1. The Role of Clinicians in Health and Wellness: Moving from Case Management to Care Management Presented by: Kathleen Reynolds, LMSW ACSW kathyr@thenationalcouncil.org

2. The Health Imperative/Disparity Individuals with Serious Mental Illness are dying approximately 25 years earlier than the general population (NASMPHD, 2006) Average age of death is 53 Substance Use Disorders and the Person-Centered Healthcare Home a 2010 report by B. Mauer finds that those with co-occurring MH/SUD were at greatest risk Average age of death is 45

3. How This Stacks Up Worldwide

4. SPMI Consumers are Dying of Preventable Causes (NASMHPD, 2006) ● Higher Rates of Modifiable Risk Factors: ◦ Smoking ◦ Alcohol consumption ◦ Poor nutrition / obesity ◦ Lack of exercise ◦ Unsafe sexual behavior ◦ IV drug use ◦ Residence in group care facilities and homeless shelters ● Vulnerability due to higher rates of: ‒ Homelessness ‒ Victimization / trauma ‒ Unemployment ‒ Poverty ‒ Incarceration ‒ Social isolation

5. Health Reform…What’s it going to be?

6. Current Reality - Nationally ● Behavioral Health budgets are being cut everywhere – Care Management is the buzz ● Healthcare Reform will impact your job ● Integration is the future ● Patient Centered Health Homes is the vision

7. 45% of Americans have one or more chronic conditions Over half of these people receive their care from 3 or more physicians Treating these conditions account for 75% of direct medical care in the US In large part due to the fact that money doesn’t start flowing in the U.S. healthcare system until after you become sick 7

8. Wagner EH. Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice. 1998;1(1):2-4.]

9. > “…in essence integrated health care is the systematic coordination of physical and behavioral health care. The idea is that physical & behavioral health problems often occur at the same time. Integrating services to treat both will yield the best results and be the most acceptable & effective approach for those being served.” > Connecting Body & Mind: A Resource Guide to Integrated Health Care in Texas and the U.S., > Hogg Foundation for Mental Health

10. Behavioral Health Physical Health --Partners in Health - Primary Care/County Mental Health Collaboration Toolkit, Integrated Behavioral Health Project (IBHP), October 2009 Healthcare Integration is just rediscovering the Neck

11. What do we do? Integrate healthcare using and expanding case management skills to: Improve the health of those we already serve through applying our skills at: Chronic disease management Health behavior change Relationships…in order to… Make ourselves indispensable to primary care and/or MCO’s Expand our services

12. HEALTH INDICATORS 1. Personal History of Diabetes, HTN, CV disease 6. Lipid Profile 2. Family History of Diabetes, HTN, CV Disease 7. Tobacco Use/History 3. Weight/Height, Body Mass Index8. Substance Use/History 4. Blood Pressure9. Medication: History and Current 5. Blood Glucose or HbA1c10. Social Supports PROCESS INDICATORS 1. Screen/Monitor Risk and Health Conditions in MH 2. Access to and utilization of Primary Care Services

13. Health Navigators/Care Managers will: > Cross the divide in the current health care system > Use existing skills in health behavior change and expand those skills to physical health issues > Increase their knowledge of questions to ask and strategies to seek > Use the community to support wellness

14. NAVIGATION/CARE MANAGEMENT SKILL: CROSSING THE CULTURAL DIVIDE BETWEEN PRIMARY CARE AND BEHAVIORAL HEALTH

15. Two worlds… Primary Care Brief, problem focused communication Immediate solution driven care Productivity measured in terms of number of patients seen Many evidence based interventions, disease management as standard part of practice Behavioral Health Process oriented Long term planning and coordination Productivity measured in units of service Individualized approach with evidence based interventions moving into practice

16. Two worlds, two lenses, one person Primary Care > Diabetes > Hypertension > Metabolic Syndrome > Smoking > ETOH > Schizophrenia Behavioral Health > Schizophrenia, co-morbid with: > Hypertension > Diabetes > Metabolic syndrome > Smoking > ETOH

17. Supporting people with PCP visits through preparation: Handout: Strategies for coordination Preparing for PCP visit Recognize the “intimidation factor” Develop a plan for “waiting” Role play strategies for communication and calming

18. NAVIGATION/CARE MANAGEMENT SKILL: SUPPORTING HEALTH BEHAVIOR CHANGE

19. What works in change: Think about a time in your own life when you successfully made a change in your lifestyle. What was the process like of getting to the change? What helped? What didn’t help? Think about a time you have supported someone else in making a change : What did you do that worked?

