forum entitled “How to Prevent Type 2 Diabetes” on Wednesday, January 24, 2007 by registered dietitian and certified diabetes educator, Rosalyn Haase. …

Improving the Health of Mental Health Consumers

Effective Policies and Practices

Anita Everett, Johns Hopkins
Jay Mahler, Alameda County Behavioral Healthcare
Janet Biblin Alameda County Healthcare
Rohan Ganguli, University of Pittsburgh
Barbara Mauer, MCPP Healthcare Consulting Inc

Executive Summary:
Consumers of mental health services die an average of 25 years earlier
than the general public In general the causes of death based on state
data mirror those of the general public although there are no national
databases available that directly track this statistic Many of the health
conditions that are associated with death in the US and premature death in
mental health consumers can be prevented and managed with positive health
habits
The six most common causes of death are: Heart Disease, Cancer,
Stroke, Lung conditions, Accidents and Diabetes Most of these medical
conditions occur in greater proportion in mental health consumers and may
occur at an earlier age The two exceptions are cancer which may not occur
at an increased rate and accidents
which occur at a higher rate in mental
health consumers Much has been done to understand the risk factors that
lead to these causes of death Through this paper we assert that many of
the known risk factors for early death can be addressed with positive
health habits We describe what is known about effective interventions for
common risk factors and where information is available, what kinds of
special interventions have been found to be effective in mental health
consumers This is a rapidly evolving area or study and much work
currently underway has not published
The many barriers to ideal healthcare are discussed in terms of three
groups of barriers Healthcare systems structure and financing create
barriers for consumers Healthcare professionals may have bias or even
fear of working with mental health consumers which can adversely impact
ideal healthcare Finally the area of health literacy of mental health
consumers is considered, particularly as Americans increasingly obtain
health information from internet resources, many consumers do not have
ready access to reliable sources of health information
In terms of effective practice, there are many practices that
can
occur to improve the health habits and reduce the risk factors for early
death in mental health consumers We discuss what is known about the
risk factors that are most associated with early death and, if they were
managed would be most likely to make the biggest difference in the health
of consumers These are generally in rank order and include: smoking,
hypertension, cholesterol, diet and weight, exercise, diabetes and
accidents
In terms of effective policy, many of these effective practices that
reduce actual risk factors for the major causes of death can be effectively
addressed at some level within communities of consumers, family and
providers Increasing health awareness within these communities is a
critical element An effective relationship with available primary care
providers is also essential in supporting ideal health This can be
facilitated by attention to communication between systems of care and can
be further facilitated for some consumers by importing primary care
services into the clinic or Community Behavioral Health Organization CBHO
thus creating a medical home at the CBHO
This paper closes with a set of recommendations that are based
on
three levels of interventions: those that can be readily implemented with
little additional resource and usually on a personal or local level, those
that require local leadership and some resources, and those that require
national leadership to transform the current poor health status of many
consumers in the US

Effective Policies and Practices

I Introduction

Persons with mental illness die an average of 25 years earlier than
the general population[i] This alarming realization has received much
recent attention in the mental health community It has long been known
that individuals with mental disabilities die earlier than members of the
general population This fresh look at the premature mortality of this
group in the US punctuates this problem and suggests that if anything the
gap between the health of the general population and the part of our
population with mental disabilities is widening This paper provides a
background of the current context of this alarming shortened lifespan as
well as current information regarding effective practices and policy This
paper concludes with a set of recommendations for
stakeholders that are
targeted to increase the health of individuals with mental illnesses in the
United States Recommendations are organized into three levels: Those
that can be virtually immediately implemented with little additional
resources, those that require substantial organizational level changes and
leadership efforts to support and those that require substantial national
leadership and promotion in order to implement Specifically this paper
aims to create a clear pathway in practice and policy that will increase
the lifespan of individuals with mental disabilities by ten years over the
next ten years Ten years within ten years is the goal

Several leading national organizations involved in driving mental
health policy have publicly prioritized the problem of health care in those
with mental disability The Technical Report from the National Association
of Mental Health Program Directors NASMHPD, Morbidity and Mortality in
People with Serious Mental Illness, identified issues related to access to
health care as among the contributing factors to chronic medical illness
and early death of people with serious mental illness 1

The NASMHPD behavioral
health/primary care integration principle,
Physical healthcare is a core component of basic services to persons with
serious mental illness Ensuring access to preventive healthcare and
ongoing integration and management of medical care is a primary
responsibility and mission of mental health authorities points the way to
a new focus on assuring that the people served by the public mental health
system have access to appropriate healthcare and that all care is
coordinated To achieve wellness, we must address the structure and funding
of the health care delivery system, lack of capacity for primary care,
stigma and discrimination, poor quality/provision of service, and lack of
adequate health care coverage
The Bazelon Center report, Get It Together: How to Integrate Physical
and Mental Health Care for People with Serious Mental Disorders, focuses
primarily on integration and the problems stemming from a fragmented health
care system The report states In a recovery-oriented mental health
system, physical health care is as central to an individuals service plan
as housing, job training or education [ii] The report describes barriers
to integrated care and highlights four service
delivery models for
integrating care
In early 2007, the National Council for Community Behavioral
Healthcare NCCBH conducted a survey of its member community behavioral
health centers CBHOs regarding general medical priorities, capacity and
current practices Among 181 respondents, 91 reported placing a high or
medium priority on increasing quality of general medical healthcare for
their clients More than two-thirds of CBHOs reported having the capacity
to screen for common medical problems hypertension, obesity, dyslipidemia
and diabetes However only one in two had the capacity to provide any
treatment for those conditions, and one in three had the capacity to
provide the services onsite The most common barriers to providing general
medical services were problems in reimbursement 721, workforce
limitations 684, physical plant constraints 608 and lack of
community referral options 558[iii]
Mental Health America MHA has developed the following policy
statement: Mental Health America MHA is committed to ensuring that
there is a significant reduction in the alarmingly high rates of overall
health problems morbidity and premature death mortality among
individuals with
serious mental illnesses For mental health consumers to
have a fair chance to live healthy and long lives, MHA believes that
medical practice, health policy and public dialogue must reflect the fact
that overall health and mental health are intertwined This statement is
associated with a call to action to promote quality healthcare for
individuals with mental illness
The National Alliance on Mental Illness NAMI has recently issued a
well developed policy document that includes advocacy for consumer self
empowerment in achieving improved health and wellbeing The NAMI policy
states that: Wellness is a part of the recovery process Consumers must
be empowered to achieve wellness through consumer education and peer
support Additionally the NAMI document advocates for increased access to
quality primary care as well as dental care for individuals with mental
illness[iv]

II Defining the Problem:

Much of the premature mortality in mental health consumers is due to
the same health problems that our general population faces In order to
understand the nature of premature death it is important to understand the
causes of mortality in the general population We need to
understand what
is known about successful health interventions and whether or not there is
value in creating specialized health interventions or facilitating access
to mainstream traditional health resources Additionally we need to have an
understanding as to the barriers to ideal health that individuals with
mental disabilities face

A Mortality in the general population

In 2004 the average life expectancy of US at birth reached a record
high at 778 years[v] The six most common causes of death in the US
general population are:

Diseases of heart heart disease;
Malignant neoplasms cancer;
Cerebrovascular diseases stroke;
Chronic lower respiratory diseases;
Accidents unintentional injuries;
Diabetes mellitus

There is no readily available national data on causes of death in persons
with mental disabilities Many of the state studies have found a similar
order with a slightly greater chance of death by accident and slightly
lower chance of death by cancer
The Framingham study was designed in 1948 to follow the development of
cardiovascular conditions of a large group of individuals over a life time
This study started out with over 5,000
participants and is now in its third
generation of recruits From this study we have learned a great deal about
the life course of many major illnesses that relate to the development of
the number one cause of death in the US, cardiovascular conditions We
have learned about the risk factors contributing to this condition such as
high blood pressure, high blood cholesterol, smoking, obesity, diabetes,
and physical inactivity Other Framingham projects include: stroke and
dementia, osteoporosis and arthritis, nutrition, diabetes, eye diseases,
hearing disorders, lung diseases, and genetic patterns of common
diseases[vi] This study has provided invaluable information about the risk
factors that contribute to these illness processes that are the leading
causes of death in the US population Information from the Framingham
study has been substantiated by the more recently developed large national
survey, the National Health and Nutrition Examination Survey NHANES
From these large US population based samples and surveys, we know a great
deal about general risk factors that contribute to death in the US From
this study we have learned that certain disease states are associated with
a
relative risk of increased death

