Wednesday, December 10, 2008

Disease Management for Severe Mental Illness

We can telephonically engage/coach/monitor and help persons with diabetes, asthma, heart failure, COPD, coronary artery disease – but how about serious persistent mental illness? Check out this interesting paper published in the latest issue of the American Journal of Managed Care by Paul F. Cook, Suzie Emiliozzi, Corey Waters and Dana El Hajj of the University of Colorado, ScriptAssist and Centene Corporation (the latter two entities paid for the study).

This was a study involving outpatient Medicaid beneficiaries who were taking anti-psychotic medications for more than 30 days. 210 candidates were identified for nurse-based telephony, but only 59 (28%) could be reached on the phone. Of these, 8 declined to participate, leaving 51 intervention patients. The remaining 151 formed a comparison group. The results that caught the eye of the Disease Management Care Blog were that intervention patients visited ERs an average of about 1 time per year, versus 5 in the comparison group. While the comparison group initially had higher pharmacy compliance rates in the first month, by 6 months is was clear that the intervention group was doing much better at taking their anti-psychotic medications at 48% vs. 26%.

This was far from a perfect study. The intervention and control groups are probably not comparable, since patients who can be reached by telephone and agree to participate are probably more compliant in general and are more likely to avoid ERs and take their medicines as prescribed. That’s called selection bias. There was also insufficient detail about the protocols used by the nurses to help the patients.

Think of this as a pilot study. That being said:

Among a population of severely mentally ill outpatients who are notorious for not taking their antipsychotic medications, the DMCB learned that it’s possible to reach a quarter of them by telephone and engage them in regular follow-up. This may reduce ER use and it may increase medication compliance. This is worth more study.

There were other lessons learned from this paper. The authors pointed out that there was a delay between the time patients got their qualifying medications and the telephony was initiated. Another was the use of a masked “unknown” caller ID when patients were called (to protect confidentiality), which in turn prompted patients to not pick-up.

Despite all the limitations, the DMCB likes this study because it’s disease management outside the usual big 5 of asthma, diabetes, heart failure, COPD and coronary artery disease. It uses a well known approach to a population that is very difficult to manage with high levels of avoidable utilization and complications. It was performed in a community setting with high generalizability and had the wherewithal to not only implement a program but simultaneously study the impact at the same time.

It is common in research settings to conclude manuscripts like this with the adage that more research is necessary. The authors of this little gem did that also. However, the DCMB would go one step further and suggest (unless there are better ideas out there) that telephonic follow-up/coaching of persons with mental illness who are on antipsychotics be expanded and that more research be performed to better assess what works and what doesn’t.


Unknown said...

Good for you for highlighting behavioral health DM. We are finding in Medicaid population that the chronic, complex medical DM patient carries a 50% co-morbidity for behavioral health dx. Numbers on over one million members! I think the key to DM, and not just behavioral health DM, is addressing the behavioral health comorbidities; this is particularly true in Medicaid. We are doing aggressive field DM with this population with notable success- using field because population is so hard to reach via telephone. Charles Gross

Jaan Sidorov said...

Interesting thought, Charles. What are the behavioral 'co-morbidities' in this population, other than drug, alcohol and tobacco abuse?

Unknown said...

The most significant behavioral health issue in the population I have reviewed is schizophrenia- with this diagnosis being the major driver of illness burden and the accompanying poor adherence re the medical co-morbidities. So for example, within the 50% co-morbid for medical and behavior, I can see well over half carrying a diagnosis of schizophrenia (this is based on claims data, so some caution is advised regarding accuracy of the dx). I am wrestling with the operational, contracting, and other myriad issues that accompany establishing a "medical home" to address the medical/ behavioral issues of this population in an integrated stop shopping- a good idea but a very steep hill to climb particularly with the challenging issues that this population presents.

Jaan Sidorov said...

Makes me wonder if the diagnosis of schizophrenia regularly warrants its own disease management program. Concurrent illnesses like diabetes, hypertension etc can be addressed as part of the plan of care, but the point is that the mental illness gets the priority attention. I'm not sure the primary care 'medical home' is operationally configured to manage this. I'd aim for getting a 'responsible provider' in place and I'd rely on nurses/coaches with a background in mental health....

Unknown said...

Exactly...that is the operational challenge! The medical home will have to have equal representation for medical/behavioral or have behavioral a seamless part of home. Looking at and looking for practices that fit the bill or are interested in build out to fit the bill. So FQHCs and large vertically integrated systems with solid behavioral health divisions are the first place we are looking.