Learning Objectives MHA Village is a community based mental health - - PDF document

APNA 29th Annual Conference Session 2012: October 29, 2015 McDermott 1

Promoting Health and Wellness Using Concepts of Integrated Healthcare and Psychosocial Recovery Principles Kathleen McDermott, DNP, RN, MSN, PMHNP BC

Disclosure

This speaker has no conflicts of interest, commercial support, or off‐label use to disclose.

Learning Objectives

 Describe how an integrated system of care can impact the health of vulnerable populations, specifically those with serious mental illness  Identify logistical issues in planning, coordinating, and implementing primary care in a community mental health setting and examine implementation challenges  Evaluate data supporting embedding primary care services and care coordination within a community mental health center

Background

 MHA Village is a community based mental health center of Mental Health America of Los Angeles (MHALA)  Founded in 1990 as a pilot project  Pioneer of the recovery movement  Provides support and assistance to its members in their recovery journey  Mission – “To assist people with mental illnesses recognize their strengths and power to recover and achieve full participation in community life. Also, to encourage system‐wide adoption of the practice and promotion of recovery and well being”

Guiding principle info

 Client choice  Quality of life  Community focus  Whatever it takes

Recovery‐focused Care

 Hope  Empowerment  Self‐Responsibility  Meaningful Role in Life

APNA 29th Annual Conference Session 2012: October 29, 2015 McDermott 2

Statistics

 Mental Illness affects 59 million people annually in US

(as cited in NIMH, n.d.)

 9.6 million of US have serious/severe mental illness (SMI) (as cited

in NIMH, n.d.)

 Schizophrenia  Bipolar Disorder  Severe Depression

 Mortality rates for persons with SMI are more than double that

• f the general population (Zolnierek, 2009)

 Deaths are largely from treatable conditions, associated with modifiable risk factors (smoking, obesity, substance abuse) & inadequate medical care (Barry & Huskamp, 2011)

System Issues

 Mental health and addiction treatment historically separated from the rest of medicine (Barry & Huskamp, 2011)  Gaps in care, inappropriate acre, disjointed care, redundant care and ↑ health costs (Kaiser Commission on Medicaid and the Uninsured, 2014)  Calls for integrated care have been noted for several decades however, segregated systems of care have persisted.  Affordable Care Act (ACA), Mental Health Parity and Addictions Equity Act (MHPAEA) of 2008, SAMHSA and HRSA

 models of integration being implemented & evaluated (Barry & Huskamp, 2011)

Barriers to optimal health for people with mental illness (SMIs):

 Increased incidence of modifiable risk factors

 smoking, alcohol/substance abuse, STDs

 Medical conditions go un‐identified / untreated  Limited access for preventative and routine care appointments  Decreased access to quality care

Barriers (continued)

 Existence of mental illness seems to affect the quality of medical care  Lack of clarity of responsibility of physical health

• f people with SMIs

 Lack of awareness of physical symptoms  Insurance – ability to apply, maintain, navigate

Even more barriers

 Transportation issues  Poor relationships with healthcare providers – lack

• f education, empathy, flexibility

 Limited continuity of care  Complexities of Health System

Timeline

 What was happening in CA and the Village during this time  Convergence of grant and ACA,

 MediCaid (MediCal in CA) expansion

APNA 29th Annual Conference Session 2012: October 29, 2015 McDermott 3

Our Population

 60% of members uninsured in 2009  High percentages of CAD, diabetes, HTN, obesity

 Similar to info in literature

Quadrant II ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ BH ↑ PH ↓ Quadrant IV ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ BH ↑ PH ↑ Quadrant I ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ BH ↓ PH ↓ Quadrant III ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ BH ↓ PH ↑

Four Quadrant Clinical Integration Model

Physical Health Risk/Status Low High Behavioral Health Risk/Status

Low High

The Chronic Care Model

Integrated Care Project

California Community Foundation Grant ‐ Objectives

• Physical assessments, short‐term primary care

(average 2‐4 visits) and education to 125 individuals with mental illness

• Connect/Reconnect 100 eligible individuals to

public medical insurance and provider

• Collaborate with physical healthcare provider

for 125 individuals with multiple needs

Concept of the Program…

APNA 29th Annual Conference Session 2012: October 29, 2015 McDermott 4

Clinic operations

 Staff

 LVN  MD

 Clinic hours  6 hours per week with LVN and MD  Funding

Medical clinic at The Village acting along the continuum to provide a bridge to care (catalyst, stop gap clinic)

seen PCP once happy and keeping appointments with PCP, none to very few ER visits, active health insurance coverage uninsured or ineffectively utilizing insurance coverage, off the streets, increased ER utilization

“Graduating” from program…

Goals of the program have been achieved. Well integrated into medical care Engaged with primary care provider Compliant with clinic visits and medications Insurance coverage is active We will see the member in ___ months to ensure stability of medical care.

