APHA Chicago

Health access and integration study

November 2, 2015E. Sally Rogers, Sc.D.Director of ResearchResearch Professor

Mihoko Maru, M.A., M.S.W.Senior Research Coordinator

Center for Psychiatric RehabilitationBoston University

Health Crisis among Individuals with Severe Psychiatric Disabilities

• Mortality rates for individuals with mental illness 2 and 3 times the general population

• Cardiovascular disease, high rates of obesity, prediabetes, hyperlipidemia, hypertension, diabetes, cancer.

• Lifestyle issues such as substance use, smoking, HIV/AIDS from risky sexual behaviors.

• Healthcare utilization is controversial—perhaps underutilization of preventative care; overutilization of ED

Probable determinants of poor physical health

• Low levels of internality (sense that one can control one’s health).

• Lifestyle factors: smoking, poor diet, sedentary lifestyle.

• Risk-taking related factors: high rates of substance use, risky sex.

• Illness-related factors: psychotropic medications, hospitalizations.

• Environmental factors: exposure to violence, poverty.

• Limited health care access.

Rationale for study

• Interaction between physical and psychiatric health status and their bi-directional influence.

• Recovery from mental health conditions may be negatively affected by poor health.

• Few successful models of holistic and integrated health and mental health care at time of study and need to address “intersection” of health and mental health.

Study Design

• Mixed methods• Randomized trial carried out at 3 mental

health clinics• Enrolled n=200 (n=94 in E group; n=106 in C)• Experimental intervention designed to

address array of co-morbidities using a nurse practitioner

• Qualitative interviews of health access and integration at the individual and system levels

InterventionStructure of NP Intervention:•Stationed in mental health setting.•Fully licensed examination room/equipment.•Open communication with mental health providers (no HIPAA barriers).Components of NP Intervention:•Assess individual healthcare needs of mental health client.•Plan & treat; coordinate existing primary care (not supplant it—participants kept their docs).•NP assesses not only primary health care needs but intersection of mental health/physical health care needs.•NP completes the picture/puzzle of healthcare.•NP focuses on health and wellness; modifiable lifestyle factors.

Control InterventionWellness Education Days

Women’s Health with breast examination, pap test, bone density screening/education

Men’s Health with prostate screen and testicular examination/education

Keep your Heart Healthy with BP checks and cholesterol screening De-Stress Day with BP and HR check, breathing control and chair

massages Dental Day with oral screening, cleanings, free supplies Body Celebration with body inventory and flu shots Feet Spa Day with foot exam, bath, powder and socks Good Sleep Day with velour sleep kit

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Study Measures• Health Functioning using the SF 36• Quality of Primary Health Care (Johns

Hopkins PCAT)• Health Beliefs• Health Locus of Control• Treatment Outcome Instrument assessing

wide array of symptoms and functioning (TOP)

• Service Utilization Costs• Assessed 4 times over 1 year

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Characteristics of Participants• Mean age of 43.

• Primary diagnoses: Bipolar disorder or major depression (55%); Schizophrenia spectrum (20%); anxiety disorders (7%). Remainder other or missing.

• A large percentage lived alone in independent or supported housing (38%).

• 50% were on SSI and 55% on SSDI; only 12% earnings from work.

• 95% taking psychotropic medications.

Characteristics of participants

• Individuals primarily female (67%) Caucasian (85%); sizable number of Latino descent (15%).

• Majority of individuals were single/never married (53%).

• 63% of individuals reported being smokers; 27% were very physically inactive.

• At baseline, report health is fair to poor (40%), experienced moderate to very severe bodily pain (55%).

• 93% had had a visit with a primary care physician or nurse in the year before baseline (this was a surprise).

Findings• E participants, about ½ saw the NP 1-3 times; much

less than desired or what was available.

Trends:

• Trend for those who engaged with the NP to improve in overall mental health and physical health, social function for the first 6 months of the intervention.

• Trend for improvement in self reported physical health among those seeing the NP frequently.

• Reported greater access to and ongoing primary care at 12 months.

FindingsTrends—participants seen by NP:•Greater internal locus of control for health (among E participants who met with NP more than 4 times).

•Believe that doctors/healthcare professionals can be helpful and less likely to believe they will have untoward medical events in the future.

•Consider their health problems seriously.

•Good news: depression, suicidaity and other indicators of mental health improved over time for whole sample

Health Care costs

• In smaller sample (n=32 E and n=41 C) were able to analyze costs.

• ED costs 40% less among E group.

• Other healthcare costs rose, like costs associated with referrals to specialists.

Qualitative InterviewsClients, Administrators and Providers• 28 mental health service recipients interviews (age:

M=42.25 +=9.03); mostly female, white and living independently.

• The majority were receiving SSDI or SSI, so quite disabled; 93% taking psychotropic medications.

• 10 providers and administrators also interviewed.

• Interviews recorded, transcribed, coded.

Barriers and Facilitators

• Lack of transportation to specialty care; distance to care.

• Lack of coverage for some routine (dental/eye) care and for specialty care (docs won’t take public insurance).

• Communication with and between medical professionals.

Conclusions• Significant barriers remain to access of some routine care

(dental and eye care) and specialty care services (e.g., specialty treatment for health conditions like cancer).

• Most of this sample did have access to PCP.

• Comprehensive health coverage for individuals increases access and utilization of primary care services.

• Primary care and mental health providers working with individuals need to increase collaboration and communication.

Most Significant Barriers—Administrators and providers

Financial Barriers—if mental health system assumes burden of care:•Cost of hiring nursing and support staff •Lack of insurance reimbursement for the services of the NP •State mental health budget cuts

Staff Barriers:•Additional responsibilities due to focus on physical health •Competencies of mental health staff to address physical health •Need for a more diverse staff to serve linguistic minority communities

Conclusions• Access to primary care alone does not change health behaviors

or health.

• Changing health behaviors and outcomes extremely difficult in individuals with healthcare issues and mental health conditions.

• The integrated approach accomplished by having a NP in the mental health setting was highly valued by clients.

• Staff/administrators see great value in seamless communication about health needs of their clients, but also something of an added burden.

Conclusions

• Primary care providers need more training on communicating effectively with individuals with SMI.

• Systemic change: address the intersection of health/ mental health, broader coverage, location of services, transportation options, healthy lifestyle options.

• For true integration of health and mental healthcare need system-wide change rather than isolated efforts by providers.

• Need for training to enhance competencies of mental health specialists in the area of physical health care.