1

How Peer Specialists Can Help Consumers Reach Wellness and

Health Goals

James Schuster, MD, MBA, Community Care Behavioral Health Organization, Pittsburgh, PA

Margaret Park, Recovery SpecialistAllegheny County Department of Human Services

September 15, 2011

2

Our goals for today

• Look at the research on life expectancy for people living with serious mental illness

• Learn what the statistics mean for real life and real people

• Understand how peers can help consumers improve their wellness and physical health

2 2

3

Pennslyvania HealthChoices

• Medical Assistance (Medicaid) Managed Care Program

• Department of Public Welfare; Office of Mental Health and Substance Abuse Services Oversight

• Statewide Behavioral Health Carve-Out

– 1915b Federal waiver

– County government is the recipient of funds

– County government contracting models vary

3

4

About Community Care

• Behavioral Health Managed Care Company

• Founded in 1996

• Federally tax exempt non-profit 501(c)3

• Sole member corporation (UPMC) – provider owned

• Licensed as a Risk-Assuming PPO

• Major focus: publicly funded behavioral healthcare system

• Identified BHO for Hudson Valley Region

4

5

About Community Care

• Medicaid/HealthChoices membership: 700,000

• Commercial/Medicare membership: 430,000

• Statewide HealthChoices presence

– 36 of 67 Pennsylvania counties

• 8 offices across Pennsylvania

• More than 500 employees

• Approximately 110,000 people served

• Statewide network of more than 2,500 providers

5

6

Erie

Crawford

Mercer

Lawrence

Beaver

Washington

GreeneFayette

Allegheny

Westmoreland

Butler

Armstrong

Venango

Indiana

Cambria

SomersetBedford

Blair

Clinton

Fulton Franklin

Cumberland

Perry

Lycoming

Dauphin

Lancaster Chester

Lebanon

Pike

Monroe

Carbon

Lehigh

Northampton

Bucks

Montgomery

DelawarePhiladelphia

Community Care Counties

Clarion

Forest

Warren McKean Potter

CameronElk

Jefferson

ClearfieldCentre

Huntingdon

MifflinSnyder

Union

Tioga Bradford

Columbia

Montour

Northum- berland

Schuylkill

Wayne

Juniata

Sullivan

Clarion

Forest

Warren McKean Potter

CameronElk

Jefferson

Clearfield Centre

Huntingdon

MifflinSnyder

Union

Tioga Bradford

Columbia

Montour

Northum- berland

Schuylkill

Wayne

Juniata

Sullivan

Allegheny

Luzerne

Wyoming

Susquehanna

Lackawanna

Adams York

Berks

Adams York

Berks

Chester

Luzerne

Wyoming

Susquehanna

Lackawanna

Pike

Monroe

Carbon

Adams York

Berks

Chester

Community Care OfficeCommunity Care Contract

6

7

What Do We Know about Physical Health in Adults with Serious Mental Illnesses?

• People with serious behavioral illness die earlier than the general population.

• People without SMI who have risk factors common to SMI (i.e. smoking, poverty, homelessness, obesity) also die much earlier than the general population

• Our behavioral and physical health systems have failed to systematically address and support prevention and wellness across all populations, especially those which suffer from socioeconomic disadvantages

National Association of State Mental Health Program Directors (NASMHPD) Medical Directors Council. (2006). Morbidity and Mortality in People with Serious Mental Illness. Alexandria, VA.

7

8

Impact of Various Factors

• Suicide and injury account for about 30-40% of excess mortality in people with SMI

• Sixty percent of premature deaths in persons with schizophrenia are due to medical conditions such as cardiovascular, pulmonary and infectious diseases.

• About 3 out of 5 people with SMI who die prematurely die from mostly preventable diseases.

8

9

Smoking

• Higher prevalence (56-88% for patients with schizophrenia) of cigarette smoking (up to 44% of all cigarettes sold in US are purchased by people with SMI)

• More toxic exposure for patients who smoke (more cigarettes, larger portion consumed)

• Smoking is associated with increased insulin resistance• Similar prevalence in bipolar disorder• Smoking cessation may be the modifiable risk factor that is

likely to have the greatest impact on decreasing mortalityGeorge TP et al. Nicotine and Tobacco Use in Schizophrenia. In: Meyer JM, Nasrallah HA, eds. Medical Illness and Schizophrenia. American Psychiatric

Publishing, Inc. 2003; Ziedonis D. Williams JM, Smelson D. Am J Med Sci. 2003 (Oct); 326(4): 223-330.