B Prevalence of high risk medical illness in persons with mental illness

Prevalence is a term used to describe the rate or number of persons who
have a certain condition Numerous studies have reported an increase in
the prevalence of general medical conditions in persons with mental
disabilities What is known about the prevalence in persons with mental
illness of each of the six major causes of mortality will be discussed In
general this information is patched together because there is currently no
central national database or source on the health statistics of persons
with mental illness Additionally, these patched together resources often
look at the prevalence of illness and health conditions depending on what
types of data are available Insurance claims health surveys, etc
The prevalence of cardiovascular illness and factors that increase the
risk of having cardiovascular illness is higher in persons with mental
illness that in the general population Several studies confirm this 7 8 9
11 16 22 25 26
A review of causes of death in UK in a community sample of persons with
serious mental illness found that the most common causes of
death were CHD
and stroke This was not wholly explained by antipsychotic medication,
smoking, or socioeconomic status[vii]
A comprehensive review of the presence of cardiovascular risk factors in
Norway found no significant difference in the rates of cardiovascular risk
factors for schizophrenia compared with bipolar disorder but found twice
the rate of these risk factors than in the general non-mentally ill
population [viii] In a study of 234 mental health clinic outpatients in
Australia, Davidson found that, the mentally ill had a higher prevalence of
smoking, overweight and obesity, lack of moderate exercise, harmful levels
of alcohol consumption and salt intake than matched community samples No
differences were found in the prevalence of hypertension Men at the clinic
were less likely to have had cholesterol screening than the women[ix]
Several federal surveys including the SAMHSA administered National Survey
on Drug Use and Health NSDUH and the National Health Interview Survey,
conducted by the Centers for Disease Control CDC, National Center for
Health Statistics NCHS use the K6 instrument an indicator for serious
psychological disturbance in lieu of actual
Psychiatric symptoms and
diagnoses The K6 looks at impairments in a persons life related to the
presence of significant mental disturbance and gives reliable estimates of
serious psychological distress or SPD[x] This survey found higher rates
of many medical illnesses in persons with SPD Specifically, those with SPD
had higher rates of obesity and were more likely to smoke They had a
higher prevalence heart disease, diabetes, arthritis, and stroke than
persons without SPD This survey concluded that persons with SPD
demonstrate disadvantage in both socioeconomic status and health outcomes
Dickerson et al looked at the presence of multiple health conditions in
persons with schizophrenia and affective disorders in Baltimore[xi] They
found a markedly lower health status in persons with mental illness
compared with a general population Persons with mental illness had an
increased rate of smoking, less exercise at recommended rates, more
presence of other major medical conditions, and more obesity defined as
BMI over 30 This method for examining health status also demonstrated a
poor health status in the non-mentally ill controls, but those with mental
illness had a lower health
status in every criterion
An additional important contribution that Dickerson et al made was the
finding that a higher level of education defined as either completing high
school or not completing high school in all groups significantly
correlated with better health status Similarly, in a review of the impact
of health literacy on the mortality of elderly demonstrated that reading
fluency had a significant impact on mortality[xii] This provides
information on the value of health literacy in promoting health behavior
for the general public as well as those with mental illness
A study in Canada regarding access to ideal treatment for cardiac
condition demonstrates inequitable access to ideal treatment This research
found that in some cases, psychiatric patients were significantly less
likely to undergo specialized or revascularization procedures, including
cardiac catheterization and angioplasty, especially those who had ever been
psychiatric inpatients[xiii]

Cancer is the second leading cause of death in the US and may be the only
leading cause of death that does not have an increased prevalence in
persons with serious mental illness compared with the general
population
Using a large pool of insurance claims, Carney found that individuals with
mental disorders were no more or less likely to develop a malignancy than
those without Within the types of cancer that did develop there was a
slightly greater chance of respiratory system cancers in persons with
mental illness which was postulated to have been related to the increased
rate of smoking in this population[xiv] Osborn et al similarly found that
the rates of cancer related deaths, other than those directly attributable
to smoking were not increased7 Levav in the UK has found a slightly
decreased rate of cancer in persons with schizophrenia he has suggested
that possible genetic links to schizophrenia may also be associated with a
genetic link to protection from cancer[xv] Carney and Jones conducted a
review of health claims for over 3500 individuals with bipolar disorder and
described a significantly greater presence of multiple medical conditions
Compared with persons that had no claims for a mental illness, persons with
bipolar disorder were more likely to have multiple comorbid and chronic
medical conditions An increased prevalence was found for conditions
spanning all organ
systems Additionally, hyperlipidemia, lymphoma, and
metastatic cancer were the only conditions less likely to occur in persons
with bipolar disorder than the general population[xvi]

Cerebrovascular accidents, which are also known as strokes are the third
leading cause of death in the US Over 14 of those with a stroke have a
second stroke within the first year Stroke is one of the leading causes of
disability in the US Risk factors for stroke include hypertension,
diabetes and high blood cholesterol and heavy drinking more than 5 drinks
a day Other risk factors include smoking, indirect smoking exposure,
moderate drinking, weight, inactivity and age[xvii] In a study of over 741
practice settings in the UK covering about 8 million lives, the death rates
of 46,136 individuals with schizophrenia, schizoaffectve disorder, bipolar
disorder and delusional disorder were compared those with the experience
of 300,426 randomly selected controls They found that individuals with a
mental illness diagnosis were 2 to 3 time more likely to die from
cardiovascular and stoke conditions, specifically they were about twice as
likely to die from stroke at an age less that 50years compared
with non-
mentally disabled individuals 7 This study also revealed that individuals
taking antipsychotic medications, either first or second generation
antipsychotic medications, were more likely than those not taking these
medications to have a stroke

Respiratory conditions are listed as the fourth most common cause of
death Smoking is a common cause of chronic respiratory inflammation and
conditions such as emphysema, bronchitis and recurrent pneumonia It is
widely known that individuals with long term mental illnesses, particularly
schizophrenia, smoke at a higher rate than the general population Not
unexpectedly, it follows that individuals with mental illness have
respiratory diseases at a higher rate than the general population Several
large studies have confirmed this 14 8 1 Looking at health claims
information of persons with schizophrenia, Levav found increased odds of
having chronic obstructive pulmonary disease or emphysema to be about twice
as high as in controls 16
Persons with mental illness have an increased rate of early death and
complications related to accidents Accidents are the fifth leading cause
of death in the US and may be relatively higher in
persons with mental
disabilities The NASMHPD paper1 concludes that about 30 of premature
deaths are related to accidents and suicide A review of causes of deaths
of individuals who had been involved with the Massachusetts Department of
Mental Health, demonstrated an increased early death rate by as much as
141 years for men and 57 for women compared to age matched controls
This study found that individuals with mental illness have an increased
rate of ongoing cardiovascular and other illnesses that contribute to early
mortality and that a disproportionate amount of these deaths were caused by
accidents which included toxicity from medications7 Accidents can be due
to many potential causes that in some cases are increased in individuals
with mental disabilities Accidents that might increase a chance for early
death might include: physical trauma from being the victim of crime of
violence, suicide attempts, homelessness, household injury

Diabetes is listed as the sixth leading cause of death in the US It has
been well documented that individuals with schizophrenia have diabetes at a
higher rate than the general population Dixon et al demonstrated that the
rate of diagnosed
diabetes existed before the onset of the use of many
second generation antipsychotic medications [xviii] Claims information
form research done by Carney in from 1996-2001 on individuals with
schizophrenia found a rate of about twice the prevalence of diabetes with
complications than in a comparison non-schizophrenia group 16While some of
the newer antipsychotic medications were available at this time, they alone
would not be solely responsible for this two fold increase in rate of
complicated diabetes as late as 2001
A discussion of the prevalence of diabetes and mental illness would not
be complete without some consideration of the contribution that several of
the new antipsychotic medications play in increasing blood glucose and risk
of diabetes Several contemporary antipsychotic medications are known to
contribute to the risk of diabetes and weight gain Information on
metabolic and the onset of diabetes associated with the use of
antipsychotic medications specifically from the Clinical Antipsychotic
Trials of Intervention Effectiveness study is reviewed by Nasrallah[xix]
Recent review of these risks of diabetes and other factors such as weight
gain and hypercholesterol
has been conducted by Newcomer[xx] [xxi] In
general, the medications clozapine and olanzapine are clearly associated
with weight gain as well as a risk of cholesterol and blood glucose
increase This leads to diabetes It has been suggested that for these
two medications, the increase in blood sugar and cholesterol may occur even
if a person does not gain weight These risks of weight gain with
clozapine and olanzapine have been described as being similar to the lower
potency first generation antipsychotics such as chlorpromazine and
thioridazine The newest medications available for use in the US,
ziprasidone and aripiprazole have not consistently been found to increase
weight, blood glucose or cholesterol In small studies, risperidone and
quetiapine which have been in use for several years, have been found to be
associated with a small amount or no weight gain and are not clearly
associated with increased cholesterol or blood sugar The risk of weight
gain with risperidone seems to be similar to that of potent first
generation antipsychotic medications such as haloperidol and fluphenazine

This section has been framed around information that connects the health
status of
persons with mental illness to the most common causes of death in
the general population A number of other studies have found general poor
health in individuals with mental disabilities In 1999, Dixon et al
reported from a review of 741 persons with schizophrenia in the PORT
Patient Outcomes Research Team Study that: a greater number of current
medical problems independently contributed to worse perceived physical
health status, more severe psychosis and depression, and greater likelihood
of a history of a suicide attempt This study underscores the need to
attend to somatic health care for persons with schizophrenia as well as the
linkage of physical and mental health status[xxii]
C Specific focus on Early Mortality in Persons with Mental Illness

Colton and Manderscheid reviewed death information on public mental
health consumers in 8 states They found that public mental health clients
had a higher relative risk of death than the general population and
reaffirmed that the most common causes of death in this population were
natural causes similar to commonest causes of death nationwide[xxiii]
This is the landmark work that pulled together informaoitn that supports
the
statement that individuals with mental disabilities die as much as 25
years earlier than others in the US Segal and Kotler in California found
that compared with the general population, residents of sheltered care
facilities were 285 times more likely to die than other age matched
Californians Early mortality was due to heart disease, cerebrovascular
diseases, and all other natural and unnatural causes except malignant
neoplasms[xxiv] A review of deaths of persons previously admitted to state
psychiatric hospitals in Ohio demonstrated that the years of potential life
lost or YPLL for persons with mental illness averaged at 32 years
Cardiovascular causes were the most common cause of death and obesity 24
percent and hypertension 22 percent were the most prevalent medical
comorbidities[xxv]
In 1996, Felker conducted a Medline review and found 66 published studies
that reported that persons with serious mental illness had an increase in
the number and severity of medical illnesses and that these individuals had
early death related to both medical problems and accidents compared with
the general population[xxvi]

