In New York City, as elsewhere, people with mental illnesses have worse physical health outcomes, on average, than the rest of the population. An estimated 239,000 New Yorkers live with serious mental illnesses, or SMI (Community Mental Health Survey 2012). They are significantly more likely to report fair or poor health compared to other New Yorkers (44% versus 20%), as well as hypertension, high cholesterol, and suffering from two or more chronic illnesses. While the causes of these health disparities are complex and varied, there are several consistent themes: people with SMI tend to smoke at a much higher rate than the rest of the population (in NYC, 44% versus 15.5%), and it is therefore not surprising that smoking-related diseases such as heart disease, respiratory disease, and cancer have been found to account for approximately 50% of deaths in people with SMI; psychotropic medications, including antipsychotics, can lead to substantial weight gain and an increased risk of diabetes; lifestyle factors, such as poor diet and physical activity, contribute as well; and, in spite of having worse health, people with SMI are less likely to receive the medical care they need. Studies show that high numbers of people with SMI who have diabetes or heart disease do not receive treatment for their physical ailment.
The health disparities faced by people with mental illnesses, combined with gaps in treatment, point to an urgent need for better coordination and integration of physical and behavioral health care. For the purposes of this article, coordination means communication between behavioral and physical health providers to arrange consistent care for their shared clients and to exchange referrals. Integration means incorporation of physical health care expertise and capability into behavioral health practices. Both are essential to ensuring people with mental illnesses receive proper treatment for their physical health conditions, and to identifying risk factors and preventing physical illnesses from occurring.
DOHMH’s HEAL 17 Experience
In 2010, the New York City Department of Health and Mental Hygiene (DOHMH) was awarded a State Department of Health grant, referred to as HEAL 17, to expand care coordination through the use of health information technology for individuals with schizophrenia and other psychotic disorders and/or major depression. The focus of this article will be a behavioral health quality improvement project conducted as part of the HEAL 17 implementation. DOHMH worked with 17 different behavioral health programs (mostly mental health clinics, but also some PROS programs and clubhouses) from five different agencies to collect physical health integration data. DOHMH measured the extent to which individuals received an appropriate clinical service within a certain timeframe. For instance, one quality measure was the percentage of adults whose current body mass index (BMI) had been documented in the past six months. The other measures included tobacco use and treatment, diabetes screening and monitoring, primary care provider visits, cholesterol screening, and alcohol and drug use screening. These measures were selected to represent the physical health conditions and risk factors most relevant for people with SMI, and were calculated every month for one year.
As one might expect, the data varied greatly. For the most part, behavioral health programs reported high rates of screening for alcohol, tobacco, and other substance use. This was unsurprising, because screening for these addictive behaviors is broadly considered to be within the domain of behavioral health care. The programs reported a moderate level of tracking whether their clients had a recent primary care visit, whether tobacco users were actively offered a cessation intervention, and whether clients had a documented BMI screening. These areas might be considered slightly outside the comfort zone of some behavioral health providers. Finally, the programs by and large struggled to report whether laboratory values were documented for cholesterol screening and diabetes screening and monitoring. Most of these behavioral health programs lacked their own integrated lab operations, and did not succeed in obtaining information on lab completion from their clients’ physical health providers. In addition, the programs were often hampered by limited communication with their clients’ physical health providers. This made it difficult for them to determine if their clients were overdue for diabetes and cholesterol screening.
While it remained a challenge for some, several programs reported increased information exchange with physical health providers, often owing to persistent efforts at establishing a communicative relationship. Some very simple infrastructure changes, like purchasing scales, allowed several programs to keep up with their clients’ BMI and report this measure more consistently, while also paving the way for on-site weight-loss initiatives.
Many programs identified the importance of having on-site nursing support. Some programs hired nurses to direct or assist with wellness initiatives; others re-dedicated nurses already on staff to take charge of groups for smoking cessation or weight loss; and others still made plans to hire nursing staff to help meet the needs identified through their quality reporting project.
