rn primary care manager in behavioral health settings · 2018-01-08 · • n = 447 patients with...
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RN Primary Care Manager in Behavioral Health Settings
Integrated Care and the Expanding Role of Nurses Seattle Airport Marriott, SeaTac, WA Tuesday, January 9, 2018
The Healthier Washington Practice Transformation Support Hub
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• Sara Barker, MPH
• Lydia Chwastiak, MD, MPH, MA
• Olga Felton, RN, MSN, CENP
Welcome & Introductions
2
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Used with permission from the University of Washington AIMS Center
Medical Co-Morbidities in Populations with Serious and Persistent Mental Illness (SPMI)
Session 1
3
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Used with permission from the University of Washington AIMS Center
Learning Objectives
• Understand the impact of medical comorbidity on patients with serious mental illnesses
• Describe evidence-based treatment approaches for
reducing cardiometabolic risk in this population • Identify the roles for nurses in integrated care
models, including behavioral health homes
APA/AMP 2016: Primary Care Skills for Psychiatrists
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Used with permission from the University of Washington AIMS Center
The Problem: Premature Mortality
• Adult Medicaid enrollees with schizophrenia have a reduced life expectancy that is, on average, 25 years shorter than the general population
• They are more than 3.5 times as likely to die of cardiovascular disease
Olfson M et al. JAMA Psychiatry. 2015;72(12):1172-1181
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Used with permission from the University of Washington AIMS Center
Increased Rates of Chronic Diseases
National Cardiometabolic Screening Program (2005-2008), n = 10,084 at 100 CMCHs • Obesity 27% were overweight; 52% were obese
• Dyslipidemia • 45% had TG > 150 mg/dl • 35% had total • 33% had FBG > 100 mg/dl
• Hypertension 51% had BP > 130/85 mm Hg
Correll CU et al Psychiatr Services 2010; 61: 892-898
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Used with permission from the University of Washington AIMS Center
Impact of Schizophrenia on Diabetes
• Prevalence of T2 DM = 11.3% (US population = 8%)1
• Increased rates of diabetes complications2
• More diabetes-related hospitalizations3
• More hospitalizations for ambulatory care sensitive conditions4
• Increased risk of re-hospitalization for T2DM in 30 days5
• Increased diabetes-specific mortality3
1Vancampfort D et al. World Psychiatry 2016; 15(2): 166-174. 2Becker T, et al. Diabetes Care 2011; 34(2): 398-402; 3Mai Q, et al. BMC Med 2011; 9:118; 4Druss BG, et al. Med Care 2012; 50(5): 428-433 5Chwastiak L, et. al. Psychosomatics 2014; 55(2): 134-143
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Used with permission from the University of Washington AIMS Center
$0
$200
$400
$600
$800
$1,000
$1,200
$1,400
$1,600
Private Sector Medicare Medicaid
No Mental Disorder
Any Mental Disorder
MH Disorder as Predictor of High Cost
Melek et al Milliman Inc, 2013
8
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Used with permission from the University of Washington AIMS Center
Contributing Factors
• Individual • Psychiatric symptoms • Health behaviors • Poverty
• Limited resources • Competing priorities
• Provider/treatment • Metabolic effects of
medications • Inadequate training and time • Lesser quality of care for
medical conditions • System
• Fragmentation of physical health and mental health services and funding
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Used with permission from the University of Washington AIMS Center Allison DB et al. J Clin Psychiatry. 1999;60:215-220.
< 18.5 18.5-20 20-22 22-24 24-26 26-28 28-30 30-32 32-34 > 34 0
10
20
30
No schizophrenia Schizophrenia
Obese Overweight Acceptable Underweight
BMI Range
Obesity
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Used with permission from the University of Washington AIMS Center
0% 20% 40% 60% 80%
No Psychiatric Illness
Any psychiatric illness
Bipolar Disorder
Schizophrenia
Prevalence of Current Smoking
Dickerson F, et.al,. Psychiatr Serv 2013; 64 (1): 44
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Used with permission from the University of Washington AIMS Center
Impact of Antipsychotic Medications
*4–6 week pooled data (Marder SR et al. Schizophr Res. 2003;1;61:123-36; †6-week data adapted from Allison DB, Mentore JL, Heo M, et al. Am J Psychiatry. 1999;156:1686-1696; Jones AM et al. ACNP; 1999.
Estimated Weight Change at 10 Weeks on “Standard” Dose
6
Wei
ght C
hang
e (k
g)
5 4 3 2 1 0 -1 -2 -3
13.2
Weight C
hange (lb)
11.0 8.8 6.6 4.4 2.2 0 -2.2 -4.4 -6.6
†
*
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Used with permission from the University of Washington AIMS Center
Quality of Diabetes Care
HEDIS measure Any MH Dx, % No MH Dx, % Adjusted OR P value
HbA1c 43.8% 47.0% 0.88 (0.86-0.89) <0.0001 Eye exam 51.1 58.9 0.73 (0.72-0.74) <0.0001 LDL screening 24.4 26.9 0.88 (0.86-0.89) <0.0001 Medical attention for nephropathy
12.0
12.4
0.96 (0.94-0.99)
0.0023
At least 2 HEDIS measures
38.4
42.8
0.83 (0.82-0.85)
<0.0001
Druss BG, et.al. Medical Care 2012; 50(5): 428-433
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Used with permission from the University of Washington AIMS Center
What Can Reduce CVD Risk?
