Patients With Serious Mental Illness Need Better Primary Care Integration, Health Advocacy
Abstract
Improving longevity for patients with serious mental illness requires better integration of care and more screening and general health monitoring by psychiatrists.
Better integration of care between community mental health organizations and primary care providers can result in better health for patients with serious mental illness (SMI), according to a white paper issued by APA at a Capitol Hill briefing last month.
Glenda Wrenn, M.D., tells members of Congress and other attendees at a Capitol Hill briefing that stigma and discrimination by health care professionals play a role in the poor health care outcomes of people with serious mental illness.
Patients with SMI often lack health insurance coverage or the means to pay for primary care, so they have trouble accessing health care as well as advocating for their own health, according to the paper. Many such patients underuse primary care services and overuse emergency and medical inpatient care, resulting in their getting fragmented and irregular services and lower rates of preventive care.
More than a decade has passed since it became known that people with SMI treated in the public mental health system were dying on average 25 years earlier than the general population. “However, little progress has been made in rectifying this disparity,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A., at the congressional briefing. “But treatment is possible, and treatment does work.”
APA convened the panel of mental health specialists to brief members of Congress and their staffs about the mental, physical, and social health needs of patients with SMI and to promote evidenced-based interventions to improving their health. At the briefing, Congresswoman Grace Napolitano (D-Calif.), founder and chair of the Congressional Mental Health Caucus, called on teaching hospitals to provide more training for physicians on understanding and recognizing mental health issues. “In doing so, it will help reduce stigma,” she said.
APA’s white paper pointed out that psychiatrists have an important role to play in helping to narrow the longevity gap experienced by patients with SMI compared with the general population by providing some care typically done by primary care providers: for example, screening patients routinely for common medical conditions and helping patients, through counseling or treatment, make lifestyle modifications to reduce cardiovascular and other health risks.
Two-thirds of the premature deaths of patients with SMI are due to natural causes, not mental illness, explained Benjamin Druss, M.D., the Rosalynn Carter Chair in Mental Health at the Emory University Rollins School of Public Health. Patients with SMI die of the same conditions as the general population, but they do so at a younger age. Rates of medical illness in those with SMI exceed those of the general population in every disease category, with cardiovascular disease, cancer, and infectious diseases topping the list, he added.
Psychiatrists Urged to Advocate for People With SMI
In addition to collaborating with primary care providers to improve clinical care and helping patients with SMI make critical lifestyle modifcations, psychiatrists have a key role to play as state, federal, and public health policy advocates for this at-risk group, according to APA’s white paper.
State policy: As state policymakers play an increasing role in shaping mental health care, psychiatrists are uniquely positioned to advocate for people with SMI by providing input on new program design and reform efforts. Psychiatrists can work with Medicaid directors, state mental health authorities, and other state agencies, such as the departments of corrections, in this important role.
Federal health policy: Psychiatrists can advocate for the federal government to continue its vital activities for patients with SMI, particularly by implementing surveillance and monitoring efforts to track the health of people with SMI and providing regulatory oversight and enforcement of existing policies to ensure insurance coverage, access, and quality of care for these patients.
Public health policy: Premature mortality in populations with SMI is ultimately a public health problem. Psychiatrists can advocate for a “robust public health infrastructure that ensures prevention and treatment of ill health in individuals with SMI and addresses the community and social risk factors underlying poor outcomes in this vulnerable population.”
The current fee-for-service model of reimbursement, now in use by Medicaid and other payers, does not adequately reimburse for care management, peer and wellness services, and many components of the team-based interventions that show promise for improving the physical health of patients with SMI. New payment structures are needed, like the monthly case rate used in collaborative care models or those that allow a per-member, per-month payment for these services, noted the report.
Lauren Swanner, R.N., assistant director of Health Homes for Mosaic Community Services of the Sheppard Pratt Health System, said Medicaid reimburses the clinic a flat $102 per month for each client who completes at least two services, but if patients need more services, the payment rate stays the same. However, most SMI patients lack the motivation, insight, or financial resources to schedule and attend critical medical and dental appointments, she added.
“That’s why they need a health care advocate or case manager, at least in the beginning,” Swanner said. “While these patients desperately need primary care, first you need to overcome the hurdle of their mental illness. Johnny is so depressed he can’t get out of bed. He needs someone to pull him out of bed and get him there.”
In addition to integrating and coordinating care, Swanner said universal electronic health records for patients with SMI are critical. Such records allow community providers to tell at the click of the mouse whether a patient has had a recent metabolic screening while also avoiding unnecessary repeating of costly lab work.
As of September 2016, 19 states and the District of Columbia have launched Medicaid “health home” model demonstrations like the program in which Swanner works. That program received funding under the Affordable Care Act of 2010 to provide comprehensive care coordination for high-cost, complex conditions, including serious mental illness.
Psychiatrists Can Address Lifestyle Modifications
While patients with SMI suffer from economic disadvantage and chronic stress caused by their illness, modifiable risk factors also play a role that psychiatrists can readily address. Patients with SMI are more likely than the general population to use tobacco or other substances, have a poor diet, lead a sedentary lifestyle, and not comply with treatment regimens. These factors, coupled with the propensity for psychotropic medications to cause obesity and metabolic disorders, all contribute to the early mortality of patients with SMI.
Medical professionals’ bias against and stereotyping of SMI patients, particularly in the emergency department (ED), can also imperil the lives of these patients, said Glenda Wrenn, M.D., director of the Kennedy-Satcher Center for Mental Health Equity at Morehouse School of Medicine in Atlanta. In fact, ED physicians list dealing with psychiatric patients as their “chief complaint” about doing their job, she said. She has seen cases in which patients with SMI died of delirium tremens because ED physicians failed to recognize acute alcohol withdrawal.
Medical training for psychiatrists is often limited to medical school and a few months of internship, pointed out Druss. To keep their skills up to date, training in outpatient medical care should be provided to practicing psychiatrists in continuing education programs and cross-training opportunities with other medical service providers.
Adrienne Kennedy, a board member with the National Alliance on Mental Illness, told attendees that she believes her son Devin would be alive today if it weren’t for medical missteps and a tragic lack of integration and coordination of care in his 17-year battle with mental illness. Devin was simultaneously diagnosed with type I diabetes, bipolar disorder with psychotic features, and severe substance use disorder at age 23. He received no treatment while incarcerated, and even while he was hospitalized, of all the medical providers he saw, “no one ever talked with his endocrinologist or primary care provider,” she said. The time involved in overcoming legal hurdles in obtaining a court order to force her son to take his insulin nearly cost him his life.
In her pursuit of effective treatment for him, she spent three fruitless years “knocking on every door to try find a cognitive-behavioral therapist for him” in Austin, Texas, where he lived. Devin lacked health insurance, so Adrienne and her husband had to spend $150,000 out of pocket for the first 18 months of his care and were forced to remortgage their house and spend down their retirement savings.
Ultimately, APA’s white paper calls for more study of various care-delivery models to improve the physical health of people with SMI, as little research has been done in this area, as well as to understand the optimal role of psychiatrists in these models. ■
“Psychiatry’s Role in Improving the Physical Health of Patients With Serious Mental Illness” can be accessed here.
