The Mind and Other Matters

One of the mechanisms the Affordable Care Act created to help integrate and coordinate the care of complex patients was health homes. A state plan option to serve Medicaid users with chronic conditions (including mental health and substance use disorders), health homes are a team-based, whole-person effort to link and orchestrate the array of services (primary and behavioral care, acute and long-term services, and family- and community-based services) required for high-need beneficiaries. They provide comprehensive management and coordination, transitional care, health promotion, patient and family support, and referral to supporting community and social resources. The ACA provides a temporary 90% federal matching rate for health home services.

Greater integration of services is the very idea of health homes, and for patients with serious mental illness, basing them in community mental health centers (CMHCs) makes great sense. CMHCs are certified entities that provide a basic set of core services described by the Public Health Service Act for the mentally ill and others.

In January 2012 Missouri became the first state green-lighted to operate these health homes, and it’s become a national leader in utilizing CMHCs to provide those services.

“What we did was design two types of healthcare homes: primary care and CMHC healthcare homes,” explains Dorn Schuffman, who coordinated the CMHC initiative for the Missouri Department of Mental Health. “The primary care homes obviously focus on people with things like diabetes and cardiovascular disease and hypertension and asthma/COPD. The CMHC healthcare homes focus on people with serious mental illness but also target, because they’re overrepresented in this population, people with serious mental illness who have things like diabetes, cardiovascular disease, asthma, hypertension and other chronic diseases.”

Of the 62 healthcare homes that operate in Missouri, 35 are primary care-based, 27 behavioral—all CMHCs. Enrollees in the state’s behavioral health homes outpace the rates of the general population for many common chronic diseases:

• COPD (24% to 15%);

• Diabetes (26% to 18%);

• Hypertension (35% to 30%);

• Obesity (38% to 33%);

• Extreme obesity (20% to 3%);

• Developmental disability (13% to 2%);

• Substance abuse (44% to 7%). 

Across all of these areas, and particularly in the areas of hyperobesity and substance abuse, the mentally ill come with much greater risk than the mentally healthy. And taken together, such figures well demonstrate the need for improved coordination of such people’s mental and physical care.

Earlier Efforts

Because the CMHCs were already set up to deal with these people’s mental illnesses, the challenge for Missouri lay in evolving them to deal with the physical stuff too. Some earlier programs helped provide a leg up.

Knowing people with serious mental illness often had chronic conditions and received inadequate care, the state created an initiative where it invited seven CMHCs and seven federally qualified health centers (FQHCs, which provide services similar to the CMHCs for the primary care of underserved populations) to work collaboratively to bring primary care to those in the CMHCs and behavioral health services more strongly into the FQHCs. To that end the FQHCs opened primary care clinics at the CMHCs, and the CMHCs embedded behavioral health consultants in the FQHCs.

For the FQHCs, “the purpose of that was to focus on first identifying people’s behavioral health needs, but then also doing very brief interventions and referring them for other services they might need but weren’t getting,” says Schuffman. “We wanted to provide behavioral supports to deal with their conditions.” That worked well, and behavioral health consultants remain as part of the care teams in primary care health homes.

At the CMHCs, this integration initiative demonstrated that providing primary care at CMHC sites was actually not as important as just educating CMHC staff about people’s health status and chronic diseases, making sure all patients had access to primary care somewhere, and coordinating their primary and behavioral healthcare.

The CMHCs already conducted metabolic screenings, so the DMH had some basic data on the numbers of users with things like diabetes, hypertension, cardiovascular disease and asthma/COPD, and parameters like their blood pressure and A1C levels. This initiative—known as DMH Net—also created at least a part-time nurse liaison at each CMHC. They weren’t delivering primary care, but it helped provide a deeper understanding of the primary care needs of CMHC consumers.

“The DMH Net initiative was our first opportunity to really introduce primary care into that setting and really start trying to change the culture,” says Rachelle Glavin, director of clinical operations for the Missouri Coalition for Community Behavioral Healthcare. “We weren’t just focusing on the head anymore—we were really trying to look at the whole person.”

The bulk of the CMHCs’ work with clients is done by community support specialists, basically case managers who work individually with clients to help them learn to manage their mental illnesses. The health home intiative increased the number of nurses, now called nurse care managers, and added a primary care physician consultant to each CMHC. This doctor doesn’t provide primary care or prescribe meds, but makes quickly available the highest level of judgment and counsel.

“By adding nurses who have an understanding of what’s happening with these other chronic diseases and how to impact that,” says Schuffman, “that really bolsters the ability of the community support specialists to look more broadly at the person they’re serving.”

DMH Net eventually rolled into an outreach program called Disease Management 3700 for high-cost Medicaid clients with impactable chronic medical conditions. With that the state identified high utilizers who had a behavioral health diagnosis but weren’t being treated by DMH providers. The DMH sent names to the CMHCs, which conducted outreach that also yielded intelligence on their primary care problems.

All of that earlier work gave Missouri a solid foundation when it came time to establish its actual behavioral health homes.

