10% - PASRR Technical Assistance Center

SHOW - ME
Integration of Behavioral
Health and Primary Care

My Background
• DMH Medical Director
• Consultant to MoHealthNet (Missouri Medicaid)
• President NASMHPD Medical Director’s Council
• Practicing FQHC Psychiatrist
• Director Missouri Institute of Mental Health –
University of Missouri St Louis

National Association of State Mental
Health Program Directors (NASMHPD)
• Membership is the Commissioners/Directors of state
mental health agencies all 50 states, 4 territories, and
the District of Columbia who are responsible for the
provision of mental health services to citizens
utilizing the public system of care.
• Represents the $23 billion public mental health
service delivery system serving 6.1 million people
annually.
• NASMHPD Medical Directors Council identifies
emerging clinical and provides policy guidance to
national mental health leadership

Morbidity and Mortality in People
with Severe Mental Illness
• 13 th Technical Report of The NASMHPD
Medical Director’s Council
• Available in full at
http://www.nasmhpd.org/medical_director.cfm
• Original Research by NASMHPD Research
Institute (NRI)
• Funded by CMHS-SAMHSA

Overview: THE PROBLEM
• Increased morbidity and mortality associated with serious
mental illness (SMI)
• Increased morbidity and mortality largely due to preventable
medical conditions
– Metabolic disorders, cardiovascular disease, diabetes mellitus
– High prevalence of modifiable risk factors (obesity, smoking)
– Epidemics within epidemics (eg, diabetes, obesity)
• Some psychiatric medications contribute to risk
• Established monitoring and treatment guidelines to lower risk
are underutilized in SMI populations

Multi-State Pilot Study
• Compared DMH clients with general population
• 1997 – 2000
• States: Arizona Missouri
Oklahoma Rhode Island
Texas Utah
Virginia District of Columbia

Mortality Associated with Mental Disorders:
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
Lutterman, T; Ganju, V; Schacht, L; Monihan, K; et.al. Sixteen State Study on Mental Health Performance
Measures. DHHS Publication No. (SMA) 03-3835. Rockville, MD: Center for Mental Health Services,
Substance Abuse and Mental Health Services Administration, 2003. Colton CW, Manderscheid RW. Prev
Chronic Dis. Available at: ttp://www.cdc.gov/pcd/issues/2006/apr/05_0180.htm.

Results
Measure Range Mean Mode
Standardized
Mortality Rates
Average Years
Life Lost
Average Age
at Death
0.6 – 4.9 2.2 2.2
13.5 – 29.3 25.2 26.9
48.9 – 76.7 56.8 57.7

Total YPLL by Primary Cause for Public
Mental Health Patients with Mental Illness
Combined data for schizophrenia and schizoaffective disorder from 5 US
states (MO, OK, RI, TX and UT) from 1997 to 2001
Total YPLL
Primary cause of death
(Person-years lost) Deaths (n)
Heart disease 14,871.2 612
Cancer 5,389.9 241
Suicide 4,726.1 115
Accidents, including vehicles 3,467.0 98
Chronic respiratory 2,700.9 113
Diabetes 1,419.6 61
Pneumonia/influenza 1,254.2 67
Cerebrovascular disease 1,195.9 58
All causes of death* 47,812.2 1,829
*Note: Includes deaths from causes not listed; YPLL = years of potential life l
Unpublished results courtesy of CW Colton

Change in US General Population Age-
Adjusted Mortality (1979-1995)
Decline (%)
10
0
-10
-20
-30
-40
-50
-60
Noncardiovascular Disease
Coronary Heart Disease (CHD)
Stroke
79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95
Year
Morbidity and Mortality Weekly Report. 1999; 48(30):649-656.