Figures on the death of persons with mental disabilities are not
readily
available in national databases as they are with other designated health
disparate groups such as Hispanics, African Americans or Asian and Pacific
Islanders These health disparity groups have varying disparities in death
rates, but none have a life expectancy that is greater by even 10 years
more than the general population The widest gap in traditional health
disparity groups is seen in black males with a life expectancy of 695
years in 2004 This is 83 years shorter than the national average life
expectancy For most minority groups this gap in life expectancy is
slowly closing These readily available statistics enable trends within
these special populations to be identified and prioritized in policy,
health promotion and resource allocation for these groups This kind of
information about persons with serious mental illness is not readily
available on a national scale
Clearly the 25 year shortened lifespan for persons with mental illness as
reported in the NASMHPD technical report is off the scale and should
activate alarms throughout health communities that this is of vital
concern

D Barriers to Effective Health Care

Individuals with mental disabilities
die prematurely and the causes of
death are similar to the cause of death for all other persons Many of the
conditions related to these causes of death can be treated and/or prevented
through access to effective health care information and health care
providers There are several possible ways to organize a discussion of
barriers This work organizes them into three categories: the health care
delivery system including structure, professionals, and financing; the
health literacy of mental health consumers; and other indirect factors such
as socioeconomic stressors that impact ideal health care for persons with
mental illness

1 Barriers in the Structure and Funding of Health Care Delivery

Access to physical health care for people with serious mental illness is
hindered by both the structure and the under-funding of the publicly
supported physical health and behavioral health systems of care Issues
include:
Lack of reimbursement for coordinated care across service systems
Lack of reimbursement for health education, support and family services
Inadequate and under-skilled case management services to support self
management and linkage to services
Poor coordination
between health care and behavioral health care systems
Lack of integrated treatment for co-occurring mental health and substance
use disorders which lead to inadequate diagnosis and treatment of
substance use disorders 1

Negotiating the US health care system in its current state can be a
challenge under the best of circumstances Thirty years ago, as was
idealized in the popular television series Marcus Welby, individuals who
required an evaluation were often admitted to a hospital for a full work up
or treatment of a problem This included daily interaction with a caring
physician as well as access to a host of highly qualified hospital and
nursing staff who had a role in healthcare promotion and education It
was not hard to imagine your physician and these related staff as being
your medical home In contrast, today the physicians office often
conceptually serves as a hub from which there are referrals or outsourcing
to a variety of labs, radiography settings, specialists and providers such
as physical therapists, nutritionists, etc Inside this conceptual hub, or
primary care setting additional pressures have restricted the time
available for the physician to
oversee all aspects of an individuals
health as well as take the time to consistently educate all patients on all
aspects of a current presenting problem as well as potential health risk
factors The increasing role for consumerism in obtaining ideal health and
is discussed below in section c
An additional factor that may increasingly limit access is a projected
potential shortage of primary care physicians, particularly in rural and
underserved areas [xxvii]
For individuals with mental disabilities there can be additional
difficulties in negotiating these complex systems This is particularly
true if the consumer experiences competing uncoordinated demands in keeping
up with the management of mental and physical wellbeing It has been
suggested that the creation of a medical home within a community mental
health center CBHO or mental health treatment program for individuals
that have frequent visits to these centers might facilitate greater access
to services that support ideal health as well as mental health In other
words for many individuals, importing a medical home into the place they
choose for mental health care, may make access to all healthcare more
efficient and
therefore more effective
Whereas at one time, conceptually at least, the most seriously mentally
ill were treated in all inclusive asylums which provided health care
onsite, our current treatment paradigm is bifurcated with primary care
sites being distinct from specialty mental health care
In the last decade we have learned some detail about the efficacy of
programs designed to increase the diagnosis and treatment of some
behavioral health conditions in primary care settings Through the
MacArthur Depression and Primary Care Initiative,[xxviii] we have learned
that the identification and treatment of depression in primary care can be
greatly enhanced through specialized training of office staff as well as
the importing of direct onsite access to mental health treatment with
defined follow up The evidence based tool kit culminating from this
project recommends a system approach in enhancing the diagnosis of
depression in primary care Through the work of the PRISM E study we have
learned that elderly individuals seen in a primary care setting are more
likely to receive more appropriate diagnosis and treatment of a substance
abuse or a mental health condition when specialty
mental health care are
imported into the primary care clinic Imported providers were more
effective than facilitated referral out to mental health specialists[xxix]

This line of services research has resulted in more primary care practice
settings being better equipped to address depression and behavioral health
problems onsite Additionally the US, HHS, Health Resources and Services
Administration HRSA which funds Community Health Centers CHC, has
changed requirements such that to be considered a full spectrum clinic
site, CHCs are working to provide onsite mental health services The CHC
system in the US now serves over 14 million individuals in nearly 1200
clinical sites and targets uninsured individuals in underserved areas[xxx]
Although significant progress has been made in the area of increasing
access to the treatment of depression in primary care, significant barriers
remain In many settings financing is described as the greatest barrier
Work on integrating mental health services into primary care settings
has demonstrated that there are a number of barriers in how Medicaid and
Medicare reimbursement is structured eg, disallowance of more than one
type on
encounter on the same day For example, the 2005 National Correct
Coding Initiative Policy Manual for Medicare Services, Chapter XI,
Evaluation and Management Services, C; Psychiatric Services, contains the
following language: When medical services, other than psychiatric services,
are provided in addition to psychiatric services, separate evaluation and
management codes cannot be reported The psychiatric service includes the
evaluation and management services provided according to CMS policy
Medicaid and Medicare must become partners in improving access to care,
data analysis, and designing and implementing strategies that will be
effective with the population served by the public mental health system
The NASMHPD Report recommends the following:

Assure financing methods for service improvements Include reimbursement
for coordination activities, case management, transportation and other
supports to ensure access to physical health care services
As a health care purchaser, Medicaid should:
Provide coverage for health education and prevention services primary
prevention that will reduce or slow the impact of disease for people
with serious mental
illness
Establish rates adequate to assure access to primary care by persons
with serious mental illness
Cover smoking cessation and weight reduction treatments
Use community case management to improve engagement with and access to
preventive and primary care 1

There is some but far less information and research on models of care
that import primary care into existing mental health care centers At
least one study has determined that [xxxi]

Lack of Adequate Health Care Coverage
According to the SAMHSA 2005 National Survey on Drug Use and Health,
one in five people with a serious mental health condition are uninsured
Lack of health care coverage represents an enormous barrier to addressing
the health care needs of the uninsured population with serious mental
illness Within the CHMC population, the uninsured may be as many as one in
four, depending on the state system; in some states, people with serious
mental illness who are uninsured may have difficulty being served in the
mental health system, much less the health care system
Individuals may be uninsured or underinsured Many individuals who
seek services in community mental health
centers have healthcare insurance
through Medicaid Eligibility for Medicaid is determined by each state and
is income based Depending on the state Medicaid system, from 25 to 90 of
persons served by CBHOs will be covered by Medicaid some of the year An
unpublished analysis done by MCPP Healthcare Consulting shows that subsets
of people frequently drop on and off of Medicaid coverage within any given
year
CBHO infrastructure may not be familiar with Medicare as a payer
source Even though many individuals who are disabled are Medicare
beneficiaries, Medicare has minimal coverage for outpatient mental health
services so that it may not have been billed for specialty mental health
services Most CBHO behavioral rehabilitative services are covered by
Medicaid and not Medicare Medicare does however become an important
payer when considering the delivery of physical health care services The
morbidity and mortality that has been identified in this group has enormous
impact on healthcare costs Moving toward more prevention and early
intervention services could have significant long range impact
In some states, contracts with managed care companies to manage
general health
care are used to provide enhanced and preventive oriented
benefits for individuals and reduce emergency room care In some cases,
such as Washington State, the population with serious mental illness,
covered under the disability aid codes of Medicaid, is not included in
Medicaid managed care contracts
Another contemporary facet in considering barriers to services for
Medicaid and Medicare enrollees is that due to low reimbursement rates, in
certain areas of the country, primary care physicians are closing their
practices to these patients Additionally there is a trend in some states
since the enactment of the 2006 Deficit Reduction Act to provide greater
benefits and incentives to Medicaid recipients who agree to be compliant
with preventive medical recommendations These are new program designs,
and it is not at all clear at this time that any restrictions of access
based on noncompliance will help individuals who have difficulties with
health literacy to become more proactive in the management of their own
healthcare In other words, many individuals opine that this style of
program will only further the gap between individuals who are health
literate, compliant and do well
and those that struggle with basic access
to and compliance with ideal healthcare recommendations[xxxii]

