It is all well and good to say that the integration of behavioral health and primary care is beneficial, even vital, to the improvement of health outcomes for people who have a serious mental illness. However, unless we are able to provide evidence of such, it remains merely speculation. But how can we provide evidence?
Tracking outcomes allows for determining whether the healthcare interventions are effective. It is particularly important to screen for the following and routinely track as indicated:
- Body-mass index (BMI)
- Blood pressure
- Hemoglobin A1c
- Family history of diabetes, hypertension, and cardiovascular disease
- Tobacco use history
- Substance use
- Other areas as indicated
There are many screening tools and diagnostic labs that allow for screening many of the above. Ideally, these will be conducted on the initial visit to provide a baseline. Subsequent visits can focus on the areas that were identified a need and allows for tracking effectiveness of treatments.
These measurements provide an objective method of tracking response to treatment. This information is invaluable not only for treatment planning for the individual patient, but also provides data to demonstrate the effectiveness of the healthcare providers.
Demonstrating Treatment Efficacy
Electronic Health Records allow for the efficient gathering and reporting of outcomes. This data may be used as evidence of treatment efficacy, which is necessary for securing and maintaining funding (which is, of course, necessary for staying in business). This example is from a report from a behavioral health and primary care integration team that highlights the six month outcomes from 295 people served (click here for details): Behavioral Health – Primary Care Integration Outcomes.
In a similar collaborative effort between a community behavioral health organization and a private disease management initiative, the outcomes indicate a positive correlation between integrated efforts and follow up with health screenings (click here for details): Community Behavioral Health – Private Disease Management Collaboration Outcomes.
These two examples provide evidence of the effectiveness of behavioral health and primary care integration efforts to impact the health outcomes of people with serious behavioral health disorders.
Routine collection and reporting of data provides ongoing feedback to the team. The data allows for:
- Reassurance of effectiveness of methods for team members
- Evidence of efficacy for regulatory and funding organizations
- Timely identification of areas requiring calibration for increased effectiveness
- Potential and current patients/clients can make an informed decisions in choosing healthcare providers
“Psychiatrists need to pay attention to weight, lipid levels, blood pressure, and exercise in our patients with serious mental illness,” declares psychiatrist Dale Svendsen, M.D., medical director at the Ohio Department of Mental Health and co-author of the NASMHPD report. “The psychiatrist of the future is going to have to be more of a general physician than in the past, and our training programs are going to need to adapt.” In Those With Serious Mental Illness Suffer From Lack of Integrated Care, in Psychiatric News January 5, 2007, Vou. 42, No. 1, Pg. 5 Mark Moran summarizes the National Association of State Mental Health Program Directors (NASMHPD) report “Morbidity and Mortality in People With Serious Mental Illness.” Emphasizing the recommendation that people with serious mental illness “be designated as a distinct health-disparities population under the federal government’s initiative to reduce disparities in health outcomes.” Perhaps psychiatrists need to pick the stethoscope back up again…. and actually touch their patients.
Moran goes on to look at compelling data: In a study of people (25 to 44 years old) with serious mental illness in Massachusetts over a six year period, the cardiovascular rate was nearly seven times that of the general population. In another study in Ohio, state psychiatric hospital discharges were tracked over a six year period. People who had been hospitalized there died at three times the expected rate, primarily due to cardiovascular disease. The average loss of life was a startling 32 years. The NASMHPD report drew clear connections between antipsychotic medications in the development of metabolic syndrome in people with serious mental illness, particularly when multiple medications are prescribed. Their recommendations include integration of behavioral health and physical health, promotion of the recovery model, supporting wellness, and the implementation of care-coordination models.
In the nearly four years since this was published, there has been a marked increased in focus on the serious health disparities of this vulnerable population. The question remains whether there has been an improvement in overall health among this group. While ongoing studies must be conducted to adequately address this question, I am encouraged by the concentration on the issue. The National Council for Community Behavioral Healthcare, the Mental Health Corporation of America, Association of Healthcare Research and Quality, the Carter Center, the Collaborative Family Healthcare Association, National Institute of Mental Health, Substance Abuse and Mental Health Services Admistration, National Association of State Mental Health Program Directors, Institute for Clinical Systems Improvement, Collaborative Care Research Network, Health Resources and Services Administration, and a variety of other national and state associations have initiatives directed toward integration efforts. These efforts include new programs, partnerships, grants, learning collaboratives, and research. APS Healthcare of Georgia’s Disease Management division is working on an initiative with various community behavioral health organizations to create a ‘Virtual’ Medical Home. This novel approach is led by Dr. Bob Climko, Senior Medical Director. Health indicators in people with serious mental illness are monitored through telephonic health coaching and Medicaid claims data made available to providers.
It is hopeful that this increased focus will result in a significant increase in longevity for people with serious mental illness. In the words of UN Secretary General Ban Ki-moon, “Let us recognize that there can be no health without mental health.” It would appear that the reverse is true as well: There can be no mental health without health.