Improving the health and wellness of those with serious mental illness

Innovative behavioral health homes are the key to revolutionizing care

It’s no secret that our health care system is undergoing a rapid transformation, but the struggle for many people continues to be accessing high-quality care and learning how to manage their own health-related challenges. This holds especially true for one of our nation’s most vulnerable populations — those with serious mental illness (SMI).

An estimated one in 17 Americans experiences SMI.¹ Despite the underlying condition, these individuals have one thing in common: complex medical needs. However, individuals with SMI often have trouble accessing routine care to address their health needs. Many also engage in behaviors that can place their health at further risk, such as smoking, poor diet, and limited physical activity. As a result, those with SMI have high rates of early chronic disease onset and die 13 to 30 years younger than the general population.²

This can’t continue.

As a world-renowned health care provider and insurer that is affiliated with the University of Pittsburgh Schools of the Health Sciences, UPMC has the power to effect real change. We are pioneers in health care. Our role is to lead the charge, not follow it.

That’s exactly what we’re doing through research and innovations dedicated to improving the health and wellness of individuals with SMI.

The health consequences associated with complex behavioral health conditions can be mitigated through care that addresses the holistic health of patients, including their mental, physical, and social needs. Such care is not always provided through traditional service delivery approaches because of poor coordination of resources or a lack of attention to the “whole person” in both behavioral and physical health settings. To address these challenges, we are partnering with our members, families, and other stakeholders to create innovative behavioral health home models. Our integrated approaches will show behavioral health providers how to train current staff in health and wellness, which will empower them to improve overall health outcomes for those with SMI.

Creating a culture of wellness

Traditional behavioral health treatment is not designed to address both behavioral and physical health needs. Treatment approaches typically focus on the social and behavioral challenges of those with SMI. The approaches rarely consider related physical health conditions.  

Our solution: Behavioral Health Home Plus (BHHP). This innovative model was developed by Community Care Behavioral Health — a nonprofit behavioral health managed care organization that is part of the UPMC Insurance Services Division — in collaboration with members, families, and other partners. BHHP creates a culture of wellness by promoting healthy lifestyles, disease prevention and management, and health education through both Provider-Supported and Patient Self-Directed approaches.

Services for members can include access to on-site wellness nurses and disease self-management tools and resources. Supports for providers may include patient registries and avenues for increased collaboration with physical health providers — on top of training all behavioral health provider staff in wellness training and coaching.

A large-scale evaluation showed important and promising results of both approaches. Today, over 50 community mental health providers are implementing the BHHP model across Pennsylvania.  

How did we get there?

With support from the Patient-Centered Outcomes Research Institute, the UPMC Center for High-Value Health Care conducted a four-year study that compared the Provider-Supported and Patient Self-Directed behavioral health home approaches. The study, which was approved by the University of Pittsburgh Institutional Review Board, sought to determine what support and communication strategies work best to engage adults with SMI who have multiple health challenges. Unlike most traditional research studies, this work took place in real-world settings where patients were receiving care, namely from community mental health providers.

The Patient-Centered Outcomes Research Institute (PCORI) is a U.S.-based nongovernmental institute created under the Patient Protection and Affordable Care Act. PCORI was established to fund research that can help patients and those who care for them make better-informed decisions about the health care choices they face every day, guided by those who will use that information.

The UPMC Center for High-Value Health Care is a nonprofit research organization housed within the UPMC Insurance Services Division. It was created to support innovation, learning, and dissemination of patient-centered, value-driven service delivery and payment models. Our interdisciplinary platform brings together key stakeholders who work to improve patient health, lower health care costs, and enhance the experiences of those we serve as well as others across the nation. 

The Provider-Supported approach involved community mental health providers who had a full-time registered nurse onsite to educate patients and other staff about common medical comorbidities. Nurses also helped to coordinate and assess preventive, primary, and specialty medical services, monitored patients’ medical progress, and provided additional wellness support.

Through the Patient Self-Directed approach, patients had access to a secure web portal where they could read content tailored to their needs, goals, and conditions, and take an active role in their own health care. Patients could also receive support from wellness coaches and use paper-based health education and disease self-management resources.

Study facts

• 11 community mental health providers participated (provider-supported = 5 sites; self-directed = 6 sites)
• 1,229 individuals with SMI participated (37 percent were men and 63 percent were women)
• 713 participants in Provider-Supported; 516 participants in Patient Self-Directed
• All participants were Medicaid-enrolled and age 21 years or older (mean age = 43 years)
• Most participants were white (90 percent)

The results

After conducting a large-scale evaluation of the Provider-Supported and Patient Self-Directed approaches, we found that individuals with SMI became significantly more involved in their health care (more quickly with Provider-Supported), with a 2-point overall increase in patient activation scores. They also increased their use of outpatient physical health services by 36 percent overall.  

Patient activation, which measures patients’ interest in managing their health conditions, is an important — and highly modifiable — factor that can influence health outcomes for patients and more efficient use of care. For example, improvements in patient activation can lead to decreased use of inpatient services and improved medication adherence.^6,7 Increased use of outpatient care can lead to better disease management and receipt of routine preventive and primary care services.^8,9 Improved activation and increased outpatient care use could provide a downstream benefit to health care systems. 

The Patient Activation Measure is a survey that identifies where individuals fall within four levels of activation. Results of the survey can provide insights for providers and health coaches seeking to more effectively support each individual.⁶

Where do we go from here?

Right now, BHHP is used to help people across Pennsylvania. This innovative model is a game-changer because it can — and will — be used to address the unmet needs of other at-risk populations across the nation.

Sources

1. National Institute of Mental Health. The numbers count: Mental disorders in American Washington, DC: National Institute of Mental Health; 2006 [cited 2012 June 14]. Available from: nihm.nih.gov/publicat/numbers.cfm.
2. De Hert M, Correll CU, Bobes J, Cetkovich-Bakmas M, Cohen D, Asai I, et al. Physical illness in patients with severe mental disorders. 1. Prevalence, impact of medications and disparities in health care. World Psychiatry. 2001; 10 (1): 52 – 77.
3. Why UPMC? Accessed January 25, 2018, at upmc.com/about/why-upmc/pages/default.aspx.
4. Hibbard JH, Greene J. What the evidence shows about patient activation: better health outcomes and care experiences; fewer data on costs. Health Aff (Millwood). 2013; 32 (2): 2017 – 14
5. Harvey L, Fowles JB, Xi M, Terry P. When activation changes, what else changes? The relationship between change in patient activation measure (PAM) and employees’ health status and health behaviors. Patient Educ Couns. 2012; 88 (2) : 338 – 43.
6. Insignia Health. Patient Activation Measure (PAM) [August 24, 2017]. Available from: insigniahealth.com/products/pam-survey
7. Insignia Health earns ‘Best in Class’ endorsement from National Quality Forum for a person and family-centered care measure. June 6, 2016 [May 10, 2017]. Available from: prweb.com/releases/2016/06/prweb13466816.htm].
8. Druss BG, Rohrbaugh RM, Levinson CM, Rosenheck RA. Integrated medical care for patients with serious psychiatric illness: a randomized trial. Arch Gen Psychiatry. 2001;58(9):861-8.
9. Banta JE, Morrato EH< Lee SW, Haviland MG. Retrospective analysis of diabetes care in California Medicaid patients with mental illness. J Gen Intern Med;24(7):802-8.