New Jersey Association of Mental Health and Addiction Agencies, Inc

New Jersey Association of Mental Health and Addiction Agencies, Inc.

Integrating Physical Health & Behavioral Health Care

(November 20, 2009)

Prepared by:

New Jersey Association of Mental Health and Addiction Agencies

Committee on the Integration of Physical & Behavioral Health Care

John Monahan, ACSW, LCSW, Chair

New Jersey Association of Mental Health

and Addiction Agencies

Integrating Physical Health & Behavioral Health Care

Serious untreated medical conditions combined with problems of access to and utilization of quality medical care present major complicating factors in the recovery of many with serious mental illness. Moreover, according to epidemiological studies, those with serious mental illnesses can expect to die 25 years earlier than the general population largely due to untreated medical conditions.[1] To address these problems, behavioral health providers throughout New Jersey have taken steps to ensure better integration of medical care and behavioral health services. Efforts at integration have been stymied in many agencies by many challenges, especially by insufficient resources.

To address these problems, the New Jersey Association of Mental Health and Addiction Agencies (NJAMHAA) proposes a multi-year, state-funded initiative to integrate physical and behavioral health care, and to target adult consumers with serious mental illness. For many consumers, the behavioral health setting may be the most accessible, least stigmatizing, and most supportive environment for securing not only behavioral health services, but also medical services.[2] Because of this, the focus for this initiative is on implementing “medical homes” in behavioral health settings, and on implementing and/or adapting best practices for ensuring effective primary care for both acute and chronic medical conditions.

NJAMHAA proposes a three-fold process to be phased in over the next five years:

I. Implementing/Adapting Evidence-based Practices & “Best Practices”

II. Implementing Disease Management & Treatment for Chronic Conditions

III. Implementing “Medical Homes” in Behavioral Health Settings

I. Implementing/Adapting Evidence-based Practices & “Best Practices”

Engaging consumers around the need for medical treatment can be complicated and time-consuming. For many consumers, the fear of medical treatment is as debilitating as the physical distress caused by lack of treatment. In addition, many consumers seeking medical care often confront unwelcoming health care providers, who are ill-informed about behavioral health issues, and apprehensive about treating someone with such problems. This makes engaging in medical treatment a more difficult and frightening prospect for many consumers. As a result, many delay treatment until medical conditions reach the crisis stage, where treatment is provided at much greater cost, and with less favorable outcomes than if it had been initiated much earlier.

Although most agencies providing case management services (e.g., PACT, ICMSS, RIST, Supportive Housing, etc.) include wellness goals and coordination of primary medical care in their treatment planning, new funding is required to ensure the greater systematization necessary to accomplish the goals of medical integration:

• the cultivation of healthy lifestyles through person-centered wellness goals;

• on-going access to and utilization of primary care for medical, dental, vision, hearing and other needs;

• improved screening and monitoring of health risks and serious medical conditions (e.g., diabetes, heart disease, etc.); and

• improved collaboration with medical providers;

• improved continuity of care by establishing consistent oversight and treatment with an individual physician/nurse or a specified team of physicians/nurses.

Because many consumers are apprehensive about medical treatment, behavioral health providers should also employ evidence-based, motivational strategies based on the Stages of Change/Stages of Treatment to motivate and assist consumers in managing their apprehension, engaging in the treatment process, and moving through treatment toward established outcomes.

NJAMHAA proposes the promulgation of evidence-based practices and “best practices” for primary care (i.e., wellness, prevention, and treatment) for all those with serious mental illness. Because it may be difficult without new funding to implement these practices in some of the areas described below, providers should take steps to show reasonable movement in this direction, until adequate resources are secured.

1. Treatment Planning for Physical Health

Treatment planning should include wellness skill development goals – such as planning nutritious healthy meals, learning basic food preparation, mindfulness in eating, regular exercise and fitness routines, proper sleep, the avoidance of harmful behaviors (e.g., smoking, substance use, etc.) – all these are necessary for health maintenance, disease prevention, and the cultivation of healthy lifestyles. Treatment planning should also include medical care coordination to address both acute and chronic health problems. (Please see below for more on chronic health problems.)

Recommendations:

1.1. Behavioral health providers should ensure that wellness skill development is an integral part of assessment and treatment planning, and includes medical history and physical baselines for all consumers with serious mental illness, to be implemented over the next two years. The HARP (Health and Recovery Peer Project) based on StanfordUniversity’s Chronic Disease and Self Management Program for mental health consumers and InSHAPE (Safe Health Action Plan for Empowerment) from Maine are possible evidence-based options for replication in our state.

1.2. Behavioral health providers should ensure that treatment planning also includes service coordination and follow-up for both acute and chronic medical problems, to the extent that resources permit.

