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Innovative Approaches to
Health Behavior Change In
Psychiatric Disabilities
Stephen J Bartels, MD, MS
Sarah Pratt, PhD
Kelly Aschbrenner, PhD
Dartmouth Medical School and
the Dartmouth Centers for Health and Aging
• Grant Funding:
– NIMH
– CDC
– HRSA
– Endowment for Health
– Bosch Healthcare
– CMS
• Consultant:
Disclosures
– Substance Abuse and Mental Health Administration
– National Association of State Mental Health Program
Directors
1

Overview
• The Context: High rates of medical
comorbidity, early mortality, and nursing
home placement for persons with SMI
• Five research based interventions and their
potential applications
• Putting it together in the context of the
current health care environment
Longevity: An American Success Story
in Population Health?
Life Expectancy At Birth
In the year: Men Women
1900 47.1 50.7
1990 71.8 78.8
2020 75.7 82.3
2050 79.7 85.6
Source: National Center for Health Statistics, U.S. Decennial Life Tables for
1989-91, vol. 1, no. 3, Some Trends and Comparisons of United States Life
Table Data: 1900-91. Hyattsville, MD; 1999, p. 2, Table A.
2

Global Life Expectancy Disparities:
Expl: US (79 yrs) vs. Ethiopia (55 yrs)
Pop Quiz
What large population group in the USA has the following
characteristics?
• 25-30 year shorter life span than the general population
• Similar life expectancy to people in Ethiopia
• A declining life expectancy over the past 3 decades
• Disproportionate risk of death from dramatically
increased preventable cardiometabolic risk factors
• Substandard health care for common chronic illnesses
• Presents a paradigm for a high-risk, disadvantaged
cardiovascular health disparity population
3

The Epidemic of Premature Death in
Middle-aged Persons with Mental Illness
The average life expectancy in the US has steadily increased
to 77.9 years (increasing by almost 5 years since the 90s alone)
At the same time……….
For people with serious mental illness:
The average life expectancy is 53 yrs.
50 is the New 75
An Epidemic of Early Mortality:
Mean Years of Potential Life Lost
Year AZ MO OK RI TX UT
1997 26.3 25.1 28.5
1998 27.3 25.1 28.8 29.3
1999 32.2 26.8 26.3 29.3 26.9
2000 31.8 27.9 24.9
Compared with the general population, persons with
major mental illness lose 25-30 years of normal life span
Colton CW, Manderscheid RW. Prev Chronic Dis [serial online] 2006 Apr [date cited].
Available at: URL:http://www.cdc.gov/pcd/issues/2006/apr/05_0180.htm
4

Cardiovascular Disease Is Primary Cause
of Death in Persons with Mental Illness*
Percentage of deaths
60
50
40
30
20
10
0
MO OK RI TX UT VA
Heart Disease Cancer Cerebrovascular
Chronic Respiratory Accidents Diabetes
Influenza/Pneumonia
Suicide
*Average data from 1996-2000.
Colton CW, Manderscheid RW. Prev Chronic Dis [serial online] 2006 Apr [date cited].
Available at URL: http://www.cdc.gov/pcd/issues/2006/apr/05_0180.htm
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;35:196-202. 2. Allison DB, et al. J Clin Psychiatry. 1999; 60:215-220.
3. Dixon L, et al. J Nerv Ment Dis. 1999;187:496-502. 4. Herran A, et al. Schizophr Res. 2000;41:373-381.
5. MeElroy SL, et al. J Clin Psychiatry. 2002;63:207-213. 6. Ucok A, et al. Psychiatry Clin Neurosci. 2004;58:434-437.
7. Cassidy F, et al. Am J Psychiatry. 1999;156:1417-1420. 8. Allebeck. Schizophr Bull. 1999;15(1)81-89.
5