20. Habits & Health Behavior Change > “40% of the actions people perform each day weren’t actual decisions, but habits.” > Bad habits never die they are replaced by better habits. > All habits have a Cue-> Routine-> Reward > Golden Rule of Beh. Change: Use the same cue & the same reward but replace the routine Charles Duhigg--The Power of Habit: Why We Do What We Do in Life & Business

21. Motivational Interviewing basics: what we know about change > Motivation for change is malleable & particularly formed in relationships & through belief > Motivation is gained in the presence of active collaboration and shared decision making > People have inherent resources for change when the change is connected to their goals, values and dreams > Honoring the right not to change can make change possible.

22. Four key strategies > Listen for change talk > Deal with ambivalence > Look for degree of commitment > Look for degree of confidence

23. What Does This Look Like In Real Life?

24. Diet basics > Eat low > Eat color > Divide your plate > Consider your portions Principle: Even small (5-10%) weight loss makes a big difference!

25. American Dietetic Association: www.eatright.org

26. Challenging Health Behavior: Exercise- principles > Anything is better than nothing > Adding a small change will improve health > Small steps can lead to big changes > Support and accountability contribute to change > 3 months to make a habit (see resource list for websites that can help)

27. CHRONIC ILLNESS CHALLENGE: DIABETES

28. What do you already know about diabetes: > Cause? > Impacts? > Management?

29. Diabetes and Persons with SPMI

31. Routine medical examinations and tests for people with diabetes* >Measure blood pressure at every visit >Check feet for sores at every visit, and give a thorough foot exam at least once a year >Give a hemoglobin A1C test at least twice a year, to determine average blood glucose level over the past 2 to 3 months >Test urine and blood to check kidney function at least once a year >Test blood lipids (fats) – total cholesterol at least once a year LDL, or low-density lipoprotein (“bad” cholesterol) HDL, or high-density lipoprotein (“good” cholesterol) Triglycerides >Dental checkup twice a year >Dilated eye exam once a year >Annual flu shot >Annual pneumonia shot *www.CDC.gov

32. Know your diabetes ABCs > Talk to your health care team about how to manage your A1C, Blood pressure, and Cholesterol. This can help lower your chances of having a heart attack, stroke, or other diabetes problems. Here's what the ABCs of diabetes stand for: > A for the A1C test (A-one-C). > It shows what your blood glucose has been over the last three months. The A1C goal for many people is below 7. High blood glucose can harm your heart and blood vessels, kidneys, feet, and eyes. > B for Blood pressure. > The goal for most people with diabetes is below 130/80. > High blood pressure makes your heart work too hard. It can cause heart attack, stroke, and kidney disease. High blood pressureheart attackstrokekidney disease > C for Cholesterol (ko-LES-ter-ol). > The LDL goal for people with diabetes is below 100. The HDL goal for men with diabetes is above 40. The HDL goal for women with diabetes is about 50. > LDL or “bad” cholesterol can build up and clog your blood vessels. It can cause a heart attack or a stroke. HDL or “good” cholesterol helps remove cholesterol from your blood vessels.heart attack

33. Body Mass Index (BMI) ● An approximate measure of body fat based on height and weight. ● A BMI between 19 and 25 is considered a normal amount of body fat. ● If someone's BMI is 25 to 29.9, that person is said to be overweight. ● A person is said to be obese if his or her BMI is 30 or higher. ● The higher your BMI, the greater your risk for diseases such as Diabetes, Heart Disease, Arthritis, and certain cancers.