Mortality Risk From All Causes and From
Cardiovascular Disease Increased Among Patients
With Schizophrenia Between 1970-2003
Men
Women
3
2.5
Relative Risk for
Standardized Mortality Ratio
2.5
2
1.5
1
0.5
Relative Risk for
Standardized Mortality Ratio
2
1.5
1
0.5
0
1970-
1974
1975-
1979
1980-
1984
1985-
1989
1990-
1994
1995-
1999
2000-
2003
0
1970-
1974
1975-
1979
1980-
1984
1985-
1989
1990-
1994
1995-
1999
2000-
2003
All Causes
Cardiovascular Disease
All Causes
Cardiovascular Disease
Test for time trends of excess relative risks for SMRs were statistically significant (P

Ohio Study-Discharged Inpatients
Standardized Mortality Ratios
Cause
Overall
N SMR
All causes of death 608 3.2†
Intentional self-harm (suicide) 108 12.6†
Symptoms, signs, & abnormal 32 9.7†
clinical & laboratory findings, NEC
Pneumonia & Influenza 16 6.6†
Chronic lower respiratory diseases 31 5.5†
Accidents (unintentional injuries) 83 3.8†
Diseases of heart 126 3.4†
Diabetes mellitus 18 3.4†
Assault (homicide) 10 1.7
Cerebrovascular diseases 10 1.5
Malignant neoplasms (cancers) 44 0.9
† P

Maine Study Results: Comparison of Health
Disorders Between SMI & Non-SMI Groups

What are the Causes of Morbidity and Mortality
in People with Serious Mental Illness?
• 88% of the deaths and 83% of premature years of life
lost in persons with serious mental illness are due to
“natural causes”
– Cardiovascular disease
– Diabetes
– Respiratory diseases
– Infectious diseases

BMI Distributions for General Population
and Those With Schizophrenia (1989)
30
Underweight
Acceptable
Overweight
Obese
20
10
0
< 18.5 18.5-20 20-22 22-24 24-26 26-28 28-30 30-32 32-34 > 34
Allison DB et al. J Clin Psychiatry. 1999;60:215-220.
BMI Range
No schizophrenia
Schizophrenia

Mental Disorders and Smoking
• Higher prevalence of cigarette smoking(56-88%) for SMI
patients (overall U.S. prevalence 25%)
• More toxic exposure for patients who smoke (more
cigarettes, larger portion consumed)
• Smoking is associated with increased insulin resistance
• 44% of all cigarettes in US are smoked by persons with
mental illness
George TP et al. Nicotine and tobacco use in schizophrenia. In: Meyer JM, Nasrallah HA, eds.
Medical Illness and Schizophrenia. American Psychiatric Publishing, Inc. 2003; Ziedonis D,
Williams JM, Smelson D. Am J Med Sci. 2003(Oct);326(4):223-330

Comparison of Metabolic Syndrome and Individual
Criterion Prevalence in Fasting CATIE Subjects and
Matched NHANES III Subjects
Males
CATIE NHANES p
N=509 N=509
Females
CATIE NHANES p
N=180 N=180
Metabolic Syndrome
Prevalence
36.0% 19.7% .0001 51.6% 25.1% .0001
Waist Circumference Criterion 35.5% 24.8% .0001 76.3% 57.0% .0001
Triglyceride Criterion 50.7% 32.1% .0001 42.3% 19.6% .0001
HDL Criterion 48.9% 31.9% .0001 63.3% 36.3% .0001
BP Criterion 47.2% 31.1% .0001 46.9% 26.8% .0001
Glucose Criterion 14.1% 14.2% .9635 21.7% 11.2% .0075
Meyer et al., Presented at APA annual meeting, May 21-26, 2005.
McEvoy JP et al. Schizophr Res. 2005;80:19-32.

Leading Contributors to
Early Mortality
• Obesity
• Cardiovascular disease
(including hypertension and COPD)
• Diabetes
• Sedentary lifestyle
• Smoking
• Substance abuse

Access To Health Care
• An issue for all people with limited income,
particularly preventive care
• Over use of emergency and specialty care
• Complicated by mental illness
• Significantly lower rates of primary care
• Significantly lower rates of routine testing
• Very poor dental care
• Little integration of primary care and psychiatry

Survival Following Myocardial
Infarction
• 88,241 Medicare patients, 65 years of age and
older, hospitalized for MI
• Mortality increased by
– 19%: any mental disorder
– 34%: schizophrenia
• Increased mortality explained by measures of
quality of care
Druss BG et al. Arch Gen Psychiatry. 2001;58:565-572.