2 Barriers related to Health Care Professionals

Research suggests that people with serious mental illness frequently
face discrimination in accessing and receiving appropriate health care
This may be due to: unease of primary care providers with the needs of the
serious mental illness population and decreased expectations of clients as
partners in care1 Often physical health care providers erroneously
believe that persons with mental illness are not capable of participating
in making decisions regarding their own health care and do not involve them
in weighing risks and benefits, considering alternative treatment
strategies etc They may be dismissive of that persons motivation to be
healthy which may result in lesser care such as not recommending smoking
cessation etc Primary care providers who have not had much contact with
persons with serious mental health issues often think that they are
dangerous and are afraid of them
There is some research that indicates that there is a difference
which could be labeled discrimination in the healthcare that people
with
mental illness receive The VA system offers better health care access and
more support for recommended monitoring and disease management than is
available to many people with serious mental illness Despite this, Desai
et al found that in the VA system, the odds were greater that a diabetic
with a record of a psychotic or substance use disorder received standard of
care diabetic monitoring eg, HbA1c testing, LDL testing, eye
examination at lower rates than those who did not have a record of a
behavioral health diagnosis This may be the best case scenario
currently experienced by diabetic individuals with serious mental illness-
those without health care coverage and/or a medical home would likely
receive less monitoring and disease management[xxxiii] A study of access
to cardiac revascularization procedures in a large national sample found
that individuals with any history of a mental illness diagnosis were
significantly less likely to have received procedures such as angioplasty
and cardiac surgery after having an MI or heart attack[xxxiv] Additional
research in a study of elderly Medicare recipients recovering after
myocardial infarction found that individuals with mental
illness had
significantly higher mortality one year after the signal hospitalization
than those without a mental illness[xxxv] A fourth related study of
access to preventive care in the VA found that individuals with mental
illness were only slightly less likely than other veterans to receive
preventive care[xxxvi]

Poor Quality / Poor Provision of Service

Druss and colleagues provide us with examples from his research regarding
Overuse, Underuse, and Misuse of services related to the population with
serious mental illness:

Overuse of intensive resources:
Persons with serious mental illness have high use of somatic emergency
services

Underuse of less intensive resources:
Fewer routine preventive services 36
Lower rates of cardiovascular procedures34 35
Worse diabetes care68

Misuse:
During medical hospitalization, persons with Schizophrenia are about
twice as likely to have infections due to medical care postoperative deep
venous thrombosis and postoperative sepsis[xxxvii]

3 Barriers related to the Health Literacy of Mental Health Consumers

Increasingly the health literacy of individual patients has become a
vital component in assuring ideal
health Americans can no longer expect
that all health information comes from a single primary care resource,
rather health information is provided from a variety of resources including
communities, schools, public health campaigns, social networks and from a
variety of commercial advertisements Thus being able to access as well as
effectively sort out the relative validity of health information has become
complex
Health literacy is defined by the US, Health and Human Services HHS
in Healthy People 2010 as: the degree to which individuals have the
capacity to obtain process and understand basic health information and
services for appropriate health decisions[xxxviii] Others have extended
this definition to include the ability to act on health information
Increasingly individuals are receiving health information from a
variety of resources on the internet which is relatively unmonitored and
unregulated The Pew Foundation, issued a report in 2003, that found that
half of Americans receive health information from the internet [xxxix] By
now, in 2007 this is likely to have significantly increased Common health
searches included questions about weight management, smoking
cessation and
information on prescription drugs Additional information from this project
reveals that low income households defined in this study as households
less that 30,00000 a year are less likely to have internet access than
other households [xl] Mental Health consumers particularly those in low
income settings may have difficulty accessing internet based health
information which can be a disadvantage in understanding and implementing
health recommendations
Consumers bring to any healthcare encounter their experience,
knowledge and expectations Anyone can experience barriers to an ideal
health encounter, but some mental health consumers may have additional
barriers These might include intense anxiety, difficulty concentrating,
and active features of a mental illness such as paranoia about the provider
or certain procedures An example of this would be a consumer with a
family history of breast cancer who refuses routine mammogram screenings
This could be a temporary paranoid feature of a mental illness that is not
consistent with the persons usual belief and/or it could be a concern
about radiation that is completely unrelated to any state of a mental
illness Either
way this is a barrier to accessing ideal health
It is also important to remember that some mental health consumers
have experienced the trauma of treatment including coercive treatments,
involuntary institutionalization, misinformation regarding known side
effects of medication and other mistreatment by mental health
professionals They have lived historical reasons for mistrusting medical
professionals Special needs such as this may be hard for traditional
primary care providers to sort out efficiently and may result in
frustration in working with a person who might appear to be resistant to
sound medical advice Individual consumer issues are very important to
understand in working to achieve ideal health care One study of VA
patients has established a pattern of differences in health care access
between individuals with Schizophrenia and Bipolar disorder Kilbourne et
al determined that VA consumers with bipolar disorder reported greater
problems with actual access to health care, while those diagnosed with
schizophrenia were less satisfied with the process of care[xli]
Often mental health consumers dependent on SSI or SSDI live on very
limited income which limits
their range of food choices and living
environments There is much information regarding the impact that financial
limitations have on health Turrell recently demonstrated that food
shoppers in low-income households were less likely to purchase foods that
were high in fiber and low in fat, salt and sugar[xlii] One interesting
example of this is a study by Cauter and Spiegel that suggests that
disrupted sleep may be a significant factor in overall poor health
status[xliii] Cauter suggests that often individuals living in low income
and transient settings are unable to get good sleep which significantly
impacts their overall health status In general, persons living at or
near poverty have a variety of difficulties with initial access to
providers, access to procedures and tests and limitations in the capacity
to consistently adhere to long term treatment and follow-up services
Druss et al reviewed CBHO consumer accounts of access to general
health care This was a sample of primarily Medicaid recipients in South
Carolina This was a small study but it demonstrated several interesting
points Mental Health consumers reported lower quality of care and more
difficulty accessing
care They reported that usually care was not
coordinated between their primary care and mental health care
professionals This study did not find mental health consumers to be
uninterested in primary care or to doubt the benefits of medical health
care[xliv]

III Effective Practice: What Works

In the first sections of this paper the background for the scale and
scope of the health problems in persons with mental illness was defined
Persons with mental disability in the US have high rates of common medical
illnesses and have markedly early deaths associated with this The impact
of virtually all of these medical conditions can be reduced through changes
in health habits Health habits include: lifestyle changes such as
nutrition and exercise, attention to recommended preventive monitoring, and
adherence to recommended medical treatments that are designed to reduce or
prevent longer term complications of an illness
Keeping in mind the overarching goal of this project in achieving ten
years of life added to the average lifespan of individuals with mental
illness within ten years we will focus on the illnesses and processes most
associated with death and then to think
about how members of the mental
health community might shape effective interventions to address these
The health habits that contribute to the common causes of death
overlap so that a change in one health habit may help to reduce the risk of
several medical conditions that are associated with death Smoking, for
instance, contributes directly to the five most common causes of death
Each health habit or risk factor will be discussed in terms of what are
current recommendations for effective interventions, what if anything is
known about the efficacy of these interventions in persons with mental
disability

A Smoking

The Robert Wood Johnson Foundation, Smoking Cessation Leadership
Center site states that Persons with mental illness smoke half of all
cigarettes produced-and are only half as likely to quit as smokers without
mental illness Approximately 50 of those with serious mental illness are
smokers, compared with 23 for society at large Half of MH deaths are due
to smoking related illnesses [xlv] These are alarming facts
Stopping smoking has immediate and long term effects Quitting
smoking has an immediate effect on improving cardiovascular risks and
over
time reduces the risk of respiratory cancer It has been estimated that 35
year old males who quit smoking extend their lives by 69 to 85 years for
men and 61 to 77 years for women Quitting at any age extends life span
[xlvi] In the quest to add ten years to the lifespan of individuals with
mental illness, we propose that stopping smoking will get us more than five
of the ten years
Today there are a number of effective interventions that can be used
to help persons quit smoking The majority of individuals, who quit, maybe
as many ay 80 of all quitters do so on their own without a specific
program or medical assistance Individuals who attempt to quit and are
actually able to quit were more likely to have some college education and
to value health than those who are not interested in quitting Factors that
predispose one to be able to quit include: Smoking less than one pack a
day, perceiving oneself as being less likely to be smoking in a year,
having fewer smoking friends, and being employed Factors that were
associated with less likelihood of stopping smoking are higher number of
cigarettes a day and marginal understanding and belief in the negative
health risks of
smoking[xlvii]
Research in smoking cessation in consumers has revealed information
that is helpful in thinking about promoting smoking cessation Rohde et al
studied factors that are associated with likelihood of successful quitting
in 941 individuals with major mental disorders Individuals with antisocial
personality traits and major depression were less likely to be able to
quit Persons with all other major psychiatric diagnoses were equally as
likely to be able to quit smoking Other traditional factors such as
nicotine dependence predicted quit rates and this was independent of the
mental disorder[xlviii] Smoking for some with mental illness can be a
normalizing experience[xlix] Gershon in Los Angeles found that
individuals with substance use and schizophrenia/schizoaffective disorder
were less likely to have stopped smoking after entry into an out patient
smoking cessation program They concluded that more specialized programs
might be useful for certain types of behavioral disorders such as substance
use and schizophrenia/schizoaffective disorders [l] Dalack et al
concluded that smoking cessation and the use of a nicotine patch do not
cause worsening of the
hallucinations that can be associated with
schizophrenia, although there might be a slight increase in dyskinesia[li]
[lii]
There is much more information from hospital based smoking cessation
experience than for outpatient community mental health center experience
There may be useful material from hospital based experience with smoking
cessation that could be used to help community programs develop smoking
cessation initiatives At least one recent study has determined that there
is no clear advantage in providing specialized smoking cessation groups for
individuals with schizophrenia Vs using generally available community
resources such as those provided by the American Lung Association[liii]
In summary, there are a variety of methods available that can be used
to facilitate smoking cessation There is no clear information that
specialized programs are superior to other programs, but for certain
persons, individually created supports might increase the likelihood of
success with smoking cessation

