Healthy Connections. Executive Summary PRIMARY BEHAVIORAL HEALTH CARE INTEGRATION (PBHCI) EVALUATION & PERFORMANCE OUTCOMES REPORT

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1 Healthy Connections Executive Summary 2013 Prepared by: PRIMARY BEHAVIORAL HEALTH CARE INTEGRATION (PBHCI) EVALUATION & PERFORMANCE OUTCOMES REPORT Minakshi Tikoo, MBI, PhD Michael J. Hettinger Christine Langton, MSW, MPH Darcé Costello, EdD, MPH, MBA Biomedical Informatics Center (BMIC) Connecticut Institute for Clinical and Translational Science (CICATS) University of Connecticut Health Center 1

2 EXECUTIVE SUMMARY Introduction Greater Nashua Mental Health Center (GNMHC) at Community Council in New Hampshire was one of the 64 grantees that were awarded a four-year Primary and Behavioral Health Care Integration (PBHCI) grant by Substance Abuse and Mental Health Services Administration (SAMHSA) to help demonstrate the value of integrating primary care with behavioral health services. GNMHC is part of Cohort I grantees from September The Center started seeing patients with the PBHCI protocol on February 15, The primary focus of the four-year grant is to demonstrate: Improved access to primary care services; Improved prevention, early identification, and intervention to reduce the incidence of serious physical illnesses, including chronic disease; Increased availability of integrated, holistic care for physical and behavioral disorders; and Better overall health status of clients. In the third year of the grant GNMHC received additional $200,000 to adopt and demonstrate use of health information technology (HIT). The HIT supplement awarded in September 2011 was primarily intended to support the following activities (A and B): A. Electronic Health Records (EHR) Development or enhancement of a certified Electronic Health Record System; and/or Development toward achieving Stage 1EHR meaningful Use Specification B. Health Information Exchange (HIE) Development and implementation to participate in appropriate health information exchange (local, regional or state); and Development and implementation of an exchange of health information to achieve improved health outcomes for patients. GNMHC implemented their electronic health record (EHR), Essentia by Lavender & Wyatt Systems, Inc (LWSI), in October To help evaluate its HIT supplement and overall PBHCI evaluation, GNMHC contracted with Minakshi Tikoo, PhD, Director of Evaluation, Biomedical Informatics Center (BMIC), University of Connecticut Health Center. The major aim of the the proposed evaluation was to create a web-based clinical repository and conduct an outcome evaluation. This report presents the results of analyses of various treatment outcomes for clients served by the Greater Nashua Mental Health Center s Primary Behavioral Health Care Integration (PBHCI). The report compares outcome data collected at each client s initial baseline PBHCI assessment with data captured at each client s most recent 2

3 Consumer demographics Slightly over half (50.2%) were male, while 49.2% were female. Most (83.0%) were white. 11.1% were non-white. A majority (88.5%) were non-hispanic. Only 11.3% were Hispanic. Most (76.8%) were aged 35 or older, while 23.1% were aged A majority (86.1%) of all PBHCI clients who were discharged dropped out of treatment. In comparison, 80.4% of PBHCI clients who were included in the outcome analysis and who were discharged dropped out of treatment. Almost half the consumers (48.8%) used tobacco at baseline, while 36.1% of clients did not. 27.1% of all clients used alcohol at baseline, while 57.4% of clients did not. 10.7% of all clients used marijuana at baseline, while 74.0% of clients did not. Almost four out of five (78.9%) clients reported not being in the labor force. Almost four out of five (79.9%) of clients lived independently. 24.9% of all clients enrolled had less than a 12 th grade education. 41.8% had a high school diploma or equivalent; 33.0% had some college. 6.3% of all clients had both Serious Mental Illness (SMI) and substance abuse diagnoses. 3.6% had multiple SMI diagnoses but no substance abuse diagnosis. 28.9% were diagnosed with schizophrenia only; 20.3% were diagnosed with bipolar disorder only, and 32.5% were diagnosed with major depression/mood disorder only. 6.7% had an anxiety disorder diagnosis but no SMI diagnosis. 44.0% of all clients had no physical health diagnoses. 29.1% of all clients had multiple physical health diagnoses. Changes in outcomes from baseline to follow-up Overall Health 13% of consumers improved from a negative outcome at baseline to a positive outcome at their most recent 31% of consumers had a positive outcome at both baseline and at their most recent The Overall Health outcome did not improve in a statistically significant manner. Employment Status 11% of consumers improved from a negative outcome at baseline to a positive outcome at their most recent 70% of consumers had a positive outcome at both baseline and at their most recent The Employment Status outcome did not improve in a statistically significant manner. Living Situation 6% improved from a negative outcome at baseline to a positive outcome at their most recent 78% had a positive outcome at both baseline and at their most recent 3 At baseline Almost no one reported being arrested in the last 30-days 2 in 5 did not use tobacco 3 in 5 did not use alcohol 3 in 4 did not use marijuana 4 in 5 lived independently 3 in 4 had completed high school 1 in 10 had multiple diagnosis 3 in 10 had multiple physical health diagnosis 4 in 5 were not participating in the labor force. 13% of the consumers reported improving while 31% maintained positive overall health

