hypertension
Cardiomyopathy
Diabetes
Trauma
Stroke
More serious alcohol disorders
Cancers
• particularly upper GI and
breast cancers
Medical Comorbidities
Figured from Babor et al (World Health Organization), AUDIT Guidelines for Use in
Primary Care, 2001
Childhood
Adversity
Chronic
Medical
D/O
•Loss
•Abuse & Neglect
•Household
dysfunction
RWJ Synthesis
Project 2/2011
Stress
•Adverse Life
Events
•Chronic
Stressors
Adverse Health
Outcomes:
Obesity,
smoking, poor
self care,
disability
SES
•Poverty
•Neighborhood
•Social support
•Isolation
Mental
D/O
Types of Stress
POSITIVE
STRESS
TOLERABLE
STRESS
• Part of normal development
• Brief increased HR, and hormone changes
• e.g. cramming for a test
• Stress response may affect brain; stopped with good support
• Allows brain to recover
• e.g. death of a loved one or disaster
• Prolonged activation of stress response
• Impact on brain and body
TOXIC STRESS • e.g. recurrent physical, sexual, or emotional abuse
Health Consequences of Chronic Stress
SAM   BP, heart
rate
HPA  immunosuppression
Relationship Between Number of Adverse Childhood Experiences
and Smoking Behaviors and Smoking-Related Lung Disease
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ACE Score
Percent With Health Problem (%)
18
0
1
2
3
4 or more
16
14
12
10
8
6
4
2
0
Early smoking
initiation
Current smoking
COPD
Risk Factors for Adult Heart Disease are Embedded in Adverse
Childhood Experiences
JACK P. SHONKOFF, M.D.
DIRECTOR, CENTER ON THE DEVELOPING CHILD
HARVARD UNIVERSITY
Odds Ratio
3.5
3
2.5
2
1.5
1
0.5
0
1
2
3
4
ACEs
5,6
7,8
Source: Dong et al, 2004
CDC Study concluding comment
“The mind-body dichotomy that persists in
Western medical training may lead clinicians
away from understanding the role that
childhood trauma and stress has on the
health of their adult patients.…understanding
the role of these childhood experiences on
adult health will become increasingly
important in making decisions about
prognosis, diagnosis and treatment.”
CDC research group (2008) BMC Public Health 8:198.
Improving Care Delivery
• Behavioral Health Home to Foster Collaboration
• Supporting Coordination of BH, PH, and SA
Prevention and Promotion
• Work on Primary Prevention by targeting risk
factors
• Active Secondary Prevention with health screening
in Mental, Medical, and Community Settings
Role of the Behavioral Health
Home
• Provide a person-centered system of care
• Development of a “virtual team” for each
individual
• Enhance physical health competencies in the
BH team
• Develop person-centered plan with the individual
• Coordination of physical, behavioral and
supportive services
• Promote health, wellness, recovery, use of
personal medicine and self-management
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© 2011 Community Care
Planned Steps
• Steps of Hope Program
– Enhances Members’ quality of life by providing guidance, assistance,
and support for their recovery journey; fosters hope.
– Provides a Member-centric focus (as opposed to disease-centric) to
contacts, materials, and interventions.
– Imparts knowledge about recovery, knowing that knowledge is
accompanied by responsibility.
• Program materials are carefully prepared or selected to ensure that
they are recovery-oriented and Member-centered.
• Includes strategies to help Members with communication skills for
talking to: Psychiatrists and primary care physicians, other service
providers. family, friends, and other supports.
Member Interventions
• Members in the highest stratification group
(actively engaged in the program) are assigned
a “Specialized Care Manager” who:
– Ensures that a crisis plan is in effect after an
inpatient stay.
– Makes quarterly follow-up calls to Members in
order to provide support and assistance for living
in the community.
Goals of PH/BH Integration
at the Provider Level
• Development of a true Clinical Home
– BH treatment options in PH settings for non-SMI
consumers.
– PH monitoring/coordination for SMI consumers
in MH settings.
– Management of the same issues that obstruct
coordination of other specialties.
• Inclusion of PH in Recovery Goals/WRAP plans
– Need to improve PH of SMI consumers.
– Not the usual focus of BH treatment (tobacco
cessation, weight management).
Information Line for Practitioners
1-888-251-2224
• Primary care physicians and other health care
practitioners can call the information line with
questions about diagnostic criteria and psychiatric
medications.
• Community Care psychiatrists and pharmacists
are available 24 hours a day, seven days a week.
• Answer questions about Community Care
members related to medication effects,
medication side effects, diagnostic criteria, and
treatment resources.
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