Problem:
SMI and Reduced Use of Medical Services
• Less likely to be screened or treated for
dyslipidemia, hyperglycemia, hypertension
• Less likely to receive angioplasty or CABG
• Less likely to receive drug therapies of proven
benefit (thrombolytics, aspirin, beta-blockers,
ACE inhibitors) post-myocardial infarction
• More likely to have premature mortality postmyocardial
infarction
Newcomer J, Hennekens CH. JAMA. 2007;298:1794-1796.
Druss BG et al. Arch Gen Psychiatry. 2001;58:565-572.

Comparison of Metabolic Syndrome and Individual
Criterion Prevalence in Fasting CATIE Subjects and
Matched NHANES III Subjects
Males
CATIE NHANES p
N=509 N=509
Females
CATIE NHANES p
N=180 N=180
Metabolic Syndrome
Prevalence
36.0% 19.7% .0001 51.6% 25.1% .0001
Waist Circumference Criterion 35.5% 24.8% .0001 76.3% 57.0% .0001
Triglyceride Criterion 50.7% 32.1% .0001 42.3% 19.6% .0001
HDL Criterion 48.9% 31.9% .0001 63.3% 36.3% .0001
BP Criterion 47.2% 31.1% .0001 46.9% 26.8% .0001
Glucose Criterion 14.1% 14.2% .9635 21.7% 11.2% .0075
Meyer et al., Presented at APA annual meeting, May 21-26, 2005.
McEvoy JP et al. Schizophr Res. 2005;80:19-32.

The CATIE Study
At baseline investigators found that:
• 88.0% of subjects who had dyslipidemia
• 62.4 % of subjects who had hypertension
• 30.2% of subjects who had diabetes
WERE NOT RECEIVING TREATMENT
Nasrallah HA, et al. Schizophr Res. 2006;86:15-22.

“Mental Health” Care in Primary
Care Settings
• Psychological distress drives primary care utilization
• Most somatic complaints don’t have an identifiable cause
(Kroenke & Mangelsdorf, 1984)
• Only 30% of primary care visits are for an identified medical
condition (Strosahl, 1998)
• More mental health interventions occur in primary care than in
specialty mental health settings
• Behavioral health problems inflate medical costs and impede
outcomes

The Problem
Clinical Cost Drivers:
Untreated Medical Illness
Poor patient adherence to effective treatments
Medical Errors
Administrative Cost Drivers:
Lack of coordination of care
Provider lack efficient HIT decision support systems
Fragmentation of systems of care

CMHC Mission
Recovery for
Persons with SMI

CMHC Problem
Early Death from
Physical Illness Prevents
Recovery from SMI

FQHC Mission
Healthy Patients
including those with
Mental Illness

FQHC Problem
Persons with Serious Mental
Illness Die in their 50s of
Chronic Treatable Medical
Illness

Safety Net Paradigm Shift
• Traditional Mental Health safety net (CMHCs)
shifted course
• Health status of the seriously mentally ill – a
new health disparity (NASMHPD, 2006)
• Expanded mental health service capacity of
FQHCs
• Recognition of the behavioral health nature of
primary care

11th Technical Report
Integrating Behavioral Health and
Primary Care
• Six Reports in One
– 3 Background:
• Conceptual Models
• Overview of Community Health Centers
• Relationships among providers – same models
– 3 Recommendation Areas:
• System Coordination
• Serious Mental Illness
• Primary Care

Primary and Behavioral Health Care Integration
Strategies in Search of a Model
• Preferential Referral Relationship
• Formalized Screening Procedures
• HIT Based Care Coordination
• Co-Location of Services
• Behaviorist on Primary Care Team
• Disease Management
• Health Care Home for Chronic Conditions