B Hypertension:

Persons with hypertension have increased rates of heart attacks, heart
failure; stroke, dementia related to small recurring cerebrovascular
infarcts
strokes, diabetes, and kidney failure and can cause damage to
many other body organs Hypertension can easily be checked by trained lay
people in many places It is recommended that a primary care provider be
involved with initial diagnosis and planning a treatment course There are
two basic elements to treatment, lifestyle changes and medications
Generally medications would need to be provided by a primary care physician
or provider however the lifestyle changes can be made by an informed
individual and supported by others such as family and mental healthcare
providers
To help make treatment choices, the US National Heart, Lung, and
Blood Institute has created categories denoted as groups A, B, and C
according to a patients risk factors for heart disease Applying these
categories to the severity of hypertension helps determine whether
lifestyle changes alone or medications are needed [liv]

Risk factors for heart disease include the following: family history of
heart disease, smoking, unhealthy cholesterol and lipid levels, diabetes,
being over 60 years old

Hypertension and Lifestyle Changes

Healthy lifestyle changes are an important first step for lowering blood
pressure Current guidelines recommend that people should:

Exercise at least 30 minutes a day
Maintain normal weight
Reduce salt intake
Increase potassium intake
Limit alcohol consumption; however, moderate alcohol consumption 1 -
2 glasses a day may actually lower the risk for heart attack among
men with high blood pressure
Consume a diet rich in fruits, vegetables, and low-fat dairy products
while reducing total and saturated fat intake The DASH diet is one
way of achieving such a dietary plan
It is known that individuals with hypertension especially untreated or
under treated hypertension die at an earlier age[lv] Estimating exactly
how much life is to be gained in
approaching our goal of 10 years in ten
years is difficult to estimate This is because there is not readily
available information and because there is considerable variability in the
severity of the high blood pressure and variability in treatment
compliance

C High Cholesterol

High levels of cholesterol or blood lipids lead to cardiovascular disease
such as atherosclerosis or building up of plaque in the artery walls
Considered alone it is not clear that moderately high cholesterol directly
causes death, rather it contributes to heart disease and is associated with
other metabolic abnormalities that clearly increase the chances of having
cardiovascular disease and death
High cholesterol can be caused by many factors and can be caused by
certain of the new antipsychotic medications and is part of what we call
the metabolic syndrome The metabolic syndrome is a combination of high
cholesterol, high blood sugar, and being overweight Hypertension is
commonly included This collection of features increases the chances of
having heart disease, stroke and progressive diabetes High cholesterol can
also be caused by genetic risk factors and diet High cholesterol is
diagnosed by
a blood test which may be checked by a physician or primary
care provider from medical or psychiatric settings In general, once
diagnosed, the treatment has two aspects: lifestyle changes and
medication
The most important lifestyle changes that help to treat cholesterol
levels include:

Choose foods low in saturated fat

Exercise regularly

Lose weight if you are overweight

Get routine health checkups and cholesterol screenings

These are changes almost everyone can make on their own or with help from
a supportive family member or other supportive persons including a mental
health professional If lifestyle changes do not reduce the cholesterol
enough, your doctor may recommend medication There are several types of
drugs available to help lower blood cholesterol levels Some are better at
lowering LDL cholesterol; some are good at lowering triglycerides, while
others help raise HDL cholesterol The most commonly used drugs for
treating high LDL cholesterol are called satins Other drugs that may be
used include bile acid sequestering resins, cholesterol absorption
inhibitors, fibrates, and nicotinic acid niacin[lvi]Generally these are
prescribed by a
primary care physician or provider

D Diet and Nutrition:

There is ongoing debate regarding whether or not being overweight or
obese causes early death [lvii] [lviii] Leading research indicates that
being overweight but not obese may not alone increase death Overweight is
generally defined as being a BMI that is between 25 and 30 Obesity, or a
BMI greater than 30, may be a significant cause of premature death,
particularly in younger and middle aged adults [lix]
What is very clear about being overweight and obese is that it is
associated with many factors that contribute to lower overall health and
early death Individuals who are obese have a much more high risk of
problems with many medical conditions They have more complications from
general surgery, have more falls, and less active lifestyles
Sustaining a healthy weight and nutrition is difficult for most
Americans There is no single diet or intervention that works uniformly
well Ganguli has recently published a summary of the relative effects of
weight loss interventions in persons with schizophrenia[lx] This review
determines that individuals with mental illness can successfully lose
weight and maintain
weight loss, and that there is no single most effective
best practice Additionally this work included the results of a short term
study that found that individuals with schizophrenia and mental illness can
effectively avoid gaining weight associated as a side effect of certain
medications when nutrition, diet and exercise are addressed early This is
confirmed by a small study by Jean Baptist et al that used an established
weight loss program, modified for this specific population This program
was supplemented with practical community education regarding grocery
shopping and preparing healthy food They found that cognitive impairment
had no bearing on the outcome and concluded that this type of intervention
can be very successful in a community sample of persons with mental
illness [lxi]
There are several approaches that can be taken to increase the quality
of the diet and nutrition for individuals with serious mental illness
Certain individuals would require consultation with a registered dietitian
Others would need consultation with a primary care physician to define any
special needs However for many, simple community based intervention that
could be supported by case
management or peer specialists can be
implemented This might include grocery store choices, healthy food
preparation, and substitution of healthy for less than healthy foods,
portions, elimination of full calorie drinks and other simple behavioral
guidelines

E Exercise and Fitness

It has been demonstrated that fitness has many health benefits Most
recently a focus on metabolic syndrome which dramatically increases the
risk of premature death due to cardiovascular disease can be reduced if not
prevented with cardiovascular fitness[lxii] It has been demonstrated that
sedentary individuals who are a normal weight, overweight and obese have a
significantly greater chance of death from cardiovascular causes[lxiii]
Several studies over time have demonstrated an increase in a sense of
wellbeing and overall mental health with the onset of an exercise program
[lxiv] There is much work that supports the idea that there is a mental
health benefit from exercise and fitness A study in the VA found that in
a system of care that emphasizes preventive healthcare and counseling,
individuals with mental illness received the same level of exercise and
nutrition counseling that
individuals without mental illness received[lxv]

F Monitoring

Monitoring includes a wide variety of health activities that are
designed to identify risk for or an actual illness as early as possible
This includes routine cancer screening such as pap smears and mammograms
for women, periodic lab testing and the administration of vaccines that
prevent illness Druss et al identified in a VA sample of over 100,000
individuals with chronic medical illnesses, individuals with serious mental
illness were less likely than those veterans without mental illness to have
received 4 of the 6 preventive health interventions These preventive
indices were: two measures of immunization, four measures of cancer
screening, and two of tobacco screening and counseling[lxvi] They also
found that individuals with co-occurring substance abuse had fewer of the
recommended preventive interventions than individuals with mental illness
Although Cancer itself may not occur at an increased rate in mentally
disabled individuals, it remains as a significant cause of death and all
recommended screens should be followed Most of these tests and actual
screens require ordering and coordination through a
primary care physician
Interested communities of mental health providers and peers could easily
administer basic health screens and provide this information to consumers
and primary care providers

F Diabetes

Studies of individuals in community settings indicate that there is a
wide range but overall lower quality of diabetes care provided to
individual with serious mental illness compared with non seriously mentally
ill individuals in the same community Goldberg et al in studies the
diabetic care of just over 300 individuals in Baltimore This study looked
at diabetic laboratory monitoring tests as well as follow up on maintenance
checkups such as eye exams and foot care They found that individuals with
serious mental illness received fewer recommended services and less
education about diabetes Thus this study demonstrated that individuals
with SMI were less likely to receive the full complement of recommended
services and care support [lxvii]
Krein et al conducted a national review of care delivered to 36,546
veterans with diabetes in a attempt to determine if care delivered to
individuals with serious mental illness had poorer outcomes [lxviii] They
determined
that in the VA system, individuals with serious mental illness
received diabetes care that was comparable with the care that other
patients with diabetes received This included frequency of monitoring of
hemoglobin A1c, low-density lipoproteins LDL, and cholesterol Both
groups had comparable A1c, LDL, and cholesterol values Patients with
diabetes and serious mental illness had more outpatient visits, both
primary care and specialty visits, and made more multiclinic visits,
including visits to both primary care and mental health services on the
same day This is in contrast to an earlier study published in 2003 of the
records of over 38,000 individuals with diabetes served by the VA This
study conducted by Desai et al determined that Veterans with mental
disorders were slightly less likely to have had the same level of ideal
diabetic care that those without mental illness had33 Furthermore they
determined that most of the difference was seen in individuals with
substance abuse and not as much in those with mental illness alone This
important work establishes that at least in a relatively closed and
coordinated system with a common electronic medical record such as the
VA,
barriers to care can be effectively addressed
While in general it is beyond the scope of practice for most CBHOs and
other mental health providers to provide diabetes treatment, monitoring for
diabetes can readily occur There are many things a community mental
health staff and/or peer counselors can to do facilitate good diabetic
control and follow up with the recommended examinations, diet and health
screens for diabetes It is possible to receive reimbursement for diabetes
education classes under some circumstances

