October 2013 presentation on Life-Span Disparity, Wellness & Social Determinants of Health - http://bit.ly/lifespan-disparity In 2007, USA Today first reported on the 25 to 30 year life-span disparity for individuals with serious mental illness. Much of the initial discussion of integration focused on broader systems and planned care with little thought to those with Schizophrenia, Bipolar Disorder and Major Depression. If we are to make an impact, a broader wellness and social ecology approach is required in addition to better mental health and medical care integration.

1. 25 Year Life-span
Disparity & Third
Revolution of BH
DAVID COVINGTON, LPC, MBA—
CRISIS ACCESS, LLC
crisisaccess.com

2. The
Chasm

3. Polling Question #1
Behavioral Health Version 3.0 – What
does the integrated care revolution mean
for you?
A. The sky is falling
B. When is my retirement date?
C. The sun will come out… maybe
tomorrow
D. Hooray. Our day has come!

4. From Burning
Platform to Plan
of Action

5. May 2007
2007
2008
2009
2010
2011
2012
USA Today article published “Mentally
ill
die 25 years earlier, on average”
―Although individuals with SMI have high
accident and suicide rates, about 3 out of
5 die from mostly preventable diseases‖
Odds are not good – people with SMI die
at age 51 vs. 76 for Americans overall
Cause
◦ Heart disease
◦ Diabetes
◦ Accidents
◦ Respiratory
◦ Pneumonia, flu
Times more likely to die
3.4
3.4
3.8
5
6.6
5

6. Sept 2007
2007
2008
2009
2010
2011
2012
NASMHPD publishes state hospital
smoke-free toolkit
―Tobacco-Free Living in Psychiatric
Settings‖
Nearly half the cigarettes smoked in the
US (45%) are consumed by people with
psychiatric or addictive disorders
Silently, and insidiously, tobacco sales and
smoking were an accepted part of life in
our public mental health treatment facilities
prior to this report.
6

7. Jan 2010
2007
2008
2009
2010
2011
2012
SAMHSA Transformation Transfer
Initiatives Focused on Whole Health
SAMHSA grant provides funding for
wellness support groups in SMI clinics.
Focus includes healthy eating, physical
activity and medical issues
Larry Fricks gives whole health forums
with Ike Powell
Introduces Stanford Research by Kate Lorig
and successful Chronic Disease SelfManagement Program (CDSMP) as model for
behavioral health (originally designed for
diabetes, etc.)
7

8. May 2010
2007
2008
2009
2010
2011
2012
Milbank “Evolving Models Behavioral
Health Integration in Primary Care”
Four Quadrant model combines high/low
physical health risk/complexity and
high/low behavioral health risk/complexity
Introduced collaboration continuum from
minimal to fully integrated
Did not address the complex and multivariable needs of individuals with SMI
8

9. Poll Question #2:
Comparing Your Odds
Pick #1 Way to Decrease Mortality
Avoid/Abstain Excessive Drinking
Get Flu Shot
Increase Friends/Social Relationships
Increase Physical Activity/Exercise
Lose Weight – Lean BMI vs. Obesity
Move to Low Air Pollution City/Area
Quit/Decrease Smoking

10. Poll Question #2:
Reviewing the Answers
Action & Impact on Odds
1. Friends/Social Relationships
0.60
2. Quit/Decrease Smoking
0.50
3. Abstain Excessive Drinking
0.31
4. Get Flu Shot
0.25
5. Increase Physical
0.23
Activity/Exercise
6. Lose Weight – Lean BMI vs.
0.20
Obesity

11. July 2010
2007
2008
2009
2010
2011
2012
Social Relationships & Mortality Risk
Study: A Meta-analytic Review
Holt-Lunstad et al surveyed 148 studies and
found a 50% increased likelihood of survival
with stronger social relationships
◦ More significant impact than smoking, alcohol
consumption, flu vaccine, exercise or BMI
(lean vs. obese)
◦ Widely publicized (including CNN) and
demonstrates life-disparity answers are public
health, social ecology and behavioral health,
not just physical health related
11

