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Addressing the Impact of Behavioral Health in Diabetes Neda Laiteerapong, MD, MS Michael Quinn, PhD Department of Medicine University of Chicago in collaboration with MWCN Disclosures • none 2 Learning Objectives • Understand prevalence and impact of behavioral health issues in patients with diabetes • Understand facilitators and barriers of providing evidence based behavioral health care in primary care • Become aware of efforts at MWCN to improve behavioral health care for patients with diabetes 3 CASE STUDY: BOB 45 YO “HEALTHY” MAN 4 Bob’s History • Urgent visit – Acute chest pain – Shortness of breath • 1 pack per day smoker of 30 years • Family history of heart attack • Diagnosis: Pneumonia Bob At First Office Visit • Chest pain, shortness of breath resolved • Still smoking, desire to quit • Family history: – Father: smoker, died of MI at 60 yo – Mother: Type 2 DM, insulin therapy • BP 140/92, BMI 29 Bob At First Office Visit • Recommendations – Smoking cessation counseling, bupropion – Fasting blood work – Follow-up in 3 months Bob At First Office Visit • Recommendations – Smoking cessation counseling, bupropion – Fasting blood work – Follow-up in 3 months “OK” Bob At Second Office Visit • 7 months later • Smoke-free since quit date 6 mos prior • BP 148/96, BMI 31 • Total cholesterol 220 mg/dL • HDL 26 mg/dL • FBG 110 mg/dL Bob At Second Office Visit • Recommendations – Acknowledge smoking cessation – High cholesterol - Atorvastatin – Hypertension - Lisinopril + HCTZ – Pre-diabetes - Offered metformin Bob At Second Office Visit • Recommendations – Acknowledge smoking cessation – High cholesterol - Atorvastatin – Hypertension - Lisinopril + HCTZ – Pre-diabetes - Offered metformin “I don’t want to start any pills” “I’ll watch my diet and get more exercise” Bob 10 years Later • • • • • • Bob returns to clinic 10 years later Smoking relapse, 1 pack per day BP 150/96 BMI 32 kg/m2 TC 210 mg/dL, HDL 25 mg/dL FBG 160 mg/dL Bob 10 Years Later • Recommendations – Smoking cessation counseling, bupropion – High cholesterol - Atorvastatin – Hypertension - Lisinopril + HCTZ – Diabetes - Metformin “I don’t want to start any pills. That’s why I didn’t come back to see you earlier.” “I’ll quit smoking, watch my diet and exercise” Bob 20 Years Later • • • • • Still smoking, 1-2 packs/day Appears depressed, c/o sleep disorder BP 150/96, BMI 36 kg/m2 TC 220 mg/dL, HDL 20 mg/dL FBG 180 mg/dL Bob 20 Years Later • Atorvastatin- stopped taking • Lisinopril + HCTZ – skips when feeling OK • Metformin – skips when stomach upset Bob 20 Years Later • Recommendations – High cholesterol – Atorvastatin- increase – Hypertension - Lisinopril + HCTZ – Diabetes – Start insulin “I’m tired of being sick. These pills don’t help.” “No insulin. It killed my mother.” Bob’s Current Behavioral Health Needs • Health behavior changes – Intensive smoking cessation counseling – Medication adherence counseling – Diet and exercise counseling • Assessment and treatment of mental health Bob’s Past Behavioral Health Needs What behavioral health services could have helped Bob 20 years ago? BACKGROUND: DIABETES 19 Diabetes • 29.1 million U.S. adults • FQHCs care for disproportionate share of patients with diabetes – 9% general population vs. 13% at FQHCs 20 Early Diabetes: Usual care • Patients receive: – Advice to modify lifestyle (diet and exercise) – medical nutrition therapy (nutrition referral) • Patients may be prescribed oral agents Goal of treatment is to prevent long-term complications Nathan, 2002; Edelman et al., 2003 Advanced Diabetes: Usual Care • Patients receive: – Continued advice to modify lifestyle – Medical nutrition therapy (nutrition referral) – Instructions to monitor blood glucose • Patients prescribed multiple oral agents and/or insulin • Patients at risk for polypharmacy Diabetes Management Challenge • Daily responsibilities rests with patient – Requires significant lifestyle change across multiple target behaviors • Multiple barriers to optimal selfmanagement • Difficulty maintaining motivation Adherence to Diabetes Self-Care is Poor Treatment Oral medications (>80%) Insulin SMBG Smoking cessation Diet (< 30% fat) Exercise (150 min/wk) Rates of Adherence 20% 20% 35% 20% 70% 70% Clinicians Can Influence Behavior Change 22.1% 16.0% Smoking Cessation Rate 13.4% 10.9% No Contact <3 Minutes 3-10 Minutes > 10 Minutes (AHRQ, 2000) Brief Counseling of 2-3 Minutes Increases Exercise 80 Minutes per Week 70 60 50 40 30 20 10 0 Control Baseline 6 Weeks Brief Counseling N = 255 Calfas et al., 1996 BEHAVIORAL HEALTH INTEGRATION: OVERVIEW 27 Behavioral Health and Primary Care Integration Definitions 28 Definition: Behavioral Health Care • Umbrella term that addresses behavioral problems bearing on health including: – Health behaviors and patient activation – Stress-linked physical symptoms – Mental health – Substance abuse 29 Health Centers Care About Behavioral Health • Onsite counseling and treatment – Mental health: 70% – Substance abuse: 40% • 20% offer 24-hour crisis intervention • All provide outside referrals to substance abuse and mental health services 30 MENTAL HEALTH AND DIABETES 31 Mental Health 32 Percentage of persons aged 12 and over with depression, by age and sex: United States, 