Recommendations – Provide
Information to Healthcare Providers
• HIPAA permits sharing information for
coordination of care
• Nationally consent not necessary
• Exceptions:
– HIV
– Substance abuse treatment – not abuse itself
– Stricter local laws

What Drives Primary Care
Crazy
• No responses back when they refer a patient
• Long responses that use mental health jargon
• Lack of explicit recommendations they can act on
• No response to a medical record/release of
information request
• Long delays in getting patient seen for initial consult

Option
Separate one time consultation and
recommendation service
• Rapid access to consultation
• Usual wait list for ongoing service

Missouri’s CMHC/FQHC
Integration Project

Benefits of Co-Location
• Patients prefer it
– % of f/u raises from 15-20% to 40-60%
• Builds personal relationships – the foundation
of any enduring arrangement
• Allows more accurate understanding of each
other’s incentives, methods and constraints
• Opportunities for informal consultation
• Single clinical record reduces errors

Progress to Date
• More Organizations are both CMHC and FQHC
– One CMHC obtained new FQHC status
– One merger of a CMHC with a FQHC
• Three FQHCs have chosen to contract with
CMHCs for BH services at other sites beyond the
grant rather than develop their own BH services
• Three CMHCs applying to become FQHCs
• Funding through Federal 330 Grant look-alike
method leverages funding for uninsured by 30%

DMH NET
Missouri’s CMHC
Health Care Home
Project

Principles
• Physical healthcare is a core service for
persons with SMI
• MH systems have a primary responsibility to
ensure:
– Access to preventive healthcare
– Management and integration of medical care

DMH NET – Strategy
• Health technology is utilized to support the service
system.
• “Care Coordination” is best provided by a local
community-based provider.
• Community Support Workers who are most familiar
with the consumer provide care coordination at the
local level.
• Nurse Liaisons working within each provider
organization provide system support.
• Statewide coordination and training support the
network of providers.

Components of the Health
Care Home
• Personal physician – Each patient has an ongoing relationship with a Primary Care
Physician (PCP),
• Monitored, coordinated and integrated care using electronic medical records and
personal health records
• Measured and managed adherence to evidence-based practices by the care team
and the patient
• Whole person” orientation toward adherence,
• Health coaches, who are trained to provide first-contact, continuous and
comprehensive care, are competent in the use of active listening, health coaching,
evidence-based, clinical information technology, and population-based outcome
improvement and measurement.
• An Organization responsible for the ongoing care of patients. The day-to-day
operation is focused on managing population-based outcomes and maximizing
individual adherence to a distinct, customized self-care management program that
leverages information technology

Mapping & Data Integration
Diagnosis
Pharmacy
Claims
Medical
Claims
Reference
Data
Membership
Integrated
Drug
Data Repository
Office
Hospital Laboratory
ER
7/13/2011 45

CyberAccess TM
• Current Features
– Patient demographics
– Electronic Health Record
• Record of all participant prescriptions
• All procedures codes
• All diagnosis codes
– E prescribing
– Preferred Drug List support
• Access to preferred medication list
• Precertification of medications via clinical algorithms
• Implementation of step therapy
• Prior authorization of medications)
– Medication possession ratio
– DirectCare Pro
7/13/2011 – Disease Registry for CMHCs
48

CyberAccess - Log-In Screen
Slide 49

CyberAccess - EULA
Slide 50

CyberAccess - Home Page
Slide 51

CyberAccess - Demographics
Slide 52

CyberAccess – Paid Drug Claims
Slide 53

Slide 54
CyberAccess – Paid Drug
Claims/MPR
• An MPR between 80-100% will display in green text. An MPR between 60-79% will display in yellow text. An MPR of less than
60% will display in red text. If an MPR does not exist for type of drug or the drug is not for maintenance the column will
display a dash.