G Accidents

Persons with mental disabilities are at in creased risk of death due
to accidents and other types of trauma This includes a variety of possible
causes and many that relate to living at least a portion of time in high
risk or non-ideal settings where they might be more likely to be the victim
of a violent crime, motor vehicle accident, and suicide attempt The
increased likelihood of substance abuse in persons with mental disability
brings in another set of risk factors such as driving under the influence,
being in fights, falls, suicides and other risk taking activity

H Systems organization

We have discussed each of the major
health interventions that
contribute to medical conditions that are the cause of death in the US
population In general many of these risk factors can be averted through a
good working relationship with a primary care physician coupled with access
to reliable health information and support from a community of friends and
family In many cases much health promotion can be supported and
facilitated by mental health providers

IV Recommendations:

A Background for recommendations:

So far we have reviewed the background for premature deaths in
persons with mental disabilities in the US We have considered the medical
conditions that cause early death and have related a broad overview of the
types of interventions that can be helpful in treating and managing these
health factors This section will begin with a brief discussion of
potential models for enhancing access to health promotion and healthcare
and will conclude with recommendations that are designed to stimulate
action on three levels of potential and transformational intervention
In a paper prepared for the American College of Mental Health
Administration, a review of the research concluded that a range
of
strategies appear to be effective in improving linkage with, and quality
of, medical care, and improving self-reported health outcomes in groups
with higher levels of baseline medical co-morbidity[lxix]

The table below, developed by Druss, summarizes these strategies

At one end of the continuum, training programs may provide psychiatrists
with additional medical training, or patients with expertise in self-
management and/or therapeutic lifestyle change strategies Studies in this
area have demonstrated considerable potential to reduce lifestyle risk
factors such as poor diet, smoking, and obesity in persons with serious
mental illness
In medical consultation models, a part-time or full-time medical
consultant comes on-site in the specialty mental health setting to provide
for the medical needs for patients This approach has been tested in
several inpatient studies where it has been shown to improve the quality of
medical care Collaborative care models in which care is delivered by
multidisciplinary teams made up of both internists and mental health or
substance use specialists are analogous to evidence-based approaches to
treating depression in primary care Finally,
under facilitated referral
models, a mental health facility can hire a care manager to provide linkage
and coordinate follow-through with medical care in a community medical
setting These models are among the simplest programs to implement in free-
standing mental health settings such as CBHOs, although they depend on the
availability of a high quality community medical provider and effective
linkages between the MH/SU and primary care provider organizations69
Many CBHO programs work with physician groups in seeking primary care
collaborators Yet another model that has certain advantages includes the
integrations of a nurse practitioner who is connected with a primary care
practice setting and deployed to a community mental health site Through
this type of model the primary care provider is not professionally isolated
and has colleagues that can strengthen coverage and a range of services,
equipment and advantages that are part of group medical practice The use
of a Nurse Practitioners is comparable in terms of outcome for primary care
settings[lxx] Physician Assistants are another level of provider that may
be considered Generally these providers are not able to
function
independently and the degree to which proximity to a physician varies by
state licensing regulations
CHCs and CBHOs have partnered in the past to integrate mental health
and substance abuse services into CHC primary care settings, consistent
with the federal initiative to integrate MH/SA services into primary care
CBHOs and CHCs have more recently initiated discussions about bringing
primary care into mental health settings, where the population with serious
mental illness is accustomed to receiving care, building on current
research efforts These efforts have encountered a federal policy barrier
The Bureau of Primary Health Care BPHC PIN 2002-07: Scope of Project
Policy notes that it is crucial that health centers request approval for
changes of scope in the areas of site and services, and update the BPHC
regarding any other changes to the scope of project prior to occurrence
Scope of project is described as having five core elements: services,
sites, providers, target population, and service area, and is used to:
Stipulate what the total approved grant-related project budget
supports, inclusive of 330 funding, program income and other non-300

funds
Define the scope of coverage of the Federal Tort Claims Act FTCA for
providers
Define covered entities for the 340B Drug Pricing Program
Define approved service delivery sites and services for Medicaid
Prospective Payment calculation
Define approved service delivery sites for CMS determination of
Medicare cost-based reimbursement

In local discussions about the CHC placing a primary care provider
employee in the CBHO, with documentation in the CHC chart and billing under
the auspices of the CHC, the BPHC Scope of Project policy has come up, and
there seems to be variation in understanding the policy and its
applicability The range of perceptions includes:
The CHC cannot place a provider in the CBHO because it would
completely jeopardize their 330-funding and FTCA coverage
The CHC can place a provider in the CBHO, but only if the site also
serves its other target populations, not just the population with
serious mental illness -so a separate entry door and waiting area are
being created
The CHC can place a provider in the CBHO and must file a scope of
project change per PIN 2002-07, but
anticipates no issues in doing so,
other than a 6 month wait to get it approved
The CHC can place a provider in the CBHO and does not envision that a
scope of project change will be necessary because it already
outstations providers in a number of sites
The HRSA/BPHC is currently working on a revision to the Scope of Project
policy Ideally, the policy revision will clarify the appropriateness of
placing CHC primary care practitioners in mental health settings, given the
data demonstrating the people with serious mental illness are a health
disparities population
Nationally, discussions on improving the structure and funding of health
care include the concept of a medical home The American Academy of Family
Physicians, American Academy of Pediatrics, American College of Physicians,
and American Osteopathic Association recently released Joint Principles of
the Patient-Centered Medical Home These principles include:
Personal physician
Physician directed medical practice team care that collectively takes
responsibility for the ongoing care of patients
Whole person orientation
Care that is coordinated and/or integrated

Quality and safety including evidence based care, use of information
technology and performance measurement/quality improvement
Enhanced access to care
Payment structure that reflects these characteristics beyond the
current encounter-based reimbursement mechanisms[lxxi]
Related to the payment principle, a team of physicians, including
representation from the Commonwealth Fund, has proposed a new payment
methodology tied to medical homes The encounter-based reimbursement system
would be replaced by a per-patient payment a case rate, not capitation,
substantially increasing payments for primary care in return for greater
accessibility, quality, safety, and efficiency Over two-thirds of the
payments would be for multidisciplinary health care teams[lxxii]
The public mental health system must enter into a dialogue with those
leading these initiatives, to assure that the needs of people with serious
mental illness are addressed as a part of improving the structure and
funding of health care
We suggest that there are three tiers in organizing services to
enhance the health of individuals with mental disabilities in a CBHO

B Specific
recommendations for effective policy and practice:

Recommendations stemming form this report will be organized into three
tiers As was identified in the introduction to this paper, these
recommendations are based on a structure that was proposed for
consideration of levels of organizational transformation in multiple
speeches delivered by Kathryn Power as The Presidents New Freedom
Commission Report on Transforming the US mental health system was put
forth These three levels include: A those that can be virtually
immediately implemented with little additional resources, B those that
require substantial organizational level changes and leadership efforts to
support and, C those that require substantial national leadership and
promotion in order to implement

A Initiatives that can be readily implemented with minimal additional
resources:
Expand WRAP and plans to address consumer- generated goals for
physical well-being including physical activity, nutrition and
primary care
Redesign clinical treatment and service plans so that they support
recovery that is inclusive of health promoting activities
Consumer centers and CBHO
staff access existing community health
resources and speaker programs This would include:
o Smoking cessation resources from public health departments,
local hospitals or groups such as American Lung Association
o Diet and weight related support group resources such as
overeaters anonymous and commercial programs such as Weight
Watchers that are available
o Nutrition information seminars and talks which might be
available to community groups and staff through local public
health department or hospital outreach dietitian
Include a physical activity component in existing day treatment and
other psychosocial rehabilitative programs
Restructure the work priorities of any existing nursing staff
within CBHOs so that they can devote time to the physical health
aspects of consumers
Collaborate with existing national organizations such as the
American Lung Association and the American Diabetes Association who
have a wealth of health promotion materials and protocols that
could be used by people with mental
health issues
Existing performance improvement project structures within CBHOs
can be used to create projects that promote better health
screening, monitoring, prompting about smoking cessation and care
coordination with primary care providers
Ask local county or state medical associations to provide speakers
and talks on health risks and to conduct ask the doctor sessions
to groups of consumers and/or CBHO staff Through these
connections, offer to provide consumers experience to healthcare to
medical professionals
Assure that psychiatric staff have access to CME trainings on
contemporary Smoking cessation pharmacology and other basic health
monitoring courses
Include health promotion materials in waiting rooms and create
health resource bulletin boards in consumer areas

B Initiatives that require organizational changes, leadership and
resources

Contract with a consumer operated organization to survey the physical
health concerns of consumers This would include a national snapshot
of what consumer-operated programs are currently doing as well as what

they would be willing to do This should also include having
consumers help frame the message and approaches that will encourage
and empower consumers to take positive actions in their own lives
Publish this information prominently

Encourage state level leadership to develop health promotion
initiatives for individuals with mental and other disabilities This
might include members of the department of mental health, department
of health, hospital association, state medical association, state
nursing associations, state psychiatric and other allied mental health
professional organizations, mental health and other concerned advocacy
groups, state groups of community behavioral health organizations,
statewide consumer organizations and any other stakeholder with a
vested interest in the health of citizens

