Missouri psychiatrist Joe Parks remembers working with a patient named Victoria.
For eight years he helped her with PTSD, manic depression and addiction, getting her into drug treatment, and back into school. And then, she died of a blood clot brought on by her poor physical health.
“Her behavioral health treatment had been a complete success,” Dr. Parks recalls. “She was stable, she wasn’t psychotic, she was clean and sober. But she was dead.”
Victoria’s story is similar to that of many other patients with mental illness. A 2006 report Parks edited showed that patients with serious mental illness – who disproportionately suffer from chronic health conditions like diabetes, hypertension and lung disease – were dying a full 25 years earlier than the general population.
Today, a new approach to health care delivery is helping patients like these have better outcomes. Parks helped to develop this approach - which addresses all of a patient’s health needs together in one clinic - as medical director at Missouri’s Department of Mental Health. Thanks to the new model, the state's Medicaid recipients who have both serious mental illness and chronic health conditions have seen their health improve dramatically.
Taking health care out of silos
According to Parks, who is now the director of Missouri’s Medicaid agency (MO HealthNet), it’s a big problem that mental health and physical health are often delivered in silos: A patient’s psychiatrist works independently from their primary care doctor, who works independently from their pharmacist, and so on.
“They have an illness that interferes with concentration, with memory, with their ability to keep things organized, with their ability to follow through on things. Yet we expect them to keep track of all these 12 different providers,” he says.
That’s why he helped lead Missouri in 2007 to start to integrate care to treat those different health needs in one place. Then, in October 2011, Missouri became the first state to receive approval from the federal Centers for Medicare and Medicaid for matching funds for a similar model called "health homes." The funding was written into the Affordable Care Act to encourage an integrated approach for treating Medicaid recipients with two or more chronic conditions – including a serious mental illness.
The state now has two health home programs, one for primary care clinics and one for community mental health centers. It is the latter program, with approximately 21,000 patients state-wide, that has seen the most dramatic results.
Helping keep chronic disease at bay
In three years, patients in the behavioral health home program saw their hospitalizations reduced by 9 percent. The number of patients with hypertension who registered normal blood pressure at screenings rose by 41 percent. The number of diabetics who had their blood sugar under control rose by 46 percent. And the state saved an estimated $31 million in spending on patients in the program.
Each of the state’s 27 behavioral health homes operates a little differently, but they all follow the same core procedures, according to Dorn Schuffman, a consultant who has coordinated multiple integration efforts in Missouri since 2007. Each has a primary care physician acting as a consultant for the home’s patients.
Those patients are given metabolic screenings and certain health measures like weight, blood pressure, blood sugar and tobacco use are tracked and shared among the patient’s health care team – which includes their psychiatrist, primary care doctor, a caseworker who visits the patient at their home and a nurse care manager.
The health team can use that information to set health goals and hold a patient accountable to improve their health.
At the health home at the Crider Health Center in Wentzville, Missouri 53 year-old patient Harold Abernathy sees his nurse care manager Kelly Miller. Abernathy is actually here for a psychiatric appointment, but before he sees the psychiatrist he first meets with Miller – an innovation Crider has brought to the role of nurse care managers.
Miller takes his blood pressure and weight and asks questions about his health, like, Is he still smoking? (“Yes, ma’am.”) and, How much? (“A pack or a little more a day.”)
Miller notes his responses in her computer and asks about his other health appointments. Abernathy’s primary care doctor has flagged that Abernathy hasn’t filled one of his prescriptions. So Miller gives him a nudge about his cholesterol medication.
“I haven’t started that one.”
“That’s really important,” she reminds him.
“I know,” Abernathy replies, sharing a laugh with his caseworker who just entered the room. She has also been talking to him about filling the prescription.
This team-oriented approach requires extra team members. The Crider health home has eight nurse care managers, for example. That’s eight staff positions that did not exist before. But the health homes as well as the state insist the program saves more money than it spends.
“It costs about an extra $80 per person per month,” Dr. Joe Parks says, referring to the per-member-per-month reimbursement the health homes receive from the state for the patients they see.
“[Clinics] earn that back in savings.”
The state’s behavioral health homes were recognized in early October with the American Psychiatric Association’s highest “Gold Achievement Award.”
19 states and the District of Columbia have approved similar health home programs. Others may be following suit.
If they do, Dorn Schuffman says, there is one major lesson to learn from Missouri’s example. Creating this program took significant commitments from the state’s Medicaid system, its Department of Mental Health and a coalition that represents the state’s community mental health centers.
“It sounds easy and it is easy in a sense,” Schuffman says, “but it really involved having strong, working, trusting relationships.”