Mean Change in Weight With
Antipsychotics
Weight Change (kg)
6
5
4
3
2
1
0
-1
-2
-3
Estimated Weight Change at 10 Weeks on “Standard” Dose
13.2
11.0
†
8.8
6.6
4.4
*
2.2
0
-2.2
-4.4
-6.6
Weight Change (lb)
*4–6 week pooled data (Marder SR et al. Schizophr Res. 2003;1;61:123-36; † 6-week data adapted from Allison DB,
Mentore JL, Heo M, et al. Am J Psychiatry. 1999;156:1686-1696; Jones AM et al. ACNP; 1999.
Receipt of Quality of Care Indicators
100%
80%
60%
40%
20%
37.0%
50.1% 51.8%
27.0%
58.4%
70.3%
0%
p

Early, Disproportionate, and
Inappropriate Institutionalization
in Nursing Homes
Nursing Home Placement, Schizophrenia, and Age
Overall Age 40-64 Age 65+
.04/.14
OR=1.9***
95% CI=1.5-2.2
OR=3.6***
95% CI=2.8-4.7
OR=1.1
95% CI=0.8-1.4
Andrews , 2009
7

5 Models Integrating
Rehabilitation, Health &
Fitness Promotion, and Health
Care Management
I. Group-Based Rehabilitation and Health
Care Management
Helping Older People Experience
Success (HOPES)
• Multi-site RCT (n=183, mean age 60) Mass
Mental, NSMHA, Community Council of
Nashua
• Group Skills Training Classes: Skills training
in community living skills, social skills, and
health self-management
• Health Management: Health education,
monitoring, facilitation, & coordination of
primary & preventive health by HM Nurse
8

Curriculum:
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
9

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
11

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
Individually Tailored Rehabilitation
HOPES-I
• 5-Year Career Development Award from
National Institute of Mental Health
• Two sites: CMHCs in NH
• Phase 1: Manual refinement
• Phase 2: Feasibility with 8-10 people
• Phase 3: Pre-Post Pilot with 40 receiving
HOPES-I
12

HOPES-I Content
5 Skills Training Modules
1. Making the Most of Leisure Time (6)
2. Communicating Effectively (8)
3. Living Independently in the Community (8)
4. Making and Keeping Friends (8)
5. Healthy Living (8)
Applications for HOPES
• HOPES as a potential core intervention for
community providers to address the aging
population of adults (50+) with SMI
currently residing in the community
• Olmstead Mandate and ADA: HOPES as a
model program to enable persons with SMI
residing in nursing homes to be discharged
back to the community
13

II. Improving Primary Health Care
Encounters for People with SMI
Prepare, Ask, Communicate, Tell: P.A.C.T.
• 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
14

P.A.C.T. Consumer Training
(90 minute session x 9 weeks)
• Group based skills training: Develop skills to
communicate and use tools to facilitate self-advocacy
during visit
• Health Promotion Education: Learn to identify
achievable lifestyle goals relating to smoking cessation,
exercise and nutrition, and resources for ongoing support
• Social Support Session: Training for family members
and significant others to help navigate medical
encounters, support health behavior change and healthy
behaviors
P.A.C.T. Physician Training
• Guidelines for addressing
cardiovascular risks in people with SMI
• Patient centered communication skills
• Collaborative goal identification
15

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
Consumer and Provider Training Videos
16

Application for P.A.C.T.
• Supporting the “Person-Centered Medical
Home” for persons with SMI
• Enhancing behavioral activation, shared
decision-making in the primary care
encounter and improved health behaviors
• Preparing PCPs to support and enhance
engagement and collaborative goal setting
III. Integrated Illness Self-Management
and Nurse Disease Management:
Integrated Illness Management and
Recovery(NIMH R34 MH074786)
• Individualized integrated illness self-management
skills training provided by a Masters 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)
17

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.
I-IMR Disease Management
• Comprehensive initial evaluation of health and
receipt of preventive health services
• Establishment of health care goals
• Tracking & promotion of preventive health
care, acute problems, chronic medical
illnesses
• Periodic assessment of health status
• Health education and support for selfmanagement
of medical problems
18

