finger lakes health systems agency interface of the physical and mental health care systems rcchi...
TRANSCRIPT
Finger Lakes Health Systems Agency
Interface of the Physical and Mental Health Care Systems
RCCHI Meeting
December 18, 2013
Definitions
• Behavioral Health– Mental illness– Substance abuse– Exclude dementia and developmental disabilities
• Serious Mental Illness– Psychoses (i.e.- schizophrenia, bipolar disorder)– Major depression– PTSD
• Primary vs. Secondary Diagnoses
• Not Health Behaviors
National Prevalence of Behavioral Illness
25%CDC; 2011
Prevalence of Behavioral Illness Among General Medical Outpatients
25-40%Kathol et al; 2006
Prevalence of Behavioral Illness Among Medical Inpatients
>40%Kathol et al; 2006
Mental Illness and Physical Health
• Mental illness increases risk for a variety of medical conditions– Obesity– Cardiovascular disease– Gastrointestinal disorders– Diabetes– HIV– Pulmonary Disease– Hypertension– Cancer
Dickey, et al; 2002Jones, et al; 2004Pandiani, Boyd, Banks, Johnson; 2006
REGIONAL PREVALENCE OF MENTAL ILLNESS
Q3a. Percent of adults experiencing poor physical health 14 or more days in the past month.
Monroe (n=651)
Livingston (n=641)
Ontario (n=659)
Seneca (n=641)
Wayne (n=649)
Yates (n=644)
Chemung (n=662)
Schuyler (n=657)
Steuben (n=638)
0%
10%
20%
30%
40%
50%
11.4% 10.1% 11.4% 12.1% 12.3%10.2%
12.5% 13.1% 13.0%
Data from NYS Dept. of Health, Expanded Behavioral Risk Factor Surveillance System
Monroe (n=654)
Livingston (n=647)
Ontario (n=663)
Seneca (n=648)
Wayne (n=649)
Yates (n=649)
Chemung (n=661)
Schuyler (n=662)
Steuben (n=650)
0%
10%
20%
30%
40%
50%
12.0%8.1%
10.8% 9.4%12.9%
8.5%12.0%
9.4%11.9%
Q4a. Percent of adults experiencing poor mental health 14 or more days in the past month.
0%
5%
10%
15%
20%
25%
30%
Percent of Respondents with Select Mental Health Issues Over the Past 30 Days
Monroe County, 2012
Data Source: Monroe County Adult Health Survey (AHS), 2012
0%
5%
10%
15%
20%
25%
30%
35%
Percent of Respondents with Select Mental Health Issues by Age Group
Monroe County, 2012
Age 18-64 Age 65+
**
*
*
*
* = significant difference Data Source: Monroe Co. AHS, 2012
Stress, depression
and/or problems with emo-
tions on 14 or more
days
Felt calm and peace-ful – none or a little
of the time
Felt down-
hearted and de-
pressed - all or most
of the time
Ever told they had
depression or anxiety
Taking med or re-
ceiving treatment
for any type of mental health
condition or emo-
tional prob-lem
0%
5%
10%
15%
20%
25%
30%
Percent of Respondents with Select Mental Health Issues by Race/Ethnicity
Monroe County, 2012
White African American Latino
* = significantly different from WhitesData Source: Monroe Co. AHS, 2012
*
*
0%
5%
10%
15%
20%
25%
30%
35%
Percent of Respondents with Select Mental Health Issues by Geography
Monroe County, 2012
City of Rochester Suburban Monroe County
**
*
*
* = significant difference Data Source: Monroe Co. AHS, 2012
ADOLESCENT MENTAL HEALTH
Data Source: Monroe County Youth Risk Behavior Survey, 2011
HEALTH CARE UTILIZATION AMONG INDIVIDUALS WITH BEHAVIORAL HEALTH ISSUES
Hospital Admissions in 2011 (Excluding Newborns)Finger Lakes Region, SPARCS Database
119,557
Data Source: NYS Dept. of Health, SPARCS Inpatient file
55%45%
Admissions with a Behavioral Health Diagnoses in 2011Finger Lakes Region
Primary or Secondary Behavioral Health Diag-nosis
Data Source: NYS Dept. of Health, SPARCS Inpatient file
55%
Behavioral Health Primary
Diagnosis8%
Behavioral Health Sec-ondary Di-
agnosis37%
Admissions with a Behavioral Health Diagnoses in 2011Finger Lakes Region
Data Source: NYS Dept. of Health, SPARCS Inpatient file
1 2 3 4 50%
10%
20%
30%
40%
50%
60%
Percent of Hospital Admissions with a BH Diagnosis by Race/Ethnicity and Socioeconomic Status
Finger Lakes Region, 2011
White Black Hispanic
SES (Low --> High)SES rankings are based on ZIP-code level Census Bureau data and are calculated by the FLHSA
Finger Lakes Health Systems Agency
*
*
Indicates a statistically significant difference from the White group within the same SES stratum at the p<0.05 level
*
Data Source: NYS Dept. of Health, SPARCS Inpatient file
0 1 2 3 4 5 6 7
5.03
5.98
Average Length of Stay by Presence of a Behavioral Health Diagnosis
Any Behavioral Health Diagnosis No Behavioral Health DiagnosesAverage Length of Stay (Days)
*