CyberAccess – Medical
Procedures
Slide 55

CyberAccess – Diagnosis Codes
Slide 56

Slide 57
CyberAccess – Electronic Health
Record
• Examples of CyberAccess utilization in Missouri from
April 2006 thru September 30, 2009…
– Users logged in 675,616 times
– Patient history checked 1,096,270 times.
– Drug rules checked 26,079 times.
– Medical rules checked 471,096 times.
– Prescriptions printed 1,125 times.
– Prescriptions faxed 3,453 times.
– Drug help tickets opened 10,428 times.
– Medical help tickets opened 19,431 times.

Direct Inform TM
• Access to program provided benefits
– Program integrity notification of services provides
(EOB equivalent)
• Notification of wellness lapses
• Web portal participant health information
• MORx Compare (current)
7/13/2011 58

DirectInform Screen Shot 1 MHD
7/13/2011 59

CMHC as Health Care Home
• Case management coordination and facilitation
of healthcare
• Medical disease management for persons with
SMI
• Preventive healthcare screening and
monitoring by MH providers
• Integrated/consolidated CMHC/CHC Services

Recommendation – Medical Needs Have
Same Priority as MH Needs
• Obtaining a “medical home” – a primary care
provider responsible for overall coordination
• Medication adherence – just as important for
non-MH meds
• Assisting in scheduling and keeping medical
care appointments

Care Coordination
Integrates Healthcare Issues into
CMHC Care Mechanisms
• Include healthcare goals in treatment plan
• Include healthy lifestyle goals in treatment plan
• Identify client’s internal health care
expert/champion
• Develop health and wellness services
• Provide nurse healthcare liaison – proven practice
• Verify healthcare services are occurring by utilizing
data

Provide Information to Other Healthcare
Providers
• HIPAA permits sharing information for
coordination of care
• Nationally consent not necessary
• Exceptions:
– HIV
– Substance abuse treatment – not abuse itself
– Stricter local laws

Recommendations
• Screen for general health with priority for high risk conditions
• Offer prevention and intervention especially for modifiable risk
factors (obesity, abnormal glucose and lipid levels, high blood
pressure, smoking, alcohol and drug use, etc.)
• Prescribers will screen, monitor and intervene for medication
risk factors related to treatment of SMI (e.g. risk of metabolic
syndrome with use of second generation anti-psychotics)
• Treatment per practice guidelines: eg, heart disease, diabetes,
smoking cessation, use of novel anti-psychotics

ADA/APA/AACE/NAASO
Consensus on Antipsychotic Drugs and
Obesity and Diabetes: Monitoring Protocol*
*More frequent assessments may be warranted based on clinical status
Diabetes Care. 2004;27:596-601
Start 4 wks 8 wks 12 wk qtrly 12 mos. 5 yrs.
Personal/family Hx X X
Weight (BMI) X X X X X
Waist circumference X X
Blood pressure X X X
Fasting glucose X X X
Fasting lipid profile X X X X

Metabolic Syndrome Disease
Registry
• Metabolic Syndrome
– Blood pressure - weight
– Cholesterol - height
– Triglycerides - blood sugar
• Screening Required Annually since January 1
• Disease registry with results maintained on
cyber access
• Next step – utilize data to identify care gaps

DMHNET HEIDIS Indicators
• DM1: Use of inhaled corticosteroid medications by persons with a history of
COPD (chronic obstructive pulmonary disease) or Asthma.
• DM2: Use of ARB (angiotensin II receptor blockers) or ACEI (angiotensin
converting enzyme inhibitors) medications by persons with a history of
CHF (congestive heart failure).
• DM3: Use of beta-blocker medications by persons with a history of CHF
(congestive heart failure).
• DM4: Use of statin medications by persons with a history of CAD (coronary
artery disease).
• DM5: Use of H2A (histamine 2-receptor antagonists) or PPI (proton pump
inhibitors) medications for no more than 8 weeks by persons with a history
of GERD (gastro-esophageal reflux disease).

