Health Integration Activities in the NYC Department of Health and Mental Hygiene

In recent years, health has come to be recognized more as a state of physical, mental, behavioral and social well-being, and not merely the absence of disease or infirmity. The link between physical and behavioral health has been measured in New York’s own population. According to the 2004 New York City Health and Nutrition Examination and Survey (NYC-HANES), on average, New Yorkers who had significant emotional distress were 12% more likely to engage in behaviors (including physical inactivity, binge drinking, smoking, and poor diet) that put them at increased risk for co-morbid medical conditions.

Adults with serious mental illnesses, such as schizophrenia, bipolar disorder and depression, as well as co-occurring serious mental illness and substance use, lose significant years of their life to disability, morbidity, and mortality resulting from a combination of physical and behavioral health factors. Many die prematurely from conditions such as cardiovascular, pulmonary and infectious disease at a much higher rate than individuals who do not have a serious mental illness. People living with serious mental illnesses encounter additional barriers to adequate health care such as system fragmentation and stigma and as a result receive fewer routine preventative services.

The New York City Department of Health and Mental Hygiene’s (DOHMH) Division of Mental Hygiene (DMH) through its Bureau of Mental Health and Offices of Health Integration and Mental Hygiene Quality Improvement is engaged in a two-part approach to integrating physical and mental health services. The first focuses on detection and management of depression in primary care settings. The second focuses on addressing the physical health needs of individuals receiving mental hygiene services.

While depression is commonly seen in primary care settings, it is frequently unrecognized by primary care physicians and, even when diagnosed, often results in less than adequate treatment. DOHMH’s Depression Initiative aims to better prepare primary care physicians to screen and manage depression through training, technical assistance, and care management support.

To improve the quality of depression and management in primary care, DMH works with local health care providers to promote integrated care. In one model, depression care managers provide follow-up, outreach and support to individuals who have screened positive for depressive symptoms and are receiving care from their primary care doctor. Individuals receive follow-up phone calls between their regular office visits. During these calls care managers may periodically administer the PHQ-9 depression screen to assess changes or improvement in symptoms, help people adhere to their treatment plan, and encourage self-management goals such as exercise. This information is shared with the treating primary care provider, who may also consult with a psychiatrist as needed. DMH began working to place care managers in selected Federally Qualified Health Centers (FQHCs) in 2007 and is currently evaluating the model.

The DOHMH strategy for integrating physical health care into behavioral health settings includes working with mental hygiene providers through the DMH Quality IMPACT Initiative to conduct continuous quality improvement projects aimed at improving the assessment, monitoring, and care coordination of consumers’ physical health issues in mental hygiene treatment programs. In fiscal year (FY) 09 50 participating providers will complete health screening instruments, assess for unmet physical health needs, and establish goals in partnership with individuals to address identified health care needs. Participating mental hygiene providers will also focus on a particular area of need for their program (metabolic disorders, smoking, obesity, infectious disease, or inadequate dental care).

In addition, DMH’s FY 2008 geriatric mental health initiative funded by the New York City Council supported nine programs that worked to integrate health and mental health services for the people they serve. Efforts in these programs have incorporated medical screenings that focus on various potential problem areas: breast cancer, colon cancer, cardiovascular health, etc. as well as providing mental health outreach in primary care offices for seniors.

DMH is partnering with the Department’s Bureau of Tobacco Control to pilot smoking cessation projects at two community-based clubhouse programs. In response to high smoking prevalence among individuals with psychiatric diagnoses – 75% percent compared to 22% in the general population – participating programs will deliver smoking cessation awareness training and treatment to clubhouse members and staff and will implement a smoke-free facility policy. A full-time certified Tobacco Treatment Specialist in each clubhouse will provide and supervise cessation services, supported by technical assistance from Department staff. An important component of the program is outreach to consumers’ treating primary care providers and psychiatrists, both to offer education about best treatment practices and to ensure proper care coordination.

The burden of behavioral health problems has historically been underestimated because it has failed to adequately reflect concomitant physical health problems. Mental illness increases risk for communicable and non-communicable diseases and contributes to unintentional and intentional injury. Conversely, many physical health conditions increase the risk for mental illness. These often-overlooked co-morbidities impede help-seeking, diagnosis, and treatment. DMH, through its ongoing efforts, is working to improve how physical health needs are addressed in mental hygiene service settings, and how mental health needs are addressed in primary care settings. Early identification and treatment of all health problems, including addressing unmet physical and behavioral health needs, can have a drastic effect on the quality and length of a person’s life.

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