Closing the Gap: Implementing Evidence-based Behavioral Health Practices for Older Americans

Transcription

1 Closing the Gap: Implementing Evidence-based Behavioral Health Practices for Older Americans Steve Bartels MD, MS Professor of Psychiatry, Community and Family Medicine, and The Dartmouth Institute Geisel School of Medicine at Dartmouth Director, Dartmouth Centers for Health and Aging

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3 10 Million Older Americans with Mental Illness Today- 15 million in 2030

4 Mental Health in Older Adults is a Health Care Problem

5 Mortality (%) Depression Kills Older Women 7 Years After Hip Fracture Depressive Symptoms

6 Survival free of cardiac mortality, cumulative % Depression and Greater Likelihood of Mortality After Heart Attack No Depression Mild Depression Severe Depression 3.7 X More Likely to Die P.001 Moderate Depression Severe Depression Lespérance, 2003 Time after discharge for MI, days N=896

7 Geriatric Depression and Health Care Costs Unutzer, et al., 1997; JAMA

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9 The Question: What is the Most Effective Way to Organize and Deliver Mental Health Services to Older Persons in Primary Care Settings?

10 We Know Treatment Works Evidence-based Practices Integrated service delivery in primary care Mental health outreach services Mental health consultation and treatment teams in long-term care Family/caregiver support interventions Psychological and pharmacological treatments Bartels et al., 2002, 2003, 2005

11 PRISMe Study: Primary Care Research in Substance Abuse and Mental Health for the Elderly Older Adults with Depression or At-Risk Alcohol Use Randomized Trial Comparing: Integrated/Collaborative Care Co-Located, Concurrent, Collaborative Enhanced Referral to Specialty Mental Health and Substance Abuse Clinics Preferred Providers and Facilitated appointments, transportation, payment

12 Rates of Engagement in MHSA Care: By Diagnosis/Condition (n=2022, mean age 73.5)

13 Primary Care: IMPACT Collaborative care model includes: Care manager: Depression Clinical Specialist Patient education Symptom and Side effect tracking Brief, structured psychotherapy: PST-PC Consultation / weekly supervision meetings with Primary care physician Team psychiatrist Stepped protocol in primary care using antidepressant medications and / or 6-8 sessions of psychotherapy (PST-PC)

14 Usual care Intervention 60 Substantial Improvement in Depression ( 50% Drop on SCL-20 Depression Score from Baseline) P<.0001 P<.0001 P< Unützer et al, JAMA 2002; 288:

15 Effective Treatment Saves Lives and Pays for Itself

16 Integrated Care is More Cost Effective Than Usual Care IMPACT participants had lower mean total healthcare costs $29,422 compared to usual care patients $32, 785 over 4 years.

17 Impact Model Implementation Resources

18 RCTs of Geriatric Mental Health Community Outreach Models % Recovered from Depression* * Greater than 50% reduction in symptoms or meeting syndromal criteria

19 PEARLS Intervention Conducted in the home of participants, in 8 sessions over a 19 week period: Manualized Problem-solving therapy (PST) Social and physical activation Pleasant events scheduling Clinical supervision by a psychiatrist If necessary, recommendations for medication management via phone contact with physician and/or participant Follow-up phone calls (1/month, for 6 months)

20 PEARLS 12 MONTH RESULTS %

21 Prevention Works!

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23 The Other Side of Integration The Older Adult with Serious Mental Illness and Medical Comorbidity

24 Early, Disproportionate, and Inappropriate Institutionalization in Nursing Homes

25 Middle Aged Adults with Schizophrenia 3 ½ Times More Likely to Be Admitted to Nursing Homes Overall Age Age /.14 OR=1.9*** 95% CI= OR=3.6*** 95% CI= OR=1.1 95% CI= Andrews, 2009

26 Early Mortality for People with Mental Illness Cardiovascular Disease Is Primary Cause of Death in Persons with Mental Illness* % of deaths

27 An Epidemic of Early Mortality: Mean Years of Potential Life Lost Year AZ MO OK RI TX UT Compared with the general population, persons with major mental illness lose years of normal life span Colton CW, Manderscheid RW. Prev Chronic Dis [serial online] 2006 Apr [date cited]. Available at: URL:

28 Cardiovascular Disease (CVD) Risk Factors Modifiable Risk Factors Estimated Prevalence and Relative Risk (RR) Schizophrenia Bipolar Disorder Obesity 45 55%, 1.5-2X RR 1 26% 5 Smoking 50 80%, 2-3X RR 2 55% 6 Diabetes 10 14%, 2X RR 3 10% 7 Hypertension 18% 4 15% 5 Dyslipidemia Up to 5X RR 8 1. Davidson S, et al. Aust N Z J Psychiatry. 2001;35: Allison DB, et al. J Clin Psychiatry. 1999; 60: Dixon L, et al. J Nerv Ment Dis. 1999;187: Herran A, et al. Schizophr Res. 2000;41: MeElroy SL, et al. J Clin Psychiatry. 2002;63: Ucok A, et al. Psychiatry Clin Neurosci. 2004;58: Cassidy F, et al. Am J Psychiatry. 1999;156: Allebeck. Schizophr Bull. 1999;15(1)81-89.

29 I. Integrated Rehabilitation and Health Care Management RCT Multi-site RCT (n=183, mean age 60): Rehabilitation: Skills Training Groups to Teach Community Living Skills, Social Skills, and Health Self-Management Skills Health Management: Health Education, and Monitoring, Facilitation, & Coordination of Primary & Preventive Health Care by HM Nurse Rehabilitation and Health Care for SMI: NIMH R01 MH62324 (PI Bartels)

30 7 Skills Training Modules 1. Making the Most of Leisure Time 2. Communicating Effectively 3. Using Medications Effectively 4. Living Independently in the Community 5. Making and Keeping Friends 6. Making the Most of Health Care Visits 7. Healthy Living

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32 Example: Making the Most of Health Care Visits (8 weeks) 1) Making and Preparing for An Appointment 2) Pros and Cons of Taking Medications 3) Sharing Health Information With Your Doctor 4) Reporting Physical Symptoms 5) Asking About Treatment Options 6) Making a Visit to the Dentist 7) Making an Advance Care Plan 8) Naming a Health Care Agent

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35 Nurse Health Care Management Component Intake Assessment Health examination Medication list Vital signs monitoring Preventive health care Disease specific goals Action plan Health care proxy Health Education Accompany visit to physician with consumer Medical information communication Monthly (or more frequent) visits

36 Study Participants n=183, Mean Age 60 58% female

37 Independent Living Skills

38 Negative Symptoms (SANS)

39 Summary: Results 2 and 3 Year Follow-up Improved Community Functioning Decreased Negative Symptoms Improved Self-efficacy Improved Living Skills Greater Acquisition of Health Care Advance Directives Greater Receipt of Preventive Health Care Screening Bartels S et al. (in press). Long-term outcomes of a randomized trial of integrated skills training and preventive health care for older adults with serious mental illness. American Journal of Geriatric Psychiatry.

40 II. Integrated Illness Management and Recovery,(NIMH R34 MH074786) Individualized integrated illness self-management skills training provided by a Master s level clinician Co-located medical disease management provided by a public health nurse in the community mental health center focusing on metabolic/cardiovascular, and pulmonary disorders (hypertension, hyperlipidemia, congestive heart failure, diabetes, cardiovascular disease, and COPD)

41 Integrated Illness Management and Recovery IMR Recovery Psychoeducation Stress and mental illness Social Supports and MH Psych Med Adherence Psych Relapse Prevent Psych Problem Solving Coping with Psych Sx Substance Abuse Navigating the Mental Health System I-IMR Wellness Health education Stress and health Social supports and wellness Medical med adherence Medical relapse prevent Medical problem solving Coping with pain Medication misuse Navigating the Physical Health Care System Integrated Illness Management and Recovery (NIMH R34 MH074786)

42 Integrated Illness Management and Recovery Sessions Weekly sessions aimed at: Establishing goals steps towards recovery and wellness Increasing knowledge through education of psychiatric and medical problems Enhancing self-management skills through skills training, cognitive behavioral, and motivational interventions.