4 The Living Situation outcome did not improve in a statistically significant manner. Arrests 1% of consumers improved from a negative outcome at baseline to a positive outcome at their most recent 98% of consumers had a positive outcome at both baseline and at their most recent Most of the consumers did not report being arrested in the 30-days prior to admission. We do not have sufficient variability to test for statistical significance. Social Connectedness Composite Score 20% of consumers improved from a negative outcome at baseline to a positive outcome at their most recent 48% of consumers had a positive outcome at both baseline and at their most recent More consumers improved their Composite SC Score outcome than got worse from baseline to follow-up, and the change was statistically significant. Frequency of Tobacco Use 5% of consumers improved from a negative outcome at baseline to a positive outcome at their most recent 43% of consumers had a positive outcome at both baseline and at their most recent The Tobacco Use outcome did not improve in a statistically significant manner. Frequency of Alcohol Use 10% of consumers improved from a negative outcome at baseline to a positive outcome at their most recent 61% of consumers had a positive outcome at both baseline and at their most recent The Alcohol Use outcome did not improve in a statistically significant manner. Frequency of Marijuana Use 5% of consumers improved from a negative outcome at baseline to a positive outcome at their most recent 86% of consumers had a positive outcome at both baseline and at their most recent The Marijuana Use outcome did not improve in a statistically significant manner. Overall functioning 23% of consumers improved from a negative outcome at baseline to a positive outcome at their most recent 36% of consumers had a positive outcome at both baseline and at their most recent Significantly more consumers improved their Functioning outcome than got worse from baseline to follow-up. Perception of Care 5% of consumers improved from a negative outcome at their first nonbaseline assessment to a positive outcome at their most recent 80% of consumers had a positive outcome at both their first non-baseline assessment and at their most recent The Perception of Care outcome did not improve in a statistically significant manner. Significantly more consumers improved their Functioning from baseline to follow-up 4

5 Psychological Distress 16% of consumers improved from a negative outcome at baseline to a positive outcome at their most recent 56% of consumers had a positive outcome at both baseline and at their most recent More consumers improved their No Serious Psychological Distress outcome than got worse from baseline to follow-up, and the change was statistically significant. Retention in the Community 7% of consumers improved from a negative outcome at baseline to a positive outcome at their most recent 90% of consumers had a positive outcome at both baseline and at their most recent More consumers improved their Retention in the Community outcome than got worse from baseline to follow-up, and the change was statistically significant. Blood Pressure 14% of consumers improved from a negative outcome at baseline to a positive outcome at their most recent 56% of consumers had a positive outcome at both baseline and at their most recent The Combined Blood Pressure (Systolic/Diastolic) outcome did not improve in a statistically significant manner. Body Mass Index 7% of consumers improved from a negative outcome at baseline to a positive outcome at their most recent 12% of consumers had a positive outcome at both baseline and at their most recent The BMI outcome did not improve in a statistically significant manner. Waist Circumference 6% of consumers improved from a negative outcome at baseline to a positive outcome at their most recent 26% of consumers had a positive outcome at both baseline and at their most recent The Waist Circumference outcome did not improve in a statistically significant manner. Blood Glucose Level 7% of consumers improved from a negative outcome at baseline to a positive outcome at their most recent 45% of consumers had a positive outcome at both baseline and at their most recent The HgbA1c outcome worsened in a statistically significant manner. Cholesterol HDL 10% of consumers improved from a negative outcome at baseline to a positive outcome at their most recent 55% of consumers had a positive outcome at both baseline and at their most recent The HDL Cholesterol outcome did not improve in a statistically significant manner. 5