DMHNET HEIDIS Indicators
• DM6: Presence of a fasting lipid profile within the past 12
months for patients with CAD (coronary artery disease).
• DM7: Presence of a DRE (dilated retinal exam) within the
past 12 months for patients with diabetes mellitus.
• DM8: Presence of a urinary microalbumin test within the
past 12 months for patients with diabetes mellitus
• DM9: Presence of at least 2 hemoglobin A1C tests within the
past 12 months for patients with diabetes mellitus.
• DM10: Presence of a fasting lipid profile within past 12
months for patients with diabetes mellitus.

Initial Results
• Provide specific lists of CMHC clients with care
gaps as identified by HEIDIS indicators to CMHC
primary care nurse liaisons quarterly
• Provide HEIDIS indicator/disease state training on
standard of care to CMHC MH case managers
• First quarter focus on indicator one-asthma
substantially reduced percentage with care gap
– Range 22% - 62% reduction
– Median 45% reduction

Support Patient Wellness through Self
Management using Peer Specialists
• Implement a physical health/wellness approach that is
consistent with recovery principles, including supports for
smoking cessation, good nutrition, physical activity and
healthy weight.
• Educate patient on implications of psychotropic drugs
• Teach/support wellness self-management skills
• Teach/support decision making skills using Direct Inform
• Use motivational interviewing techniques
• New psychosocial rehab focus
– Smoking cessation
– Enhancing Activity
– Obesity Reduction/Prevention

Local CMHC Initiatives
• BJC Healthcare - Quality indicators at 90% for all
consumers include: serum glucose annually, BMI
annually, smoking screening at admission,
influenza vaccination, and hypertension screening.
• Independence Center - Created a comprehensive
Wellness program for staff and clients that has
become a national training center for Clubhouse
programs.
• Crider Health Center and Hopewell - Became
Federally Qualified Health Centers and deliver a full
array of primary care services.

A Typical Participant in This Overview
• A 47 year old male
• More than one major
targeted disease
• Likely has a major
cardiovascular diagnosis
and diabetes
• Likely has experienced a
major cardiac event
• A third have a major
behavior health comorbidity
• A generally motivated
cohort
Continuously Enrolled 7/1/2007 - 6/30/2008
24,700
Disease
Number of
Individuals Percentage
Asthma 9,817 39.7%
CAD 16,982 68.8%
CHF 5,746 23.3%
COPD 8,155 33.0%
Diabetes 12,939 52.4%
GERD 12,592 51.0%
Sickle Cell 558 2.3%
Behavioral Disability 8,395 34.0%
*Includes co-morbid conditions
7/13/2011 73

Missouri CCIP Diabetes Outcomes
Hemoglobin A1c Compliance
50%
47%
Percent Compliant
40%
30%
20%
10%
0%
25%
26%
12%
HbA1c - one or more tests HbA1c - two or more tests
ENROLLED N=12,939
NON-ENROLLED N=33,631
Clinical Measure
HbA1c testing provides an estimation of average blood glucose values in people with
diabetes. Enrollees in the CCIP program received substantially more HbA1c testing than
those not enrolled.
7/13/2011 74

Missouri CCIP Coronary Artery
Disease (CAD) Outcomes
Beta Blocker Post MI Compliance
Percent Compliant
70%
60%
50%
40%
30%
20%
10%
0%
61%
33%
Beta Blocker Post-AMI
Clinical Measure
Enrolled N=16,982
Non Enrolled N=29,088
CCIP enrollees with coronary artery disease (CAD) received recommended
treatment with beta blocker medications at nearly twice the rate of non-enrollees.
7/13/2011 76