Meta-analysis for AHRQ: 33 RCTs from 1980-20121
• 28 studies addressed weight • One weight loss study of Schizophrenia and Diabetes2
Comprehensive review for NIMH3 (80 of 108 studies related to obesity)
• Strong evidence for use of four interventions – Metformin for obesity – Lifestyle modification for obesity – Bupropion for tobacco cessation – Varenicline for tobacco cessation
1Gierisch JM, et al. J Clin Psychiatry. 2014 May;75(5):e424-40. 2McKibbin CL, et.al. Schizophr Res. 2006 Sep;86(1-3):36-44. 3McGinty EE et al. Schizophr Bull. 2016 Jan;42(1):96-124
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Used with permission from the University of Washington AIMS Center
https://www.nice.org.uk/guidance/cg178/chapter/1Recommendations
2014 Treatment Guidelines for Schizophrenia (UK NICE)
• Routinely monitor weight and metabolic indicators of morbidity.
• Combined healthy eating and physical activity program
• Offer relevant interventions for rapid or excessive weight gain, abnormal lipid levels or problems with blood glucose management
• Consider interventions for smoking cessation: • NRT; Bupropion, Varenicline
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Used with permission from the University of Washington AIMS Center
32%
7% 2% 7%
25%
27%
None
Smokingonly
Diet only
Exerciseonly
Counseling by CMHC Clinicians (n=154)
• The majority of clinicians do not provide specific counseling on three CVD risk factors
• Healthier clinicians may be more likely to explicitly support healthy behaviors in clients
• Clinicians who had training were more likely to counsel Chwastiak LA et al Psychosomatics 2013; 54: 328-335
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Used with permission from the University of Washington AIMS Center
Primary Care Nurse Manager (PCARE)
Usual Care Intervention Group
Preventive Services 21.8% 57.8%
Cardiometabolic Interventions 27.7% 34.9%
Have Primary Care Provider 51.9% 71.2%
Framingham Risk Index 9.8% 6.9%
Druss BG, et al. Am J Psychiatry. 2010;167(2):151-159.
• RCT, • N= 407 with SMI • One year
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Used with permission from the University of Washington AIMS Center
PCARE: Care Management Roles
• Identify high-risk individuals • Patient education • Individualized planning with patients • Facilitate patient engagement • Monitoring of health status and adherence • Track outcomes in registries • Track care transitions
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Used with permission from the University of Washington AIMS Center
Integrating Care: Three Models
Facilitated Referral
Co-located partnership
“In House”
BHA assures coordination of PC services, which are provided off-site
BHA arranges for a PC org to provide PC services—or a PC clinic-- on-site at the BHA
BHA provides it own full array of PC services (BHA = FQHC)
PCARE model SAMHSA PBHCI Cherokee
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• Primary Behavioral Health Care Initiative [PBHCI]
• 200+ CMHC’s in US over eight years. – Co-location of
primary care – Use of registry – Care management – Health behavior
change
National Demonstration of Integrated Care (SAMHSA PBHCI)…
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...Did Not Improve Care or Outcomes
Scharff DM, et.al. Psychiatr Serv. 2016 Nov 1;67(11):1226-1232
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Challenges
• No consistent care model – Variability in outcomes and quality of care – Hard to scale
• Primary care services were often not financially sustainable
• Nurse care manager role was not sustainable when grant funding ended
• Co-located is not the same as integrated
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Integration Scores for PBHCI Grantees: Culture was Lowest
Collaboration on Tx Plans Collaboration on Goals Overall Leadership Collaboration Overall Provider Collaboration
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HOME Research Study (RCT)
• N = 447 patients with SMI and 1+ CVD risk factors – Primary outcome: 10-year CVD risk
• Behavioral Health Home vs usual care – Part-time PC ARNP + full-time RN care manager
supervised by FQHC medical director • Among those with diabetes and hypertension, those
in BHH were more likely to receive pharmacotherapy • BHH more likely to receive preventive care services • No difference in clinical outcomes
Druss B, et al. Am J Psychiatry. 2017 Mar 1;174(3):246-255.
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(Medicaid) Behavioral Health Homes
• The ACA created a new option for state Medicaid programs to provide health homes for enrollees with chronic conditions, including behavioral health conditions • Became effective 1/1/2011
• Program provides financial incentives for states • Required
• Continuity • IT • Coordinate care (not required to provide all services)
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• Strategies: Case management coordination and facilitation of healthcare
• Primary care nurse care managers
• Disease management for persons with complex chronic medical conditions, SMI, or both
Missouri Health Home Overview
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Behavioral Health Homes
• Team approach • Population-based screening • Measurement-based care • Treatment-to-target • Care coordination
–Health education –Address barriers to care –Ensure linkage to medical care
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Disease Management Diabetes Outcomes (2822 Continuously Enrolled Adults)*
*29% of continuously enrolled adults
Source: http://dmh.mo.gov/docs/mentalillness/prnov13.pdf
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• Medicaid Demonstration requirements - metrics • Existing funding of FFS care vs. addressing social
needs • Cultural change in dedicated MH staff • Workforce development (e.g., training in
motivational interviewing) • Registry development and implementation • Money in the short term
Challenges and Barriers
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• Data is required to identify treatment and prevention opportunities
• Training helps implement new evidence-based interventions – Might allow use of a lower-cost FTE
• Personal interaction is the true change agent
Lessons Learned
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• Screen for chronic medical conditions
• Participate in treatment of risk factors
• Educate about risk reduction • Advocate for and link with treatment • Identify barriers and address • Support adherence to pharmacologic treatment
Role(s) of the Nurse
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The project described was supported by Funding Opportunity Number CMS-1G1-14-001 from the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.