43 I-IMR Disease Management Comprehensive initial evaluation of health and receipt of preventive health services Establishment of health care goals Co-located FQHC NP tracking & promotion of preventive health care, acute problems, chronic medical illness Periodic assessment of health status Health education and support for selfmanagement of medical problems

44 Summary of Major Findings I-IMR Client Rated Illness Self-Management: Clinician Rated Illness Self-Management Improved participation in primary care visitgreater Greater Active Role Communicating Questions Greater Information Seeking

45 I-IMR Outcomes Improved Self-management Client and provider ratings of self-management Knowledge of Symptoms, Meds, Coping Symptom Distress Symptoms Affecting Functioning Decreased hospitalizations Hospitalizations I-IMR UC 31% 25% 25% 17.40% 12.10% Improved participation in the health care encounter 0% BL 10mo 14mo

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47 III. Improving Primary Health Care Encounters for People with SMI: Collaborative Activation Training for Primary Care (CAT-PC)

48 CAT-PC Pilot Study Feasibility trial of a brief intervention to improve primary care encounters for older persons with SMI at cardiometabolic risk Consumer training (Peer Co-led) Preparing to productively use the medical encounter Strategies for communicating health information Identifying personal health targets Use of tools to facilitate collaborative care planning

49 Peer Co-led Consumer Training (90 minute session x 9 weeks) Consumer narrated video demonstrating health care encounter skills: simulated demonstration of optimal health care visit skills Group based skills training: Develop skills to communicate, obtain health information, request treatment options, and use tools to facilitate selfadvocacy, and shared decision making Health Promotion Education: Learn to initiate and set achievable lifestyle goals and engage in shared goal-setting with primary care physician

50 Provider Training (30 minute session) Training Video: Strategies for providers to improve communication, patient activation, and engage in shared decisions for prevention and treatment Handout: ADA/APA guidelines for screening and monitoring of CVD risk in people with SMI. Evidence-based interventions including obesity, tobacco use, hyperlipidemia, hypertension, and diabetes

51 50% 40% Patient Activation Measure Level 1 - Learning patient role 30% Level 2 - building knowledge, confidence 20% Level 3 - Early action 10% 0% Pre-Intervention Post-Intervention Level 4 - Maintaining behaviors

52 Role Preference for Medical Decision Making 100% 80% 60% χ 2 = 6.3 df = 9 p = 0.18 OR collaborative relationship after intervention = 1.6 Dominant 40% Passive 20% 0% Pre-Intervention Post-Intervention Collaborative

53 IV. Improving Health Care: Automated Remote Telemedicine Disease Management Health Buddy : Electronic unit connected to a phone line provides two-way communication between healthcare providers and patients. Pilot study funded by Endowment for Health and Bosch Healthcare 100 participants age 18+ with SMI plus CHF, COPD, Diabetes, or CAD) enrolled in 12 month RCT crossover design (HB v. wait list control)

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55 63% (n=15) Fasting Glucose >130 At Baseline: 63% FG>130 After Telehealth Majority (2/3) in range FG<120

56 Service Use Outcomes for People with 3 Diabetes (both p<.05) Routine Visits Urgent Visits Pre Post

57 IV. The In SHAPE Health Promotion Program A State-wide Health Promotion Program for Serious Mental Illness

58 Body Mass Index Average weight = 204 pounds

59 The In SHAPE Health Mentor Program

60 The In SHAPE Health Promotion Intervention Participants spend time each week with personal mentors working out, taking walks, in classes or working on nutrition plans. Mentors help participants to track their progress, set goals, and stay motivated.

61 In SHAPE Key Findings Bartels et al. Psych Services (In Press 2013): N=133 participants with SMI At 12 months: Mean increase of 97.3 feet on 6MWT in intervention compared to mean decrease of 20 feet in control (p=0.02) 49% in intervention group achieved either clinically significant increased fitness (>50 m on 6MWT) or weight loss (5% or greater)

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64 Putting it Together HOPES: Aging persons with SMI, Olmstead and Nursing Discharge & Diversion I-IMR: Integrated physical and mental health self-management CAT-PC: Improving activation and shared decision making in the primary care encounter Health Buddy: High risk, high service users with SMI and unstable health conditions In SHAPE: Prevention, integrated wellness health promotion

65 Putting it Together: From Prevention to Chronic Disease Management Underlying Risk Factors Patient Symptoms & Life style Poor health behaviors Poverty, Uninsurance Lack of self management Provider Lack of knowledge Competing demands Therapeutic nihilism System Limited onsite capacity Lack of medical home Lack of reimbursement for prevention & health promotion programs Adapted from Druss, 2007 Proximal Risk Factors Lifestyle: Inactivity, poor diet, smoking Medications Integrated Wellness: Diet, Exercise Smoking Cessation Medication Switching Cardiometabolic Risk Factors Weight Glucose Lipids BP Routine Health Screening Poor Quality Detection, Treatment CAD DM Integrated: Disease Mangmt. Care Management Self-Management

66 The Health Promotion Research Team The Center for Aging Research

67 Questions?