Trend Analysis of Total Costs
$1,600
$1,400
MO HealthNet Average Total Monthly Costs for CCIP Disease
Eligible Population
$1,283 PMPM
$1,200
$962 PMPM
$1,000
$ PMPM
$800
$600
$400
$200
Actual
CCIP Enrolled
Eligible-Not Enrolled
Linear (Actual)
$-
Mar-08
Feb-08
Jan-08
Dec-07
Nov-07
Oct-07
Sep-07
Aug-07
Jul-07
Jun-07
May-07
Apr-07
Mar-07
Feb-07
Jan-07
Dec-06
Nov-06
Oct-06
Sep-06
Aug-06
Jul-06
Jun-06
May-06
Apr-06
Mar-06
Feb-06
Jan-06
Average Total Monthly Costs for CCIP-enrolled participants were below projection.
March 2008 demonstrates a $321 PMPM savings.
7/13/2011 78

Trend Analysis of Emergency
Room Utilization
300
ER Usage Rate per 1000
250
Projection
200
Achieved ER
reduction ~30%
Rate per 1000
150
100
50
0
Enrolled
Identified, Not Enrolled
Identified
Linear (Identified)
Apr-07
Mar-07
Feb-07
Jan-07
Dec-06
Nov-06
Oct-06
Sep-06
Aug-06
Jul-06
Jun-06
May-06
Apr-06
Mar-06
Feb-06
Jan-06
Mar-08
Feb-08
Jan-08
Dec-07
Nov-07
Oct-07
Sep-07
Aug-07
Jul-07
Jun-07
May-07
ER visits decreased more substantially than projected representing another key cost driver for
savings
7/13/2011 79

CMHC DISEASE MANAGEMENT
• Clients were Medicaid enrolled with a CCIP eligible
medical diagnosis and a serious mental illness
enrolled in a CMHC, but may or may not have been
enrolled in CCIP.
• Clients received Psychiatric Rehabilitation services if
they were eligible for those services.
• Average Medicaid annual medical cost for the clients
was $18,672 per year.

Statewide Information
• Community Mental Health Centers have approved 10% of the
healthcare home plans of care in the State Medicaid program.
• More than 35,000 patient histories have been reviewed in
CyberAccess.
• More than 70% of patients have had a primary care visit within a 12-
month period, according to claims; sampled chart review indicates a
higher percentage (3 agency sample over 90%).
• Outcomes review of Missouri Psychiatric Rehabilitation programs
indicates substantial off-trend cost savings for the overall healthcare
cost after admission to the program.

Cost Savings achieved for
clients in CMHCs
Base Period (CY2006) $1,556
Expected Trend 16.67%
Expected Trend with no Intervention $1,815.81
Actual PMPM in Performance Period (FY2007) $1,504.34
Gross PMPM Cost Savings $311.47
Lives 6,757
Gross Program Savings $25,254,928
Vendor Fees $0
Net Program Savings $25,254,928
NET PMPM Program Savings $311.47
Net Program Savings/(Cost) as percentage of Expected PMPM 17.15%

OFF TREND COST SAVINGS FOR
CMHC-CM CLIENTS ELIGIBLE FOR
CCIP
Category pre CMHC-CM post CMHC-CM Net Change Percent Change
Pharmacy $39,367,496 $30,154,143 ($9,213,352) -23.4%
General Hospital $23,140,172 $21,546,466 ($1,593,706) -6.9%
Psych Rehab $35,378,951 $37,467,731 $2,088,780 5.9%
Psychologist $463,069 $144,434 ($318,635) -68.8%
Independent
Clinic $3,549,715 $4,324,452 $774,738 21.8%
Overall $101,899,402 $93,637,226 ($8,262,176) -17.2%

Medicaid Cost Savings for the
6,757 people
• OFF TREND SAVINGS OF $25 million annually.
• Actual Pharmacy services decreased by $9.2
million annually or 23%
• Actual General Hospital services decreased by
$1.5 million or 6.8%
• Actual Primary Care services increased by
$774,000 or 21%

Total Healthcare Cost Trend
Pre-/Post CMHC Enrollment
• Selection Criteria – 636 persons identified
– Newly enrolled in CMHC case management
– At least nine months of Medicaid claims in each of the
preceding two years and two years following CMHC
enrollment
• Methodology
– Calculate total monthly Medicaid costs PMPM 24 months
pre and post-enrollment
– month zero is 24 months prior to enrollment, month 24 is
the month of enrollment, month 48 is 24 months after
enrollment
– Calculate linear regression trend lines