“We had to make sense out of dealing with a different population and different kind of service delivery system,” says Schuffman. “On the primary care side, you have a physician and do office visits and see people periodically; if you have a chronic disease you may see them more frequently. But on the CMHC side, we’re very intimately involved in people’s lives. We often see them daily, we’re helping them with all kind of community supports. And that actually makes it much easier to impact other chronic conditions, but it makes how you do it quite different. So we needed to kind of invent how we were going to make what happens in an office be what happens with us, where most of what we do is not office-based.”

CMHC staff had to be trained in areas like patient engagement in their treatment, support for patients with chronic medical conditions, and team-based care. CMHC users have their own primary care physicians; if they don’t, it’s the job of the health home to help them get one. The CMHC nurse care managers work with that physician, liaisoning between offices, procuring lab results, sharing information and following up on hospital admissions and discharge plans.

Outcomes

In Missouri more than two-thirds of those with mental illness have one or more chronic physical conditions. Poor nutrition is often a factor in developing problems like obesity, metabolic syndrome, hypertension and diabetes. Consequently the CMHC health homes have focused on improving areas like blood pressure, cholesterol and diabetics’ A1C levels.

They’ve broken out results for several cohorts thus far; here are the most recent highlights:

• In the first year, hospitalizations among CMHC health home clients decreased 9.1%.

• For patients with diabetes, 2½-year outcomes found good cholesterol up 37%, normal blood pressure up 42% and normal blood sugar up 46%.

• Among patients with hypertension and cardiovascular disease, 2½-year outcomes showed good cholesterol up 34% for those with CVD and normal BP up 41% for those with hypertension.

• Four in five health home enrollees now receive metabolic syndrome screening, up 68%.

• Among the extremely obese (patients with BMIs of more than 40), 56% lost weight, despite often being on newer-generation antipsychotic medications that promote weight gain. About 21% lost more than 10% of their body weight.

“It’s clear that if you make some small changes in a few areas, you’re going to have a big impact on people’s risk,” says Schuffman. “For example, a 10% reduction in cholesterol level is what you’re shooting for; that has a clinically significant impact on risk. We’ve had a reduction of more than 10% in LDL cholesterol levels among people who’ve been in for any time over a year. Similarly, with blood pressure you’re shooting for about a 6-point reduction in the systolic and/or diastolic. And looking at systolic, we’ve had between a 10- and 15-point reduction across the board, and a 6- to 8-point reduction in diastolic. So all of that means we’ve had a clinically significant impact on the people we’ve enrolled.

“By focusing on these things and giving our staff an understanding of what it takes to help people manage them, it’s really making a big difference.”

Also worth noting: cost savings. For the roughly 20,000 people enrolled in CMHC healthcare homes during their first 18 months, they saved an average of $32.98 per member per month in Medicaid expenditures, totaling $2.4 million. Missouri’s health homes have altogether saved more than $23 million since their inception.

Blending the missions “really does make sense,” says Brent McGinty, president and CEO of the Missouri Coalition for Community Behavioral Healthcare. “Our front-line staff and clinicians were trusted care providers already, so once we provided education and training on chronic diseases and population management, we had a ready-made system for changing behaviors, leading to improved health, wellness and medication adherence. It is completely unacceptable to embrace the old silo systems of care that found our clients dying 25 years earlier than the general population from inattention to chronic diseases.”

Sidebar: Tips for Behavioral Health Organizations Adding Physical Health Services

Assessment and Referral

• Take vital signs;

• Ask about preventive screenings and visits;

• Make appropriate referrals;

• Assess and monitor physical health indicators over time.

Care Coordination and Management

• Hire or train staff as care coordinators;

• Use case managers to connect physical and behavioral health providers;

• Help individuals without PCPs get them;

• Share abnormal vitals with primary care providers.

Peer Support for Self-Management and Recovery

• Place brochures in exam rooms to encourage patients to ask about physical problems;

• Use mental health clinicians or peers to work with consumers to identify goals;

• Use an evidence-based intervention such as the Illness Management and Recovery (IMR) program;

• Identify appropriate wellness programs;

• Partner with organizations to offer wellness activities;

• Offer wellness activities at CMHCs.

Navigation Services

• Use professional navigators to integrate services and coordinate care.

PC Services in BH Organizations

• Offer vaccinations at behavioral health centers;

• Offer lab services;

• Increase opportunities for warm handoffs;

• Set up a walk-in clinic staffed by a nurse or nurse practitioner.

Full Integration

• Make all health information accessible to the full care team in a central place;

• Coordinate diagnoses and treatments so they complement each other;

• Periodically reconcile all medications prescribed by behavioral and physical health practices;

• Individuals shouldn’t be able to tell the difference between behavioral and physical health practices;

• Have a single address and reception area;

• Integrate funding and maximize shared resources;

• Have a single board and governance system;

• Care teams should use best practices and evidence to jointly assess, prioritize and respond to care needs.

—Source: The Lewin Group, Approaches to Integrating Physical Health Services Into Behavioral Health Organizations 

Take-Home Points

• Community mental health centers (CMHCs) can be effective bases for Medicaid health homes.

• Enrollees in Missouri’s CMHC health homes have higher rates of many chronic diseases (including COPD, diabetes, hypertension and obesity) than the general population.

• Giving them access to primary care through their CMHC homes has improved things like cholesterol, blood pressure and blood sugar rates, as well as saving money for Medicaid.