The burden of mental illness is most intense among the 4.1 percent of U.S. adults who experience disability due to serious mental illness (SMI), which includes schizophrenia, bipolar disorder and major depression. Adults with SMI die at least a decade sooner than their non-mentally ill peers. Several factors contribute to this disparity including lifestyle choices, like tobacco use and low rates of exercise; co-occurring substance use disorders; and side effects from mental health medications, such as weight gain, diabetes, and high blood pressure. In addition, a disproportionate number of those with SMI are poor and suffer from hardships related to poverty, such as stress, unstable housing, and lack of access to healthy foods.
Adding to the problem, adults with SMI also have difficulty accessing quality preventive medical care. For instance, adults with SMI may feel or be told that they are unwelcome in clinic waiting rooms because of their appearance, hygiene or behaviors; and when they do receive medical care, it is likely to be lower quality than that delivered to other groups. Many adults with SMI report that medical providers dismiss their physical health complaints, attributing them to the mental illness. As a result, adults with SMI often have chronic physical illnesses that go undetected or untreated until the person experiences a medical crisis and he or she presents at an emergency department in need of acute care. The poor connection between adults with SMI and preventive and primary care also takes a toll on public medical systems. Emergency and acute services are more expensive than primary care services and adults with SMI and a chronic physical health condition are likely to be among the 5 percent of costliest Medicaid enrollees, who account for more than half of all Medicaid spending.
A promising strategy for helping adults with SMI gain access to appropriate primary and preventive medical services is to integrate those services into a setting in which the population already receives care. For many adults with SMI, this setting is the Community Mental Health Center (CMHC). CMHCs are often a familiar and trusted resource, offering a variety of psychiatric and psychosocial services without the barriers to care common among traditional medical settings. However, medical services have not traditionally been offered at CMHCs because of time, space, resource or policy constraints.
To address this need, in 2009, the Substance Abuse and Mental Health Services Agency (SAMHSA) awarded the first 13 of what are now 100 Primary and Behavioral Healthcare Integration (PBHCI) service grants (up to $500,000 per year for four years). The grants are intended to improve the overall wellness and physical health status of people with SMI by making available an array of coordinated primary care services in CMHCs and other community-based behavioral health settings. The earliest PBHCI grantees in particular were tasked with finding ways to make this innovative approach to care work. As of December 2013, more than 44,000 individuals enrolled in the program, with approximately half of them remaining in care for at least six months.
Starting in 2009, our RAND team designed and then conducted the first evaluation of the PBHCI grants program. Our evaluation, which included information from the first 56 PBHCI grantees and more than 25,000 consumers, was designed to answer questions about the volume and types of care delivered, whether the program leads to better physical health among persons served, and whether specific approaches to integrating primary and behavioral health care services lead to better care delivery and consumer outcomes.
Results of the evaluation showed that the SMI adults served by PBHCI programs had high rates of physical health care needs, with more than twice the national rates of smoking and obesity and nearly twice the rates of other indicators of cardiovascular disease risk (e.g., high cholesterol). Despite similarities in the consumers that they served, PBHCI programs delivered primary care to their clients in different ways that affected how consumers access care. For example, we found that consumers served by programs offering more hours and days of primary care services were more likely to access primary care. Importantly, the results of a small comparative effectiveness study in which PBHCI clinic consumers were compared to consumers served by similar clinics not offering primary care, showed that PBHCI consumers were more likely to show improvements on some (e.g., markers of dyslipidemia, hypertension, diabetes), but not all (e.g., smoking, weight) of the physical health indicators studied.
Overall, the results of this first look at the PBHCI grants program show that CMHC-based integrated care can help connect SMI adults to needed medical services, which can in turn improve some health outcomes for this very vulnerable population. It also found that SAMHSA and its partner agencies may benefit from replicating successful initiatives, refining delivery of services, and working with state policymakers to further coordinate policies affecting delivery of integrated care.
The results of this work are also important for federal and state-level policymakers who may be involved in developing state plans for Medicaid “health homes.” Specifically, the Affordable Care Act created an optional Medicaid state plan benefit for states to establish health homes to coordinate primary, acute, behavioral health and long-term care for people with Medicaid who have chronic conditions, including and explicitly focusing on SMI. As of November 2013, 13 states have approved Medicaid Health Home State Plan Amendments and another 18 are pending.
RAND recently presented the results of the PBHCI evaluation to the Centers for Medicare and Medicaid Services' health home team, who are actively refining the requirements for forthcoming Medicaid health homes. RAND is also continuing to learn more about other innovative models of integrated, behavioral-health-based care with a grant from the New York State Health Foundation. RAND is also studying the costs of this approach with a new contract from the Assistant Secretary of Health and Human Services for Planning and Evaluation, whose office co-funded the original SAMHSA PBHCI evaluation. Our work has the potential to inform improvements to both the next round of PBHCI grants and CMS health home requirements.
Deborah Scharf is a behavioral and social scientist at the nonprofit, nonpartisan RAND Corporation.
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