12. Nov 2010
2007
2008
2009
2010
2011
2012
CMS Letter to State Medicaid
Directors on Chronic Condition
Health Homes
Section 2703 State Option offers enhanced
FMAP of 90% for first two years
Requires two of the Substance Use Disorder
following conditions:
Mental Health Condition
Asthma
Diabetes
Heart Disease
Overweight (BMI >25)
Exception is that all individuals with SMI
automatically qualify without additional
medical disorders
12

13. Dec 2010
2007
2008
2009
2010
2011
2012
DHHS encourages individualized
care for those with multiple chronic
conditions
December 2010
―A Strategic Framework‖ suggests a unique
interplay of disorders when they co-exist
SMI Only
SMI with no comorbid chronic
conditions
(SMI + 0)
◦ Magellan develops a new logic map for
classifying the 32 distinct combinations
possible through SMI + 3Section + 4
the
SMI + 1 Chronic Condition
SMI + 2
SMI 2703
SMI + 5
disorders SUD + PD below)DM SUD + PD + DM + HD SMI with all five
(see SUD + PD +
Substance Use Disorder (SUD)
Pulmonary Disease (PD)
Diabetes Mellitus (DM)
Heart Disease (HD)
Obesity, BMI >25
Label “0-1”
“1-1” to “1-5”
SUD + DM
SUD + HD
SUD + BMI
PD + DM
PD + HD
PD + BMI
DM + HD
DM + BMI
HD + BMI
SUD + PD + HD
SUD + PD + BMI
SUD + DM + HD
SUD + DM + BMI
SUD + HD + BMI
PD + DM + HD
PD + DM + BMI
PD + HD + BMI
DM + HD + BMI
“2-1” to “2-10”
“3-1” to “3-10”
SUD + PD + HD + BMI
SUD + PD + DM + BMI
SUD + DM + HD + BMI
chronic
conditions,
including:
SUD, PD, DM,
HD & BMI
PD + DM + HD + BMI
“4-1” to “4-5”
“5-1”
13

14. Feb 2011
2007
2008
2009
2010
2011
2012
Robert Wood Johnson “Mental
Disorders & Medical Comorbidity”
Only 5% of population accounts for half of all
healthcare spending
Causal factors for 70% of SMI w/ co-morbid
medical is multi-variable and complex
14

15. Mar 2011
2007
2008
2009
2010
2011
2012
Complex and multi-variable: SMI logic map for addressing
whole person needs
March 2011
Adapted from the RWJF Dr. Druss model
Chronic
Medical
Conditions
Risk &
Resiliency
Factors
Impactible
Behaviors
Behavioral
Health
Conditions
Bronchial
Asthma
Abuse/Neglect
Healthy Eating
Past Trauma
Physical
Activity
Serious Mental
Illness
Diabetes
Mellitus
Heart Disease
Obesity, BMI
>25
Stressors
Poverty
Lack of Social
Support/Connectedness
Smoking
Cessation
Community &
Family
Integration
(Schizophrenia,
Bipolar Disorder,
MDD)
Substance Use
Disorder
15

16. What Has Been
Learned?

17. What Was Thought in 2010

18. Chronic Co-Morbid Medical
Conditions
Prevalence of specific physical health
conditions outlined in Section 2703
(n=12,533)
4,482
4,669
7,757
4,589
2,202
SUD
Respiratory
Problem
Diabetes
Heart Disease Overweight/
Obesity

19. Polling Question #3
Mother nature has been kind in that the
presence of one disease provides some
immunity against acquiring other
diseases.
A. True
B. False

20. Multiple Chronic Conditions
3,984
Zero
One to Two
Three Plus
In addition to SMI, how
many have more chronic
conditions and how
many?
3,593
11%
29%
2,492
60%
1,332
998
134
Zero
One
Two
Three
Four
Five

21. Clusters Chronic
Conditions
Recipient Count
0
0-01 - --
200
400
600
800
1,000
1,200
1,400
1,600
1,800
11%
1-01 - SUD
1-02 - PD
1-03 - DM
1-04 - HD
1-05 - BMI
2-01 - SUD + PD
2-02 - SUD + DM
2-03 - SUD + HD
Chronic Conditions Cluster
2-04 - SUD + BMI
2-05 - PD + DM
2-06 - PD + HD
2-07 - PD + BMI
2-08 - DM + HD
2-09 - DM + BMI
2-10 - HD + BMI
3-01 - SUD + PD + DM
3-02 - SUD + PD + HD
3-03 - SUD + PD + BMI
3-04 - SUD + DM + HD
3-05 - SUD + DM + BMI
3-06 - SUD + HD + BMI
3-07 - PD + DM + HD
3-08 - PD + DM + BMI
3-09 - PD + HD + BMI
3-10 - DM + HD + BMI
4-01 - SUD + PD + DM + HD
4-02 - SUD + PD + DM + BMI
4-03 - SUD + PD + HD + BMI
4-04 - SUD + DM + HD + BMI
4-05 - PD + DM + HD + BMI
5-01 - SUD + PD + DM + HD + BMI
14%

