Finger Lakes Health Systems Agency Interface of the Physical and Mental Health Care Systems RCCHI Meeting December 18, 2013.

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


55%

Behavioral Health Primary

Diagnosis8%

Behavioral Health Sec-ondary Di-

agnosis37%

Admissions with a Behavioral Health Diagnoses in 2011Finger Lakes Region


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

*


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


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


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


No BH Comorbidity

BH Comorbidity*

*

* Indicates a sta-tistically signifi-cant difference from the NO BH Comorbidity group at the p<0.05 level


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

*

*


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


Ad

jus

ted

Od

ds

Ra

tio *

*



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


*

*


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


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


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


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


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


Adju

sted

Odd

s Rati

o


*

*


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


Adju

sted

Odd

s Ra

tio


*

*


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


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


Monroe Southern Central0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Percent of Hospital Admissions with BH Diagnosis by Sub-Area


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)


Healthcare Spending

Roehrig, Miller, Lake, Bryant; 2009

Finger Lakes Health Systems Agency Interface of the Physical and Mental Health Care Systems RCCHI Meeting December 18, 2013.

Documents

adolescent mental health

mental health issues

physical health mental

poor mental health

health behaviors

dental health issues

poor physical health

adults mental illness