1.3.Behavioral health providers, in collaboration with NJAMHAA and with financial support from the New Jersey Division of Mental Health Services (DMHS), should standardize:

1. core competencies in wellness skill development for consumers through both self-directed learning and peer support, with peers serving as wellness coaches;

1. core competencies for behavioral health staff functioning as peer wellness coaches, treatment planners, and care managers;

1. training and supervision to establish these core competencies as an integral part of treatment in all programs, to the extent that resources permit.

1.4Over the next two years, DMHS and NJAMHAA, in partnership with Medicaid and the Department of Health & Senior Services (DHSS), should develop training and support to help behavioral health providers incorporate into assessment and treatment planning the screening and monitoring of key health indicators, including those recommended by the National Association of State Mental Health Program Directors (NASMHPD). Key health indicators to be tracked should include the following:

• Personal History of Diabetes, Hypertension, Cardiovascular Disease;
• Family History of Diabetes, Hypertension, Cardiovascular Disease;
• Weight/Height/Body Mass Index (BMI);
• Blood Pressure;
• Blood Glucose or HbA1C;
• Lipid Profile;
• Tobacco Use/History;
• Substance Use History;
• Medication History/Current Medication List (with dosages);
• Social Supports;
• Waist Circumference; and
• Physical Activity

In addition, the following process indicators should also be implemented:

• Screening and monitoring of health risks and conditions in behavioral health settings; and

• Access to and utilization of primary care services (i.e., medical, dental, vision, hearing and other specialties).

1. Access, Linkage & Coordination of Care

Treatment planning and case management services should also include scheduling and arranging transportation to health care appointments, including physical exams every year, dental care every six months, vision every two years, etc. – along with follow-up care to treat any problems identified.

Recommendations:

2.1Over the next year, DMHS and Medicaid should establish the standard of

care for primary care (and disease management – please see below) – including frequency of physical and dental exams, screens, testing, etc. – for all patients enrolled in Medicaid with serious mental illness; and

2.2Over the next five years, phase-in the implementation of this standard of care to ensure sufficient funding to:

1. reimburse medical providers to meet this standard of care for patients with serious mental illness; and

b. ensure behavioral health providers are staffed with enough care managers, peer wellness coaches, etc. to provide adequate coordination of treatment and follow-up for acute and chronic health problems, especially for those consumers in outpatient, partial care, and other treatment programs that are without case management support.

2.3Over the next year, DMHS and Medicaid should ensure that Medical Provider Databases, such as the one published by Medicaid, are adequately publicized and made available to all behavioral health providers. Medicaid should also update these databases on a quarterly basis.

1. Information-sharing in Medical Care Coordination

Behavioral health providers and medical care providers are required to share information related to medication reconciliation, changes in medications, etc. to ensure effective coordination of treatment. Although electronic data-sharing and the integration of data systems may be years away from development, lower-tech options are available, and include phone interviews and coordination with medical providers, faxes, encrypted e-mail, etc.

Recommendations

3.1Over the next two years, DMHS and NJAMHAA, in partnership with Medicaid and DHSS, should develop training to ensure that behavioral health providers are knowledgeable about the different treatment approaches and “languages” employed by medical providers to ensure more effective communication and coordination of treatment.

3.2Over the next two years, DMHS and NJAMHAA should promulgate “Best Practice” options to ensure that data sharing and medical care coordination are effectively accomplished within existing resources. Dr. Benjamin Druss from Emory University has an evidence-based practice for care management for persons with serious and persistent mental illness know as PCARE – Primary Care Access, Referral and Evaluation – that could be used as a model.

3.3Over the next two years, DMHS should update state confidentiality regulations to ensure they are not only consistent with the Health Insurance Portability and Accountability Act (HIPAA) requirements and meet current industry standards for data-sharing, but also provide for efficient and effective collaboration between providers on behalf of consumers, and allow providers to take full advantage of state-of-the-art technology for sharing information.

1. Outcomes & Quality Improvement Reviews

Behavioral health providers should monitor outcomes for wellness services, primary care and disease management as part of their quality improvement programs. Periodic sampling of clinical records combined with on-going supervision of treatment planning and service delivery can document behavioral health providers’ efforts at helping consumers develop wellness skills, and implement assessment, treatment planning, and care coordination to address health problems for those with serious mental illness. Special attention should be paid to improving outcomes in the key health indicators recommended by NASMHPD, and discussed in I.1.4 above.

Recommendations

4.1Over the next three years, behavioral health providers, in collaboration with DMHS and NJAMHAA, should define the standard of care and establish outcome measures for wellness skill development, assessment and treatment planning, and medical care coordination. These outcomes measures should be consistent across providers and based on agreed upon benchmarking targets that can also be accomplished within existing resources.

4.2Efforts to meet this standard of care would be monitored through provider quality improvement programs on a periodic basis. The goal is for providers to show – within the limits of funding – reasonable movement each year toward the seamless integration of physical health and behavioral health care for adults with serious mental illness. This would include reasonable movement toward incorporating into treatment planning the health indicators recommended in I.1.4 above.