2009–2012 33 http://www.cdc.gov/nchs/data/databriefs/db172.htm Mental Health and Diabetes In patients with diabetes – 41% have poor psychological well being – 25% have depressive symptoms – 15% have elevated anxiety symptoms In people with depression, anxiety, bipolar disorder, and schizophrenia – Higher prevalence of diabetes 34 Mental Health Illnesses and Diabetes: Share Risk Factors • Unhealthy lifestyles – Diets high in processed sugars, fats – Inadequate activity and sleep • Poor resources – Low income, low education, unsafe neighborhoods – Poor health literacy • Chronic stress response – Cortisol, proinflammatory cytokines 35 Comorbid Diabetes and Depression: Worsens Self-Management • • • • 36 Lower self-efficacy Less physical activity Worse diet Lower treatment adherence Comorbid Diabetes and Depression: Worsens Outcomes • Higher incidence of complications and at an earlier age – Heart attack, stroke, blindness, renal disease, dementia, foot ulcers, major amputations • Higher cardiovascular and all-cause mortality – Mortality rate 1.5 times higher than diabetes alone • Higher health care utilization – 50-75% greater total medical costs 37 Behavioral Health and Diabetes: Opportunity for Improving Care • Unmet mental health needs – Only 12% of people with diabetes receive psychological treatment – 55% of people with diabetes and serious psychological distress receive treatment 38 Behavioral Health and Diabetes: Opportunity for Improving Care • Access to patients in primary care – People with diabetes actually more likely to receive treatment than others with serious psychological distress (45%) – Most patients with mental health needs seen in primary care 39 BEHAVIORAL HEALTH INTEGRATION: RANGE OF SERVICES 40 Behavioral Health and Diabetes: Different levels of services • Population level – Systematic screening and tracking • Patient level – Combine psychotherapy interventions (CBT, motivational interviewing) with diabetes education and self-management 41 Integrated Care: Spectrum • Enhanced referral relationships 42 www.integration.samhsa.gov Integrated Care: Spectrum • Enhanced referral relationships • Co-location 43 www.integration.samhsa.gov Integrated Care: Spectrum • Enhanced referral relationships • Co-location • Co-habitation; staff integration 44 www.integration.samhsa.gov Integrated Care: Spectrum • • • • 45 Enhanced referral relationships Co-location Co-habitation; staff integration Full integration - multi-disciplinary team www.integration.samhsa.gov BEHAVIORAL HEALTH INTEGRATION: EVIDENCE 46 Evidence for Behavioral Health Interventions: IMPACT • 1801 adults over 65 years with depression from primary care • Usual care vs. Collaborative Care • Collaborative Care: – Team care, population-based care (registry), treatment to target, evidence-based care • 50% vs. 19% reduction in depressive symptoms (p<.001) 47 Unützer et al, JAMA 2002; 288:2836-2845 Evidence for Behavioral Health Interventions: TEAMcare • 214 adults with poorly controlled diabetes or heart disease and comorbid depression • Usual care or intervention group • Intervention included nurse working with PCP to provide close attention to diabetes control and depression care • Improved HbA1c, LDL, BP and depression outcomes; cost-savings 48 N Engl J Med. 2010; 363(27):2611-20. Summary of Evidence: Facilitators • Patient-centered care – Care at the right time and the right place – Decreases stigma • Improves outcomes – Improves diabetes outcomes – Improves mental health outcomes • Cost-effective in sites with capitated payment 49 Barriers to Integrated Care • Structural barriers – Access to notes / EMR integration – Scheduling • Financial barrier – Billing for services • Knowledge barriers – Local expertise 50 BEHAVIORAL HEALTH INTEGRATION: FUTURE DIRECTIONS 51 MWCN - BHIG • Behavioral Health Interest Group – Networking and sharing (webinars every other month) – Facilitated by Stacey R. Gedeon, Psy.D., MS Clinical Psychopharmacology, Director of Behavioral Health & Integrated Primary Care at MidMichigan Community Health Services – Next call April 20th at 12:00 EST (1 hour) – To join email [email protected] 52 MWCN Efforts • To improve behavioral health care for patients with diabetes at MWCN-affiliated community health Centers • UChicago and MWCN Behavioral Health and Diabetes Surveys – To understand current state of care in order to inform the design of a future intervention – Clinic-level Resources Survey – Provider-level survey 53 Useful Resources • Screening tool for depression: www.cqaimh.org/pdf/tool_phq2.pdf • Screening tool for anxiety: Spitzer RL, Kroenke K, Williams JBW, Lowe B. Arch Intern Med. 2006;166:1092-1097. • HRSA-specific: http://www.integration.samhsa.gov/integrated-caremodels/hrsa-supported-safety-net-providers • Models of Behavioral Health Integration and Billing Codes (p.69): Collins C, et al. Evolving Models of Behavioral Health Integration in Primary Care. 2010. http://www.milbank.org/publications/milbankreports/32-reports-evolving-models-of-behavioral-healthintegration-in-primary-care • AIMS Center: https://aims.uw.edu/ • HRSA: http://www.hrsa.gov/publichealth/clinical/behavioralhealth/ Questions? Neda Laiteerapong, MD, MS [email protected] Michael Quinn, PhD [email protected] Erin Staab, MPH [email protected]