* Indicates statistical significance at the p<0.05 level
Data Source: NYS Dept. of Health, SPARCS Inpatient file
ED - Treat & Release Home Care Inpatient Observation Transportation Urgent Care
0
50
100
150
200
250
300
350
400
450
2012 Health Care Utilization by the Presence of a Behav-ioral Health Encounter in the Preceding Year
Finger Lakes Region
No Behavioral Health Encounters in 2011 Behavioral Health Encounter in 2011
2012
En
cou
nte
rs p
er 1
,000
Pat
ien
ts
Data Source: Regional Multi-payer claims database
Summary
• Behavioral health issues are prevalent– Especially among the inpatient population
• Not an issue limited to adults
• Mental illness, substance abuse, and physical illness do not occur in isolation
• The presence of behavioral health issues are associated with increased health care utilization
EVIDENCE OF SUBOPTIMAL CARE
Diagnosis of Behavioral Health Issues
• Primary care as gate-keeper– Evidence that behavioral health issues are often un- or
misdiagnosed in a primary care setting (e.g.- Kroenke, et al. 2007; Vermani, et al. 2011)
Treatment of Behavioral Health Issues
• Unmet mental health needs:– 60% of adults with a diagnosable conditions1
– 70% of children in need of treatment2
• 54% of people with mental health issues receive no specialty treatment3
• 90% of individuals over the age of 12 with a substance abuse condition do not receive specialty treatment4
1. Druss, Wang, Sampson; 20072. DHHS; 19993. Wang, et al; 20064. Levit, et al; 2008
Treatment of Medical Conditions
• High rates of non-treatment for chronic conditions like diabetes, hypertension, high cholesterol, metabolic syndrome, and dental health issues for individuals with serious mental illness
Nasrallah, et al; 2006DeHert, et al; 2011
Hospital Readmissions
“Avoidable readmissions are a strong indicator of a fragmented health care system that too often leaves discharged patients confused about how to care for themselves at home, and unable to follow instructions and get the necessary follow-up care.”
-Ness and Kramer
Health Affairs Blog, 2013
Number of Visits with a 60 Day Readmit
% of All Visits with a Readmission
1 Heart Disease 2842 14.62 Mental Disorders 1578 8.13 COPD 1061 5.44 Symptoms (i.e.- Chest pain) 959 4.95 Bacterial Disease (i.e.- Septicemia) 956 4.96 Pneumonia/Flu 847 4.3
7 Other Diseases Of Digestive System 815 4.2
8Complications Of Surgical And Medical Care, Not Elsewhere Classified 794 4.1
9 Other Diseases Of Urinary System (UTI) 686 3.5
10Diseases Of Other Endocrine Glands (Diabetes) 669 3.4
Leading Diagnosis Clusters Associated with a Readmission within 60 DaysFinger Lakes Region, 2011
Data Source: NYS Dept. of Health, SPARCS Inpatient file
30 Day Readmit Rate 60 Day Readmit Rate0%
5%
10%
15%
20%
25%
Readmission Rates for Hospital Admissions with and without a Behavioral Health Comorbidity
Finger Lakes Region, 2011
No BH Comorbidity
BH Comorbidity*
*
* Indicates a sta-tistically signifi-cant difference from the NO BH Comorbidity group at the p<0.05 level
Data Source: NYS Dept. of Health, SPARCS Inpatient file
No BH C
omor
bidity
Men
tal H
ealth
Com
orbid
ity
Subst
ance
Abu
se C
omor
bidity
Seriou
s M
enta
l Hea
lth C
omor
bidity
0%
5%
10%
15%
20%
25%
30%
Readmission Rates by Type of Behavioral Health ComorbidityFinger Lakes Region, 2011
30 Day Readmit Rate
60 Day Readmit Rate*
**
*
* Indicates sta-tistically signifi-cant difference from the No BH Comorbidity group at the p<0.05 level
*
*
Data Source: NYS Dept. of Health, SPARCS Inpatient file
Mental Health Condition Substance Abuse Only Serious Mental Health Condition
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
Effect of Behavioral Health Comorbidities on 30-Day Read-mission Risk
Finger Lakes Region, 2011
Ad
jus
ted
Od
ds
Ra
tio *
*
* Indicates statistical significance at the p<0.05 level
Data Source: NYS Dept. of Health, SPARCS Inpatient file
Mental Health Condition Substance Abuse Only Serious Mental Health Condition0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
Effect of Behavioral Health Comorbidities on 60-Day Readmission RiskFinger Lakes Region, 2011
Adju
sted
Odd
s Rati
o
* Indicates statistical significance at the p<0.05 level
*
*
Data Source: NYS Dept. of Health, SPARCS Inpatient file
Multivariate Regression: Effect of a Behavioral Health Comorbidity on Risk for Hospital ReadmissionFinger Lakes Region, 2011