Develop a consumer run health education training module for consumers
to become peer health coaches This would include training for peers
to help other consumers interface with primary care by acting as
advocates

Utilize Pat Corrigans contact approach for combating stigma and

discrimination to primary care health providers so they can better
serve clients with serious mental health issues Focus on listening,
providing physical health care in non-judgmental ways Include
training front office staff on how to interact with consumers in a
respectful manner Opportunities for this can be explored through
state medical societies and primary care organizations

Develop RN level nursing positions within CBHOs such that they have
time allocated to provide basic teaching on common medical conditions
This could facilitate screening for basic health problems and help to
monitor health treatment

Develop onsite primary care services

Develop proactive leadership level relationships with local primary
care providers that see high numbers of consumers form a particular
CBHO

As ongoing statements of national significance on recovery are
developed and updated, include health as a prominent feature of
recovery

C Initiatives that require national leadership and promotion

National mental health advocacy groups work together with national
medical organizations
to promote awareness of the health needs of
persons with mental disabilities Organizations to contact would
include:
o American Medical Association
o American Academy of Family Practice
o American College of Physicians
o American Nurses Association
o Association of Clinicians for the Underserved
o American Academy for Physicians Assistants
o American Academy of Nurse Practitioners

Medicaid and Medicare must become partners in improving access to
care, data analysis, and designing and implementing strategies that
will be effective with the population served by the public mental
health system Assure financing methods for service improvements
Include reimbursement for coordination activities, case management,
transportation and other supports to ensure access to physical health
care services

As a health care purchaser, Medicaid should:
Provide coverage for health education and prevention services
primary prevention that will reduce or slow the impact of
disease for people with serious mental illness
Establish rates
adequate to assure access to primary care by
persons with mental disaility
Cover smoking cessation and weight reduction treatments
Use community case management to improve engagement with and
access to preventive and primary care

The BPHC within HRSA is currently working on a revision to Scope of
Project policy Seek to assure that the policy revision will clarify the
appropriateness of placing FQHC primary care practitioners in mental
health settings, given the data demonstrating the people with serious
mental illness are a health disparities population

Mental health advocates and professionals must work at the national level
to promote the value of an accountable medical home so that every
individual with mental disability has a clearly identified and trusted
medical home

The public mental health system should employ the Institute for
Healthcare Improvement IHI model in crafting a national initiative on
morbidity and early mortality in people with mental disabilities This
could be an effort lead by SAMHSA and HRSA together with national
advocacy groups that would develop an IHI care improvement
program for
addressing the health of individuals with mental disabilities

Stakeholders in the mental health community hold one or more meetings
with the HHS, Office of Minority Health to discuss the promotion of
health literacy in special and underserved populations

Wellness should be tied into the SAMHSA National Consensus Statement on
Mental Health Recovery
———————–
[i] Morbidity and Mortality in People with Serious Mental Illness, National
Association of State Mental Health Program Directors, Medical Directors
Council; Editors: Parks, Svendsen, Singer, Foti,
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wwwnasmhpdorg

[ii] Get It Together: How to Integrate Physical and Mental Health Care for
People with Serious Mental Disorders; Bazelon Center for Mental Health Law,
June 2004
[iii] Druss et al, Medical Services for Clients in Community Mental Health
Centers: Results from a National Survey Unpublished draft manuscript

[iv] Public Policy Platform of The National Alliance on Mental Illness
NAMI, Section 313 Wellness; this is available on the NAMI Website:
wwwnamiorg

[v] Deaths: Final Data for 2004; Center for Disease Control,
National
Center for Health Statistics Website: http://wwwcdcgov/nchs/deathshtm

[vi] Framingham website: http://wwwnhlbinihgov/about/framingham

[vii] Relative Risk of Cardiovascular and Cancer Mortality in People With
Severe Mental Illness From the United Kingdoms General Practice Research
Database ; David P J Osborn, PhD; Gus Levy, MSc; Irwin Nazareth, PhD;
Irene Petersen, PhD; Amir Islam, MBA; Michael B King, PhD; Arch Gen
Psychiatry 2007;64:242-249

[viii] The Level of Cardiovascular Risk Factors in Bipolar Disorder Equals
that of Schizophrenia: a Comparative Study Birkenaes AB, Opjordsmoen S,
Brunborg C, Engh JA, Jonsdottir H, Ringen PA, Simonsen C, Vaskinn A,
Birkeland KI, Friis S, Sundet K, Andreassen OA; J Clin Psychiatry 2007
Jun;686:917-23

[ix] Cardiovascular Risk Factors for People with Mental Illness; Davidson
S; Judd F; Jolley D; Hocking B; Thompson S; Hyland B; Australian and
New Zealand Journal of Psychiatry, Volume 35, Number 2, April 2001 , pp
196-2027

[x] Characteristics of Adults with Serious Psychological Distress as
Measured by the K6 Scale: United States, 2001-04 Pratt, Dey, and Cohen;
Adv Data 2007 Mar 30;382:1-18
[xi] Health Status of Individuals
With Serious Mental Illness Dickerson,
Brown, Daumit, LiJuan, Goldberg, Wohlheiter and Dixon; Schizophrenia
Bulletin, Volume 32, Number 3 Pp 584-589
[xii] Health Literacy and Mortality Among Elderly Persons; Baker, Wolf,
Feinglass, Thompson, Gazmararian JA, Huang; Arch intern Med 2007 Jul 23:
167 14: 1503-9

[xiii] Inequitable Access for Mentally Ill Patients to Some Medically
Necessary Procedures; Kisely S, Smith M, Lawrence D, Cox M, Campbell LA,
Maaten S; CMAJ 2007 Mar 13;1766:779-84

[xiv] Occurrence of Cancer Among People with Mental Health cCaims in an
Insured Population; Carney CP, Woolson RF, Jones L, Noyes R Jr, Doebbeling
BN; J Clin Psychiatry 2007 Jun;686:917-23

[xv] Cancer Risk Among Parents and Siblings of Patients with Schizophrenia;
Levav, Lipshitz, Novikov, Pugachova, Kohn, Barchana, Ponizovsky, Werner;
Br J Psychiatry 2007 Feb;190:156-61

[xvi] Medical Comorbidity in Women and Men with Bipolar Disorders: A
Population-based Controlled Study; Carney and Jones; Psychosom Med 2006
Sep-Oct;685:684-91

[xvii] Prevention of Recurrent Ischemic Stroke; Dickerson, Carek and
Quattlebaum; Amer Fam Physician , August 1, 2007 Vol 76/No 3 August 1,
2007

[xviii] Prevalence
and Correlates of Diabetes in National Schizophrenia
Samples; Dixon, Weiden, Delahant, Goldberg, Postrado, Lucksted and Lehman
Schizophr Bull 2000;264:903-12

[xix] Metabolic findings from the CATIE trial and their relation to
tolerability; Nasrallah HA; CNS Spectr 2006 Jul;117 Suppl 7:32-9

[xx] Metabolic Considerations in the Use of Antipsychotic Medications: a
review of recent evidence; Newcomer JW; J Clin Psychiatry 2007;68
Suppl 1:20-7

[xxi] Second-Generation atypical Antipsychotics and Metabolic Effects: a
Comprehensive Literature Review; Newcomer JW; CNS Drugs 2005;19 Suppl
1:1-93

[xxii]The Association of Medical Comorbidity in Schizophrenia with Poor
Physical and Mental Health; Dixon L, Postrado L, Delahanty J, Fischer PJ,
Lehman A J Nerv Ment Dis 1999 Aug;1878:496-502

[xxiii]Congruencies in Increased Mortality Rates, Years of Potential Life
Lost, and Causes of Death Among Public Mental Health Clients in Eight
States; Colton CW, Manderscheid RW Prev Chronic Dis 2006
Apr;32:A42 Epub 2006 Mar 15

[xxiv] A Ten-Year Perspective of Mortality Risk Among Mentally Ill Patients
in Sheltered Care; Segal and Kotler Hosp Community Psychiatry 42:708-
713, July
1991

[xxv] Mortality and Medical Comorbidity Among Patients with Serious Mental
Illness Miller BJ, Paschall CB 3rd, Svendsen DP; Psychiatr Serv 2006
Oct;5710:1482-7

[xxvi] Mortality and Medical Comorbidity Among Psychiatric Patients: a
Review; B Felker, JJ Yazel and D Short ; Psychiatr Serv 1996; 47:1356-
1363

[xxvii] Recruitment Data: Demand for Family Physicians Surges; Leslie
Champlin in AAFP American Association of Family Physician News 9/21/2006

[xxviii] MacArthur Foundation, Depression in Primary Care Initiative
Website: http://wwwdepression-primarycareorg/

[xxix] Improving Access to Geriatric Mental Health Services: A Randomized
Trial Comparing Treatment Engagement With Integrated Versus Enhanced
Referral Care for Depression, Anxiety, and At-Risk Alcohol Use; Stephen
J Bartels, MD, MS, Eugenie H Coakley, MA, MPH, Cynthia
Zubritsky, PhD, James H Ware, PhD, Keith M Miles, MPA, Patricia A
Areán, PhD, Hongtu Chen, PhD, David W Oslin, MD, Maria D Llorente,
MD, Giuseppe Costantino, PhD, Louise Quijano, MSW, Jack S McIntyre,
MD, Karen W Linkins, PhD, Thomas E Oxman, MD, James Maxwell, PhD
and Sue E Levkoff, ScD, MSW, SM PRISM-E Investigators; Am J
Psychiatry
161:1455-1462, August 2004