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)
20

I-IMR Evaluation
• NIMH R34 Pilot Study
– RCT n=70 adults with SMI age 50+
– 2 CMHCs in NH
• Thresholds (Chicago) Pilot Study
– RCT n=50 ethnically diverse adults
with SMI age 50+
Summary of Major Findings
Comparing I-IMR and TAU
• Client Rated Illness
Self-Management:
– Knowledge of Symptoms,
Meds, Coping
– Relapse Prevention Planning
• Clinician Rated Illness
Self-Management
– Symptom Distress
– Symptoms Affecting
Functioning
• Trend for Stanford Chronic
Disease Self-Management
Scale
• Trend for Greater Physical
Activity
• Trend for Better COPD Self
Management
21

Summary of Major Findings
Comparing I-IMR and TAU
Significant Differences for
Primary Care Encounter:
|
• Trend- Greater Active Role
Communicating Questions
• Greater Information
Seeking
Significant Difference for
Psychiatric MD Encounter:
• Information Seeking
• Trend: Less Decision
Making Autonomy
Application for I-IMR
• Integration within programs of chronic
disease self-management targettng the
highest cost, most complex individuals
• A unique program of self-management and
care management for BOTH SMI and
chronic health conditions
22

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)
Automated Daily:
- Self-monitoring
- Health Data Entry
- Self-management
Education
- Remote DM
Nurse Monitoring
23

Application for Health Buddy
• Targeted home-based management and
monitoring of complex, co-occurring medical
and mental health conditions.
• For “unstable” high-risk individuals with
recent emergency service use, hospitalizations,
or other indicators for daily prompting of self
management and remote monitoring.
24

V. Prevention: Fitness Promotion
In SHAPE: A Program with
Several Components
1. Individualized fitness and healthy lifestyle
assessment
2. Individual meetings (weekly) with a Health
Mentor (certified fitness trainer)
3. Free membership to local fitness centers (YMCA;
Dance-exercise center; Womens fitness center)
4. Group Exercise and Healthy Eating Education
5. Group health educational/motivational
Celebrations
The In SHAPE Health Mentor Program
25

Dartmouth Center for Aging
Research on In SHAPE
1. Endowment for Health: Pilot Evaluation of a Fitness
Promotion Intervention for People with SMI
2. CDC: R01 DD000140 Promoting Health & Functioning in
Persons with SMI
3. NIMH: R01MH078052 Health Promotion and Fitness for
Younger and Older Adults with SMI
4. NIMH: R01MH089811 Statewide Intervention to Reduce
Early Mortality in Persons With Mental Illness
5. CMS: 1B1CMS330880 NH Medicaid Wellness Incentives
Program (Medicaid Incentives for Prevention of Chronic
Diseases)
Bridging the Gap from Community
to Research to Population Health
Community
Development
Identification
of Need,
Community
Coalition
Development of
In SHAPE
Model
Research
Academic
Research
Partnership,
1 st Pilot Study
Effectiveness
RCT Studies
(CDC, NIMH)
Implementation
State Medicaid
Policy Change
Supporting
Sustainability
Statewide
Implementation
and Evaluation
26

Can integrated health promotion be
implemented and sustained as a core service
across an entire state system?
• Statewide roll-out over 3 years including
leadership, training, technical support,
and tracking of outcomes and costs
• In SHAPE targeting patient health
behaviors:
Exercise, nutrition, smoking cessation +
• Academic Detailing (AD) targeting
physician screening and prescribing
practices (NIMH R01, PI: Bartels)
In SHAPE Implementation Study: ISIS
• 5 year study funded by NIMH (12/1/09 – 11/30/14)
• Evaluates phased-in implementation of In SHAPE +
Academic Detailing across 8 CMHCs in NH
• Provides funding for .5FTE (Health Mentor or
Program Coordinator) for 15 months
• Provides FREE In SHAPE training and technical
assistance
• Primary Study Questions: Implementation Process,
Effectiveness of In SHAPE, Cost
27