22. Overweight & Obesity
(BMI)
Normal
47%
Over- weight
2,855
Obese
2,234
2,111
26%
25% of the
general population in
Arizona is obese, but
individuals with SMI
experience this
challenge at nearly
twice the rate.
(n=10,450)
27%
1,374
701
421
359
161
Below 18
129
18-20
20-25
25-30
30-35
35-40
40-45
45-50
105
50-55
55+

23. Smoking
6,510
16% of the general population in
Arizona smokes, but individuals
with SMI experience this
challenge at 3.25 times the rate.
4,208
(n=12,467)
1,749
Smoke
Never
Prior

24. Polling Question #4
What is the smoking rate for the BH
workforce compared to the general
population?
A.
B.
C.
D.
The same
BH workforce 25% higher
BH workforce 50% higher
BH workforce 100% higher

25. The HRA includes
three measures that
reflect social
supports: frequency
of invites, supports
to talk with about
problems and living
situation.
Social Supports
3,960
3,580
21%
2,870
41%
General
Population
Curve In Blue
38%
Frequently
Sometimes
1412
Rarely/Never
576
303
None
Very Low
• Never Receives Invitations
• No one to talk with about problems
• Lives alone
Low
Moderate
High
Very High
• Frequently Receives Invitations
• Frequently talks with others about problems
• Lives with family/others

26. In the past year, how many
times has the individual visited
their PCP for physical health
care or ER for any reason. The
national assumption has been
that persons with SMI go to the
ER and to their MH clinic, but
not their doctor.
(n=12,463)
PCP vs. ER
7,027
56%
4,377
In the past year:
• 16% - No PCP Visit
• 56% - No ER Visit
35%
3,733
30%
3,196
2,948
26%
24%
1,942
1103
16%
9%
600
5%
None
1-2x
Primary Care Physician
3-5x
Emergency Room
In the past year, how many times have you visited…
6+

27. How do you rate your
overall health?
Below
37%
Average
4,977
Above
23%
3,657
40%
1,941
960
Poor
Not Good
Average
Good
Considering
their age, less
than one in four
rate their overall
health as below
average, which
may suggest
poor health
904 literacy.
Excellent

28. Impact of Poverty
Poverty
Other Factors

29. Adopting
Wellness
Culture

30. Tomas Leon and Team People of Color Network

33. What’s Next?

34. Collaborative Care Model
The MacColl
Institute
(®ACP-ASIM
Journals &
Books)
Improved Outcomes

35. 14 Essential Elements

36. Chronic Disease Self-Mgmt
Originally Developed for:
Diabetes Mellitus
Arthritis
Chronic Pain
HIV Infection

37. Behavioral Health as Lead
Contrary to popular notions, mainstream
physical health plans and providers are seeing
SMI consumers.
We must incorporate risk & resiliency
factors,
social
connectedness,
selfmanagement,
suicide
and
impactible
behaviors like smoking cessation and
community integration.
The SAMHSA/HRSA collaborative ―Center for
Integrated Health Solutions‖ demonstrates the
power of ―bi-directional care‖ where behavioral
health is the lead.

39. Improving the Chain of
Care
Opportunities to Improve Interventions to Reduce Suicidality (NIMH, Schoenbaum, et al,
December 2009)

40. Ecological, Communitybased Models
An Opportunity Map for Societal Investment in Health (JAMA, Fielding & Teutsch, May 2011)

41. Contact Us
Email
david.covington@crisisaccess-co.com
bdruss@emory.edu
Social Networking
http://www.linkedin.com/in/davidwcovington
https://twitter.com/davidwcovington
https://www.facebook.com/david.covington
http://www.youtube.com/davidcovington
crisisaccess.com