Finally, all programs made progress with their routine assessment of tobacco dependence and assistance with cessation. Thanks to a partnership DOHMH arranged with the New York State Tobacco Cessation Centers, each program received tailored training and technical assistance on tobacco dependence treatment. Consequently, the reported quality measures for tobacco screening and intervention demonstrated marked improvement over the year.
Drawing from the challenges and strategies identified by our behavioral health partners, we arrived at a set of recommendations for integration and coordination of behavioral health and primary care.
1) Build stronger relationships between behavioral health and primary care providers. In order to coordinate effectively around client care, behavioral health and primary care providers must make a greater effort to communicate directly with each other as a virtual care team. This means both reaching out (for instance, about changes in health status or medication regimen), and being receptive to feedback from one another. Those who were able to most effectively coordinate care had made special effort to establish relationships with an array of providers from “across the fence” of health specialty. This included both those already treating their own clients for a separate health concern, as well as providers they relied on for exchanging referrals. Relationship-building strategies include making extra phone calls and arranging “meet and greets.” While time consuming, there is long-term benefit to these efforts—the behavioral health providers who most consistently communicated with their clients’ primary care physicians reported that they felt better able to manage their clients’ whole health.
2) Hire new staff and/or train existing staff to address basic physical health concerns such as diet, physical activity, and smoking cessation. As mentioned above, several programs saw considerable benefits from incorporating nursing staff. These nurses measured consumers’ vital signs, conducted groups on smoking cessation and weight reduction, and helped manage their clients’ diabetes care by following up with physical health providers. Some behavioral health programs have even co-located physicians to provide primary care services right on site, allowing consumers who have difficulty keeping primary care appointments to receive these services at the same setting where they already get their behavioral health care. Unfortunately, current reimbursement structures do not motivate the incorporation of primary care medical services into behavioral health settings, so outside funding has been required to support such efforts. However, even training existing behavioral health staff in physical health integration can have far-reaching benefits. Behavior change efforts around smoking cessation, physical activity, and nutrition can be championed by social workers and psychiatrists. Indeed, when behavioral health providers take the lead in these areas, it sends a message to consumers that they are invested in their whole health.
3) Improve the use of health information technology systems both for management of consumers’ health and for information exchange between physical and behavioral health care providers. While some communication barriers could be removed through stronger business relationships (as discussed above), better use of health information technology is also key. More providers than ever are currently using electronic health records (EHRs), including both primary care and behavioral health providers. However, interoperability (meaning the ability of different systems to communicate and exchange data) is lacking, and many providers do not optimally use their health information technology. Until regional and statewide health information exchange systems become adequately functional and resourced, and until providers go fully electronic (i.e., eliminating paper charts and using EHRs to document all client information), there will be only incomplete information available for electronic exchange. Once the state of behavioral health information technology matures, instant access to health information by all the providers who need it will give them the ability to provide the best services possible.
Additionally, HEAL 17 revealed the need for more behavioral health expertise in EHR-supported quality improvement. By using EHRs to monitor their own activity, behavioral health programs can provide better care leading to improved client outcomes. For example, using EHR reporting capabilities, a program could instantly flag the charts of all consumers who have not had a physical checkup in a specified time frame, so they could be reminded at their next visit. Or, a report could be run to identify all consumers who are smokers, for individualized outreach to a smoking cessation group. By fully utilizing EHR capabilities, behavioral health providers can provide more integrated care and ensure better health outcomes for consumers.
Our health care system has been historically, and notoriously, fragmented, and nowhere is that fragmentation more apparent than in the divide between physical and behavioral health care. However, the time is ripe for a paradigm shift towards integration. The health disparities faced by persons with mental illnesses are now more broadly acknowledged than ever before. Advancements in health information technology are on the verge of making the exchange of health information among providers truly seamless, and quality management using EHR data is easier than ever. Even funding structures are evolving, with health reform making managed care organizations responsible for addressing and maintaining the whole health of their members. It truly is an exciting time as we continue to move in the direction of integrated care.