Application for In SHAPE
• Targeted Prevention of chronic health
conditions and Wellness Health Promotion as
an integrated component of service delivery
• Prevention of chronic health conditions
associated with obesity, sedentary lifestyle, and
poor nutrition, including diabetes,
hyperlipidemia, hypertension, cardiovascular,
and cerebrovascular disease
CMS Request for Proposals
• Question: Can incentives help to
prevent chronic diseases in at-risk
Medicaid populations?
28

NH Medicaid Wellness
Incentives Program
• $10 M for 5 year project
• One of only 10 states funded
• Three types of incentives:
– Access to fitness facilities & activities
– Transportation to reduce barriers to
fitness
– Rewards for healthy behaviors
(attendance at fitness facilities, smoking
cessation programming, and smoking
abstinence)
Overview of WIP Program and
Evaluation Design
• Goal: Reduce cardiovascular risk in
smokers and overweight/obese consumers
• 4 Weight Management and 3 Smoking
Cessation Programs offered at all 10
CMHCs in NH
• Enroll 2500 in WM and 200 in SC
• Consumers can choose the programs in
which they are willing to participate
29

Supported Fitness & Weight Management
(age 18+, BMI>25, sedentary)
Group 1: Group 2: Group 3: Group 4:
Fitness Club
In Shape + Weight
In SHAPE Program Weight Watchers
Membership
Watchers
1A: 2A: 3A: 4A:
Same as 1A + individual Free membership
Free gym mebership for up
Same as groups 2A &
sessions with fitness ($20/month) for up to
to 24 months ($20/month)
3A
trainer up to 24 months 24 months
1B: 2B: 3B: 4B:
Same as above + $5/each
(up to $15/wk) for going to
gym
Same as above +
$5/each (up to $15/wk)
for going to gym w/out
trainer
Same as above + $10
to attend one weekly
meeting
Same as above plus
rewards in Groups 2B
&3B
Supported Smoking Cessation
Programs
Group 1: Group 2: Group 3:
Prescriber Referral +
Telephone CBT
$15 for signed
prescriber letter + $5/ea
for 12 sessions
Prescriber Referral +
Facilitated Quitline
Prescriber Referral Only
1A: 2A: 3A:
$15 for signed prescriber
letter + $20/ea for 3
sessions
$50 for signed prescriber
letter
1B: 2B: 3B:
Extra rewards for 1
abstinence attempt
Extra rewards for 1
abstinence attempt
Extra rewards for 1
abstinence attempt
Rewards for Abstinence: When participants quit, can come to IC
MWF and earn $50/ea for abstinence (CO

Putting it Together
• HOPES: Aging persons with SMI, Olmstead
and Nursing Discharge & Diversion
• P.A.C.T: Behavioral activation, shared goal
setting, and the “medical home” for SMI
• I-IMR: Integrated physical and mental health
self-management
• Health Buddy: High risk, high service users
with SMI and unstable health conditions
• In SHAPE: Prevention, integrated wellness
health promotion
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
31

Putting it Together:
The Context and Opportunity
• The Demographic Imperative
• CMMI and beyond: Dually Eligible and
Long- term Care ACOs
• Health Homes and Health Neighborhoods for
Persons with SMI and Disabilities
• CMS & ACA: Health Promotion and Prevention
• Olmstead Decision, the ADA and CMS:
Nursing home deinstitutionalization and diversion
Potential New Research
Opportunities
• Use of smartphone and other technology for
prompting, monitoring, and support of wellness
• Engaging families and social networks for
health behavior change
• Peer led and peer supported interventions
• Financial incentives for health behavior change
• Ethnically and culturally tailored health
promotion and illness management interventions
32

The Health Promotion Research Team
The Center for Aging Research
33