6 Cholesterol LDL 17% of consumers improved from a negative outcome at baseline to a positive outcome at their most recent 67% of consumers had a positive outcome at both baseline and at their most recent The LDL Cholesterol outcome improved in a statistically significant manner. Triglycerides 16% of consumers improved from a negative outcome at baseline to a positive outcome at their most recent 29% of consumers had a positive outcome at both baseline and at their most recent The Triglycerides outcome did not improve in a statistically significant manner. In summary, several positive changes when comparing baseline outcome data with data in clients most recent assessments. Many of these overall changes recurred across various client sub-groups (e.g. gender, age range). These positive changes include: The composite Social Connectedness scores, as well as the individual dimensions Happy with Friendships and Belonging in the Community, improved significantly. Everyday Life Functioning, Psychological Distress, and Retention in the Community outcomes improved significantly. The LDL Cholesterol outcome showed significant positive change. HgbA1c got significantly worse. Services in Healthy Connections We are unable to present a complete story about whether integrated primary and behavioral health care made a difference. Despite all attempts, GNMHC was unable to get a count of services by consumers for their primary care services partner. The primary care services were delivered through a partnership with Lamprey Health Care, the area s Federally Qualified Health Center (FQHC), which is a fully embedded onsite primary care center. A complete array of primary health and medical services are available to both insured and uninsured patients including: physical exams, immunizations, risk assessments, gynecological exams, reproductive health and preventative care. Approximately 300 GNMHC clients have become new patients of Lamprey Health Care at Healthy Connections. Physical health services delivered to consumers enrolled in the PBHCI program fall under the Healthy Connections umbrella. Healthy Connections services delivered to PBHCI consumers are comprised of primary care and behavioral health care as well as a number of wellness programs and activities such as, Empowerment, Advocacy, Recovery, Towards Support (H.E.A.R.T.S.), GNMHC s partner Peer Support organization. These programs and activities include smoking reduction/cessation, nutrition education, diabetes/chronic disease management, walking and exercise groups. The following table summarizes how PBHCI consumers utilized Healthy Connection services during the period February 10, 2010 through September 30, Healthy Connections Medical services delivered by Lamprey began during 2012, with 103 unique PBHCI consumers receiving this service type. In addition, the number of unique consumers receiving Diabetes and/or Yoga services increased in recent years, although even in 2012 a minority of consumers received these types of services. 6

7 Table 1: Healthy Connections Services Received by PBHCI Consumers from 2/10/ /30/2012 Unduplicated Clients Getting Svc. Min. Service Units Max. Service Units Mean Svc. Units Median Service Units Std. Dev. Diabetes/Diabetes Group Total Healthy Bodies Total Healthy Connections Assessment Total Healthy Connections Medical Total Healthy Cooking Total Smoking Reduction Total Tai Chi Total Walking Total Yoga Total

8 Figure 1: Baseline to Follow-Up Non-Physical Outcome Changes Got Worse Improved Overall Health 13% Employment Status 11% Living Situation 6% Arrests 1% Social Connectedness 20% (SC)*** SC Happy with Friends 19% *** SC People Enjoyable 13% [A] SC Belong In 19% Community ** SC Support In Crisis 12% Tobacco Use 5% Alcohol Use 10% Marijuana Use 5% Functioning *** 23% Perception of Care 5% Psychological Distress 16% ** Community Retention 7% ** -25% -15% -5% 5% 15% 25% Figure 2: Baseline to Follow-Up Physical Health Outcome Changes Systolic Blood Pressure Diastolic Blood Pressure Combined Blood Pressure Body Mass Index Waist Circumference Got Worse Improved 10% 7% 5% 14% 14% Plasma Glucose 0% HgbA1c ** 7% HDL Cholesterol 10% Triglycerides LDL Cholesterol ** 17% 16% -25% -15% -5% 5% 15% 25% ** represents statistically significant results where p <= *** represents statistically significant results where p <=