[xxx] Remarks to the National Association of Community Health Centers
Policy and Issues Forum

by HRSA Administrator Elizabeth M Duke; March 19, 2007; Washington,
DC; Availalble through the HRSA Press Office: 301 443-3376;
http://newsroomhrsagov
http://newsroomhrsagov/speeches/2007/NACHCmarch19htm

[xxxi] Integrated Medical Care for Patients With Serious Psychiatric
Illness:A Randomized Trial; Benjamin G Druss, MD, MPH; Robert M
Rohrbaugh, MD; Carolyn M Levinson, MPH; Robert A Rosenheck, MD Arch Gen
Psychiatry 2001;58:861-868

[xxxii] Personal Responsibility and Physician Repsonsibility, West
Virginias Medicaid Plan; Bishop and Brodkey; NEJM Aug 24, 2006; Vol
355:756-758 No8

[xxxiii] Mental Disorders and Quality of Diabetes Care in the Veterans
Health Administration
Desai MM, Rosenheck RA, Druss BG, Perlin JB Am J Psychiatry 2002
Sep;1599:1584-90

[xxxiv] Mental Disorders and Use of Cardiovascular Procedures After
Myocardial Infarction; Benjamin G Druss, MD, MPH; David W Bradford, PhD;
Robert A Rosenheck, MD; Martha J Radford, MD; Harlan M Krumholz, MD ;
JAMA 2000; 283:506-511

[xxxv]Quality of medical care and excess mortality in older patients
with
mental disorders: Druss BG, Bradford WD, Rosenheck RA, Radford MJ,
Krumholz HM; Arch Gen Psychiatry 2001 Jun;586:565-72
[xxxvi] Quality of preventive medical care for patients with mental
disorders; Druss BG, Rosenheck RA, Desai MM, Perlin JB; Med Care 2002
Feb;402:129-36
[xxxvii]Adverse events during medical and surgical hospitalizations for
persons with schizophrenia; Daumit GL, Pronovost PJ, Anthony CB, Guallar
E, Steinwachs DM, Ford DE Arch Gen Psychiatry 2006 Mar;633:267-72

[xxxviii] Healthy people 2010 2nd ed Washington DC: Department of
Health and Human Services US; 2000 Nov 2 Vols
[xxxix] Internet Health Resources: Health Searches and Email have become
more Commonplace, but there is Room for Improvement in Searches and overall
Internet Access Susannah Fox, Deborah Fallows 7/16/2003, Available at the
Pew Internet and American Life Site: http://wwwpewinternetorg

[xl] Wired for Health, How Californians compare to the Rest of the Nation:
A case study Sponsored by the California Healthcare Foundation Susannah
Fox; This was done in collaboration with the Pew Foundation, Internet and
American Life project and is available
at:
http://wwwpewinternetorg/PPF/r/105/report_displayasp
[xli] Access to and satisfaction with care comparing patients with and
without serious mental illness; Kilbourne AM, McCarthy JF, Post EP, Welsh
D, Pincus HA, Bauer MS, Blow FC; Int J Psychiatry Med 2006;364:383-99
[xlii]Socio-economic pathways to diet: modelling the association between
socio-economic position and food purchasing behaviour; Turrell G, Kavanagh
AM; Public Health Nutr 2006 May;93:375-83

[xliii] Sleep as A Mediator of the relationship between Socioeconomic
Status and Health: A hypotheses Cauter and Speigel; Ann N Y Acad Sci,
1999;896:254-61

[xliv] Barriers to Primary Medical Care Among Patients at a Community
Mental Health Center; Carolyn Levinson Miller, MPH, Benjamin G Druss,
MD, MPH, Elizabeth A Dombrowski, MA and Robert A Rosenheck, MD
Psychiatr Serv 54:1158-1160, August 2003

[xlv] Robert Wood Johnson Foundation, Smoking Cessation Leadership Center
at: http://smokingcessationleadershipucsfedu/MentalHealthhtml
[xlvi] Benefits of smoking cessation for longevity; Taylor DH Jr
Hasselblad V, Henley SJ, Thun MJ, Sloan FA In Am J Public Health 2002
Jun;926:990-6
[xlvii] Prospective Predictors of Quit
Attempts and Smoking Cessation in
Young Adults; Rose, Chassin, Presson, and Sherman; Health Psychology, Vol
15, No 4, pp 261-268

[xlviii] Psychiatric Disorders, Familial Factors, and Cigarette Smoking:
III Associations with Cessation by Young Adulthood among Daily Smokers;
Rohde, Kahler, Lewinsohn and Brown; Nicotine Tobacco Research, Volume 6,
Issue 3 June 2004 , pages 509 - 522

[xlix]Smoking and quitting: a qualitative study with community-living
psychiatric clients; Lawn SJ, Pols RG, Barber JG Soc Sci Med 2002
Jan;541:93-104

[l]Short-term naturalistic treatment outcomes in cigarette smokers with
substance abuse and/or mental illness; Gershon Grand RB, Hwang S, Han J,
George T, Brody AL J Clin Psychiatry 2007 Jun;686:892-8; quiz 980-1

[li] Nicotine withdrawal and psychiatric symptoms in cigarette smokers with
schizophrenia; Dalack GW, Becks L, Hill E, Pomerleau OF, Meador-Woodruff
JH Neuropsychopharmacology 1999 Aug;212:195-202

[lii] Acute feasibility and safety of a smoking reduction strategy for
smokers with schizophrenia
Dalack GW, Meador-Woodruff JH Nicotine Tob Res 1999 Mar;11:53-7

[liii] Nicotine transdermal patch and atypical antipsychotic medications
for
smoking cessation in schizophrenia; George TP, Ziedonis DM, Feingold
A, Pepper WT, Satterburg CA, Winkel J, Rounsaville BJ, Kosten TR Am J
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[liv] Lifespan Health Information on Hypertension, Reviewed by: Harvey
Simon, MD, Associate Professor of Medicine, Harvard Medical School;
Physician, Massachusetts General Hospital Review Date: 4/12/2007 This is
Health information that is accredited by American Accreditation HealthCare
Commission
http://wwwlifespanorg/adam/indepthreports/10/000014html

[lv] Hypertension-Related Mortality Among Hispanic Subpopulations —
United States, 1995-2002; C Ayala, PhD, MR Moreno, MPH, JA Minaya, MPH, JB
Croft, PhD, GA Mensah, MD, Div of Adult and Community Health, National
Center for Chronic Disease Prevention and Health Promotion; RN Anderson,
PhD, National Center for Health Statistics, CDC; in MMWR February 24, 2006
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[lvi] Expert Panel on Detection, Evaluation, and Treatment of High Blood
Cholesterol in Adults Executive Summary of the Third Report of the
National Cholesterol Education Program NCEP Expert Panel on Detection,
Evaluation, and Treatment of High Blood Cholesterol in Adults
Adult
Treatment Panel III JAMA 2001; 285:2486-2497

[lvii] Methods of Calculating Deaths Attributable to Obesity; Katherine M
Flegal, Barry I Graubard and David F Williamson; American Journal of
Epidemiology 2004 1604:331-338;

[lviii] Annual Deaths Attributable to Obesity in the United States; David
B Allison, PhD; Kevin R Fontaine, PhD; JoAnn E Manson, MD, DrPH; June
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[lix] Assessment of Excess Mortality in Obesity; Ralf Bender, Christoph
Trautner, Maximilian Spraul and Michael Berger; American Journal of
Epidemiology Vol 147, No 1: 42-48

[lx] Behavioral therapy for weight loss in patients with schizophrenia
Ganguli R J Clin Psychiatry 2007;68 Suppl 4:19-25

[lxi] A pilot study of a weight management program with food provision in
schizophrenia
Michel Jean-Baptiste , Cenk Tek , Ellen Liskov , Umesh Rao Chakunta , Sarah
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[lxii] Cardiorespiratory fitness is inversely associated with the incidence
of metabolic syndrome: a prospective study of men and women; LaMonte MJ,
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[lxiii] Cardiorespiratory fitness and body mass index as predictors of
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[lxiv] Inverse association between physical inactivity and mental health in
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Sci Sports Exerc 2006 Jan;381:173-8

[lxv] Receipt of Nutrition and Exercise Counseling Among Medical
Outpatients with Psychiatric and Substance Use Disorders; Desai MM,
Rosenheck RA, Druss BG, Perlin JB; J Gen Intern Med 2002 Jul;177:556-60

[lxvi]Quality of Preventive Medical Care for Patients with Mental
Disorders; Druss BG, Rosenheck RA, Desai MM, Perlin JB Med Care 2002
Feb;402:129-36

[lxvii] Quality of Diabetes Care among Adults with Serious Mental Illness;
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[lxviii]Diabetes treatment among VA patients with comorbid serious mental
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[lxix] Mauer, BJ, Druss, BG Mind and Body Reunited: Improving Care at the
Behavioral and Primary Healthcare Interface Prepared for: American
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[lxx] Primary Care Outcomes in Patients Treated by Nurse Practitioners or
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MD; Elizabeth R Lenz, PhD; Annette M Totten, MPA; Wei-Yann Tsai, PhD;
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[lxxi] Joint Principles of the Patient-Centered Medical Home, February
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[lxxii] Goroll et al, Fundamental Reform of Payment for Adult Primary Care:
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