34. Assisting People in Managing Their Diabetes My Diabetes Care Record Example Self Checks of Blood Glucose My Game Plan for Diabetes Does the organization collect the needed lab work for diabetes?

35. CHRONIC ILLNESS CHALLENGE: VASCULAR DISEASE With substantial credit to www.familydoctor.orgwww.familydoctor.org

36. Vascular Disease Coronary Artery Disease (CAD): Caused by a thickening of the inside walls of the coronary arteries. This thickening is called atherosclerosis. A fatty substance called plaque builds up inside the thickened walls of the arteries, blocking or slowing the flow of blood. If your heart muscle doesn't get enough blood to work properly, you may have angina or a heart attack. Angina is a squeezing pain or pressing feeling in your chest

38. Reducing Risks for Vascular Disease 1. Don't smoke. Nicotine raises your blood pressure because it causes your body to release adrenaline, which makes your blood vessels constrict and your heart beat faster. If you smoke, ask your doctor to help you make a plan to quit. After 2 or 3 years of not smoking, your risk of CHD will be as low as the risk of a person who never smoked.. 2. Control your blood pressure. If you're taking medicine for high blood pressure, be sure to take it just the way your doctor tells you to. 3. Exercise. Regular exercise can make your heart stronger and reduce your risk of heart disease. Exercise can also help if you have high blood pressure. Before you start, talk to your doctor about the right kind of exercise for you. Try to exercise at least 4 to 6 times a week for at least 30 minutes each time. 4. Eat a healthy diet. Add foods to your diet that are low in cholesterol and saturated fats, because your body turns saturated fats into cholesterol

39. Consumers’ take on integration > People receiving integrated services report higher quality of life and greater satisfaction with: Access Attention to their treatment preferences Courtesy Coordination & continuity of care Overall care Druss et al, Arch Gen Psychiatry. 2001; 58(9): 861-8. Unutzer et al, JAMA. 2002; 288(22): 2836-2845. Ell et al, Diabetes Care. 2010; 33(4): 706-713.

40. Integration as Part of the Strategy Integration does not mean return to a medical model Provides access to multiple services at one time and place Improves the quality of all services Creates space within the current public sector for more consumers Ultimately reduce the early loss of life for those with a serious and persistent mental illness

41. Resources for Diabetes Assistance ●American Diabetes Association www.diabetes.orgwww.diabetes.org ●CDC Diabetes Public Health Resource http://www.cdc.gov/diabetes/ http://www.cdc.gov/diabetes/ ●National Diabetes Education Program http://www.ndep.nih.gov/index.aspx http://www.ndep.nih.gov/index.aspx ●Tools Small Steps Big Rewards – Your Game Plan http://www.ndep.nih.gov/media/GP_Booklet.pdf http://www.ndep.nih.gov/media/GP_Booklet.pdf My Diabetes Care Record http://ndep.nih.gov/media/my- diabetes-care-record.pdfhttp://ndep.nih.gov/media/my- diabetes-care-record.pdf Self Checks of Blood Glucose http://ndep.nih.gov/media/self- checks-of-blood-glucose.pdfhttp://ndep.nih.gov/media/self- checks-of-blood-glucose.pdf

42. RESOURCES for Heart Disease Mind Your Heart website: http://www.mindyourheart.org.uk/http://www.mindyourheart.org.uk/ Mind Your Heart: Healthier Lifestyles Toolkit for Workers in Mental Health http://www.mindyourheart.org.uk/Docs/Mind%20Your%20Hear t%20Toolkit%20Eng.pdf http://www.mindyourheart.org.uk/Docs/Mind%20Your%20Hear t%20Toolkit%20Eng.pdf American Heart Association www.heart.orgwww.heart.org National Heart, Lung, and Blood Institute - NIH http://www.nhlbi.nih.gov/health/health-topics/topics/cad/ http://www.nhlbi.nih.gov/health/health-topics/topics/cad/ Center for Disease Control and Prevention http://www.cdc.gov/heartdisease/ http://www.cdc.gov/heartdisease/ Million Hearts http://millionhearts.hhs.gov/index.htmlhttp://millionhearts.hhs.gov/index.html