Total HealthCare Utilization Per User Per Month
Pre and Post Community Mental Health Case
Management
Average Medicaid expenditures
per month
Months with case management initiated on month 24

Goals: Lower Risk for CVD
• Blood cholesterol
– 10% ↓ = 30% ↓ in CHD (200-180)
• High blood pressure (> 140 SBP or 90 DBP)
– 4-6 mm Hg ↓ = 16% ↓ in CHD; 42% ↓ in stroke
• Cigarette smoking cessation
– 50%-70% ↓ in CHD
• Maintenance of ideal body weight (BMI = 25)
– 35%-55% ↓ in CHD
• Maintenance of active lifestyle (20-min walk daily)
– 35%-55% ↓ in CHD
Hennekens CH. Circulation. 1998;97:1095-1102.

Strategies
• Incrementally build your organizations
healthcare, competencies internally
• Build and maintain a collaborative partnership
with a healthcare organization
• Merge/consolidate with a healthcare
organization

WebSites
• www.nasmhpd.org/medical_director.cfm
– BH/PC Integration - Obesity and SMI
– SMI Mortality - Smoking in MI Facilities
– Measuring Health Indicators in SMI
• http://www.dmh.mo.gov/MHMPP/MHMPP.htm
– Pharmacy Quality Improvement
– Disease Management for SMI Populations

Health Technology
• Care Management Technologies (CMT) Programs
– Behavioral Pharmacy Management
– CMHC Pharmacy Management Reports
– Health Optimization
– Diabetes
– HEIDIS Gaps and Performance
– Data Analytic Custom Support
• ACS-Heritage Programs
– CyberAccess
– Direct Inform
– Disease Registry for Metabolic Syndrome

1-Year Weight Gain:
Mean Change From Baseline Weight
Change From Baseline Weight (kg)
14
12
10
8
6
4
2
0
0
4
Olanzapine (12.5–17.5 mg)
Olanzapine (all doses)
Quetiapine
Risperidone
Ziprasidone
Aripiprazole
8
12
16
20
24
28
32
36
40
44
48
52
30
25
20
15
10
5
0
Change From Baseline Weight (lb)
Weeks
Nemeroff CB. J Clin Psychiatry. 1997;58(suppl 10):45-49; Kinon BJ et al. J Clin Psychiatry. 2001;62:92-100; Brecher M et
al. American College of Neuropsychopharmacology; 2004. Poster 114; Brecher M et al. Neuropsychopharmacology.
2004;29(suppl 1):S109; Geodon ® [package insert]. New York, NY:Pfizer Inc; 2005. Risperdal ® [package insert]. Titusville,
NJ: Janssen Pharmaceutica Products, LP; 2003; Abilify ® [package insert]. Princeton NJ: Bristol-Myers Squibb Company
and Rockville, Md: Otsuka America Pharmaceutical, Inc.; 2005.

CATIE Trial Results:
Weight Gain Per Month Treatment
Weight gain (lb) per month
OLZ QUET RIS PER
ZIP
NEJM 2005 353:1209-1223

ADA/APA/AACE/NAASO
Consensus Recommendations on Responding to
Antipsychotic-associated Metabolic Changes
• If weight gain is ≥ 5% of body weight, consider
interventions, including switching to another second
generation antipsychotic
• If glycemia or dyslipidemia worsen, consider switch
to an second generation antipsychotic not associated
with significant weight gain or diabetes
• Gradually discontinue/cross-titrate
• Closely monitor psychiatric symptoms during
changeover
American Diabetes Association. Diabetes Care. 2004;27:596-601.

Change in Weight From Baseline
58 Weeks After Switch to Low Weight Gain Agent
5
6
10
14
19
23
27
32
36
40
45
49 53 58
LS Mean Change (lb)
0
-5
-10
-15
-20
-25
*
***
*P