30 Day Readmission 60 Day Readmission
AOR p-value 95% CI AOR p-value 95% CINo Behavioral Health Comorbidity REF
Mental Health Condition 1.11 0.001 1.04 1.18 1.09 <0.001 1.05 1.14
Substance Abuse Only 1.05 0.364 0.95 1.16 1.06 0.217 0.97 1.17
Serious Mental Health Condition 1.41 <0.001 1.17 1.70 1.32 <0.001 1.13 1.54
Data Source: NYS Dept. of Health, SPARCS Inpatient file
Emergency Department Utilization
• Emergency Department– High cost– Not well suited to delivering continuous primary care
• Avoidable use of this care setting has been used as an indicator for inadequate access to primary care and poor care coordination
Christakis, et al; 2001Gill, Mainous, Nsereko; 2000Sarver, Cydulka, Baker; 2002
Leading Causes of Non-Injury Related ED Treat and Release VisitsFinger Lakes Region, 2011
Rank Diagnosis Cluster # of Visits % of Total Non-Injury T&R Visits
1Symptoms (chest pain, abdomen pain) 99,275 29.94
2 Mental Disorders 23,416 7.07
3 Acute Respiratory Infections 22,107 6.67
4 Back Pain 21,814 6.58
5 Urinary System Diseases (UTI) 14,541 4.39
6 COPD 11,602 3.5
7 Ear Infections 10,425 3.14
8Diseases Of Oral Cavity, Salivary Glands, And Jaws 10,068 3.04
9 Skin Infection 8,672 2.62
10 Headache/Migraine 8,363 2.52
Data Source: NYS Dept. of Health, SPARCS Inpatient file
Repeat Visit Within 30 Days Repeat Visit Within 60 Days0%
5%
10%
15%
20%
25%
30%
35%
40%
Rates of Repeat ED Treat and Release Visits by Presence of a Behavioral Health Diagnosis
Finger Lakes Region, 2011
No Behavioral Health Diagnosis Behavioral Health Comorbidity Behavioral Health Primary Diagnosis
*
**
*
* Indicates statistically significant difference from the No BH Diagnosis Group at the p<0.05 level
Data Source: NYS Dept. of Health, SPARCS Inpatient file
Behavioral Health Comorbidity Behavioral Health Primary Diagnosis0.6
0.8
1.0
1.2
1.4
1.6
1.8
Risk of Repeat ED Treat and Release Visit Within 30 Days by the Presence of a Behavioral Health
Finger Lakes Region, 2011
Adju
sted
Odd
s Rati
o
* Indicates statistical significance at the p<0.05 level
*
*
Data Source: NYS Dept. of Health, SPARCS Inpatient file
Behavioral Health Comorbidity Behavioral Health Primary Diagnosis0.6
0.8
1.0
1.2
1.4
1.6
1.8
Risk of Repeat ED Treat and Release Visit Within 60 Days by the Presence of a Bheavioral Health
Finger Lakes Region, 2011
Adju
sted
Odd
s Ra
tio
* Indicates statistical significance at the p<0.05 level
*
*
Data Source: NYS Dept. of Health, SPARCS Inpatient file
30 Day Repeat Visit 60 Day Repeat Visit
AOR p-value 95% CI AOR p-value 95% CI
No Behavioral Health Diagnosis REF Behavioral Health Comorbidity 1.38 <0.001 1.34 1.42 1.39 <0.001 1.36 1.43Behavioral Health Primary Diagnosis 1.66 <0.001 1.61 1.71 1.66 <0.001 1.61 1.71
Multivariate Regression: Effect of a Behavioral Health Diagnosis on Risk for a Repeat ED Treat and Release Visit
Health Outcomes
• People with serious mental illness die, on average, 25 years earlier than their age cohorts in the general population
• The presence of comorbid mental illness increases the risk of mortality for individuals with a variety of chronic diseases
Parks, et al; 2006Phillips, et al; 2009Williams, Ghose, Swindle; 2004
Conclusions
• Evidence that individuals with behavioral health issues are not being treated optimally– Bidirectional
• The local experience seems to be consistent with national findings
• Suboptimal care has real impacts– Health of the community– Efficiency of the health care system
Questions
Data Source: Monroe County Youth Risk Behavior Survey
Data Source: Monroe County Youth Risk Behavior Survey
White Black Hispanic0%
10%
20%
30%
40%
50%
60%
Percent of Hospital Admissions with a BH Diagnosis by Race/Ethnicity
Data Source: NYS Dept. of Health, SPARCS Inpatient file
0-18 19-34 35-49 50-64 65-74 75-84 85+0%
10%
20%
30%
40%
50%
60%
70%
Percent of Hospital Admissions with BH Diagnosis by Age
Data Source: NYS Dept. of Health, SPARCS Inpatient file
Monroe Southern Central0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Percent of Hospital Admissions with BH Diagnosis by Sub-Area
Data Source: NYS Dept. of Health, SPARCS Inpatient file
1 2 3 4 50%
10%
20%
30%
40%
50%
60%
Percent of Hospital Admissions with a BH Diagnosis by Socioeconomic Status
SES (Low-->High)
Data Source: NYS Dept. of Health, SPARCS Inpatient file
Healthcare Spending
Roehrig, Miller, Lake, Bryant; 2009