Member Perspective

 Video

So let’s talk results…. a.k.a. – here comes the data!

APNA 29th Annual Conference Session 2012: October 29, 2015 McDermott 5

• 159 members seen,
• 59 identified to have no insurance
• 62 Insured ‐ aware of status / 36 Insured ‐

unaware of status

• By end of grant, 43/59 applied for insurance or

became insured (77%)

• 16 members not connected with insurance or

application process

Results ‐ Insurance

Applied 1% Insured 39% No Inurance 37% Unaware 23%

• Ins. status at beginning of grant

Applied 6% Insured 84% No Inurance 10% Unaware 0%

• Ins. status at end of grant

Insurance Results

• 159 members seen,
• 98 had no community PCP
• 15 connected to community PCP
• 2 had 1st appt. with community PCP
• 43 have identified a community PCP
• In the end, 55 connected, 22 members not

connected

• 122 members connected, 1st appt, identified PCP

Results – Community PCP

Connected 30% First visit 22% Identified 26% Not connected 22%

Grant initiation

Connected 45% First visit 17% Identtified 24% Not connected 14%

Close of Grant

Community Primary Care Provider Status

What worked? What didn’t?

 Systems issues  Member issues  Strategies to promote success  Know / learn community resources

Program Approach

 Community integration  Empowering members to make health decisions

 To advocate/understand their care  Switch doctors as desired

 Graduate from MH doesn’t mean losing your PCP  Partnerships with the community

APNA 29th Annual Conference Session 2012: October 29, 2015 McDermott 6

Current status

 Program update  Impact of having this grant

Recommendations (Lessons Learned)

 Department of Health and Human Services  Rapport is key  Keep focus on health and wellness

Take home points

 Strategic partners  Grant structure is important  It CAN be done (even with limited resources)  This is a worthy effort

 Barry, C. L., & Huskamp, H. A. (2011). Moving beyond parity — Mental health and addiction care under the

• ACA. New England Journal of Medicine, 365(11), 973‐975. doi:10.1056/NEJMp1108649



• CalMEND. (2011). Integration of mental health, substance use, and primary care services, Volume 1. Retreived

from http://www.integration.samhsa.gov/sliders/slider_10.3.pdf  De Hert, M., Correll, C., Bobes, J., Cetkovich‐Bakmas, M., Cohen, D., Asai, I.,… Leucht, S. (2011). Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health

• care. World Psychiatry 10(1), 52‐77. doi:10.1002/j.2051‐5545.2011.tb00036.x

 Kaiser Commission on Medicaid and the Uninsured. (2014, February). Integrating physical and behavoiral health care: Promissing medicaid models. Washington, DC: The Henry J. Kaiser Family Foundation. Retrieved from http://kaiserfamilyfoundation.files.wordpress.com/2014/02/8553‐integrating‐physical‐and‐behavioral‐ health‐care‐promising‐medicaid‐models.pdf  Lewin Group (2012). Approaches to integrating physical health services into behavioral health organiztions. Retrieved from ttp://www.integration.samhsa.gov/Approaches_to_Integrating_Physical_Health_Services_into_BH_ Organizations_RIC.pdf  Manderscheid, R., Druss, B., & Freeman, E. (2008). Data to manage the mortality crisis. International Journal

• f Mental Health, 37(2), 49‐68. doi:10.2753/IMH0020‐7411370202

 National Institute of Mental Health (NIMH). (n.d.). The numbers count: Mental disorders in America. Retrieved from http://www.nimh.nih.gov/health/publications/the‐numbers‐count‐mental‐disorders‐in‐ america/index.shtml#Intro  Parks, J., Svedson, D., Singer, P., & Foti, M. (2006). Morbidity and mortality in people with serious mental

• illness. Retrieved from www.nasmhpd.org

 Peek, C. & the National Integration Academy Council. (2013). Lexicon for behavioral health and primary care integration: Concepts and definitions developed by expert consensus. Agency for Healthcare Research and

• Quality. Retrieved from http://integrationacademy.ahrq.gov/sites/default/files/Lexicon.pdf.

 Wagner E., Austin, B., Davis, C., Hindmarsh, M., Schaefer, J., & Bonomi, A. (2001). Improving chronic illness care: translating evidence into action. Health Affairs,(20), no.6. 64‐78. doi:10.1377/hlthaff.20.6.64  Zolnierek, C. (2009). Non‐psychiatric hospitalization of people with mental illness: systematic review. Journal

• f Advanced Nursing, 65(8), 1570‐1583. doi:10.1111/j.1365‐2648.2009.05044.x

References