1. Screening & Prevention Equipment

To help increase awareness regarding the importance of wellness and prevention and to monitor changes in health status, consumers and behavioral health providers require health screening equipment and materials that can be made easily accessible to consumers.

Recommendations

5.1Over the next two years, DMHS and NJAMHAA should jointly develop requests for appropriations from the legislature, and seek out grants from foundations, pharmaceutical and health insurance companies, etc. to ensure that a basic infrastructure of health screening equipment is available to all behavioral health providers under contract with DMHS sufficient to monitor the health indicators recommended in I.1.4 above.

5.2Health screening equipment that should be available in all behavioral health agencies include: self-monitoring blood pressure cuffs; glucometers; CO2 meters to monitor levels of carbon dioxide; digital scales, and tapes to measure waist circumference, weight/height, body mass, and percent of fat; health kiosks that provide a variety of computerized screening services; etc. – all of these offer low-cost/high impact resources to help consumers develop greater health awareness, screen for serious medical conditions, and monitor on an on-going basis changes in health status.

II. Disease Management for Chronic Medical Conditions

Accurate and reliable data is not available in New Jersey regarding the incidence of chronic medical conditions among those with serious and persistent mental illness. Although the incidence of diabetes among those in state psychiatric hospitals is reportedly upwards of 30%, state-wide incidence data is not available for diabetes or any other chronic illness in the outpatient population.[3] We do know that nationally, someone with serious and persistent mental illness is likely to die 25 years earlier than the general population.[4] People with serious mental illnesses also have high rates of medical morbidity and mortality, largely due to conditions that could have been prevented.[5]

These are problems that should not continue to go unaddressed.

In addition to addressing the treatment needs of those with chronic illnesses, a state-wide registry of incidence data for chronic illnesses should be begun as soon as possible, and, in accordance with the federal mandate to increase the life span of consumers with serious mental illness, both DMHS and Medicaid should begin monitoring trends among the consumer population. Once consumers have been screened for chronic illnesses, gathering incidence data for trend analysis can be accomplished by behavioral health providers at minimal cost. But, as noted above, behavioral health providers are ill-equipped and not funded to provide such screening. Moreover, they are even less able to provide the care coordination required once a chronic medical condition is identified.

Medical care management for chronic medical conditions can be a complex and time-consuming process. Direct service staff generally lack sufficient medical sophistication to interact effectively with medical providers. Moreover, consumers with complex medical

problems can absorb disproportionate staff time, leaving the behavioral health needs of other consumers underserved by the program. Although some programs hire nurses to

manage complex medical problems, this often leaves program staffing with less direct service staff time to manage caseloads and address the behavioral health and case management needs of these and other consumers.

Recommendations

1. Disease Management Initiative

Securing treatment and coordinating care for such complex chronic illnesses as HIV/AIDS, diabetes, heart disease, chronic obstructive pulmonary disease, etc. requires the development of a state-wide Disease Management Program for Chronic Illnesses to be implemented over the next three years. Currently, few, if any, agencies are adequately staffed to provide the care management, medical coordination, and peer wellness coaching that consumers with complex medical conditions require. As discussed in I.1.4 above, the recommended health indicators for persons with serious mental illness from the NASMHPD should be adopted. Existing evidence-based protocols for asthma, Chronic Obstructive Pulmonary Disease (COPD), diabetes, cardiac and other diseases should also be explored for replication in New Jersey. Both DMHS and Medicaid should also begin planning to increase the life span of consumers, per the federal mandate, and begin monitoring progress toward this goal by implementing a state-wide registry of chronic illnesses, and by analyzing health outcomes and trends produced by the disease management programs proposed for development under this initiative.

1. Disease Management Staffing

DMHS, in collaboration with Medicaid, should allocate sufficient resources to ensure that over the next three years, every behavioral health provider has funding to hire a disease management team comprised of Advance Practice Nurses (APN), Registered Nurses (RN), and/or Licensed Practical Nurses (LPN) to ensure a nurse-to-consumer ratio of one to seventy-five. Care managers and peer wellness coaches round out the team. Although the recommended caseload of patients without serious mental illness may be larger, staffing for this population should be more intense because of the severity and multiplicity of problems and the greater difficulty coordinating care, as discussed above. Because of the great time commitment required for coordinating with medical providers, programs should bill for such coordination, as well as face-to-face time with consumers, at the ICMSS rate of $124.40 per hour. Care management for those consumers not enrolled in Medicaid should be subsidized by DMHS at the same rate.

1. Testing & Labwork for Chronic Illnesses

Although medical care managers could provide some basic screening services to

identify those who might have chronic illnesses, additional tests and labwork are required for medical providers to complete the diagnosis, and some of these may not be authorized for reimbursement under Medicaid. DMHS, in collaboration with Medicaid, should allocate sufficient resources over the next three years to ensure that funding is available to cover a basic but comprehensive package of medical tests and labwork required to diagnose someone with a chronic illness.