National Association of State Mental Health Program Directors (NASMHPD) Medical Directors Council. (2006). Morbidity and Mortality in People with Serious Mental Illness. Alexandria, VA.

9

10

Obesity

• Obesity among persons with serious mental disorders is greater than among the general population

• Increased incidence of Metabolic Syndrome in SMI population• Obesity in individuals with mental disorders attributed to a number

of factors:– a sedentary lifestyle– poor nutritional choices– lack of access to healthy food (which is also associated with poverty)– the effects of both the mental disorder itself and the medications used to treat it– lack of access to adequate preventative medical care

National Association of State Mental Health Program Directors (NASMHPD) Medical Directors Council. (2006). Morbidity and Mortality in People with Serious Mental Illness. Alexandria, VA.

Citromea, L., Vreeland, B., Obesity and Mental Illness. Thakore J, Leonard BE (eds): Metabolic Effects of Psychotropic Drugs. Basel, Karger, 2009, vol 26, pp 25-46.

10

11

Coronary Heart Disease

• The leading cause of death worldwide• Following cardiac events, individuals with mental illness

experience a 14% lower rate of invasive coronary interventions (47% in the case of schizophrenia) and an 11% increased mortality rate

• Despite continued improvements of care, inequalities in the quality of care of those with mental health diagnoses have been documented including the receipt of preventive care

Mitchell, A.J., Lawrence, D., (2011). Revascularization and mortality rates following acute coronary syndromes in people with severe mental illness: comparative meta-analysis. The British Journal of Psychiatry, 198, 434-441.

Hennekens C.H., Hennekens, A. R., Hollar, D., Casey, D. E., Schizophrenia and increased risks of cardiovascular disease. Am Heart J, 2005; 150: 1115-21.

11

12

Suicide

• Suicide is the 11th leading cause of death in the U.S. (CDC)• An estimated 2-15% of individuals diagnosed with major

depression die by suicide• An estimated 3-20% of individuals diagnosed with bipolar

disorder die by suicide• An estimated 6-15% of individuals diagnosed with

schizophrenia die by suicide• Suicide is the leading cause of premature death in those

diagnosed with schizophrenia

http://mentalhealth.samhsa.gov/suicideprevention/suicidefacts.asp

12

13

Impact of Medications

Problems with psychiatric medications can include:• Overweight and obesity• Insulin resistance• Diabetes and hyperglycemia• Dyslipidemia

National Association of State Mental Health Program Directors (NASMHPD) Medical Directors Council. (2006). Morbidity and Mortality in People with Serious Mental Illness. Alexandria, VA.

13

14

Inadequate Access to Physical Health Care

• Lack of capacity in some health care systems• Stigma and discrimination• Poor quality and poor provision of services in some

areas• Lack of adequate health care coverage (in some areas)• Monitoring and treatment guidelines are underutilized

with the SMI population (as they are in most populations)

National Association of State Mental Health Program Directors (NASMHPD) Medical Directors Council. (2006). Morbidity and Mortality in People with Serious Mental Illness. Alexandria, VA.

14

15

Vulnerabilities

People with SMI are vulnerable due to higher rates of:• Homelessness• Victimization or trauma• Unemployment• Poverty• Incarceration• Social Isolation

National Association of State Mental Health Program Directors (NASMHPD) Medical Directors Council. (2006). Morbidity and Mortality in People with Serious Mental Illness. Alexandria, VA.

15

16

Why do we have shorter life spans?

• Some of the lost years of life are because of mental health symptoms like suicide & risk-taking behavior (30% to 40%)

• Most of the premature deaths of people with mental illnesses are due to heart problems, strokes & complications from diabetes. (60% to 70%)

16

17

60% - 70%: Preventable & Treatable Illnesses

• Obesity (and antipsychotics & antidepressants can increase that problem)

• Diabetes (atypical antipsychotics are linked)

• High cholesterol (antidepressants)

• Smoking (double the general population)

• Low rates of physical activity & exercise

• Substance use and misuse

• Lack of good medical care (‘flu’ shots, regular tests…)

17

18

All of these problems are “synergistic”

• Smoking increases your risk of breathing problems, allergies, colds and the ‘flu’, heart disease & cancer.

• Being overweight increases your risk of breathing problems, diabetes, heart disease (high cholesterol & stroke) and cancer.

• Lack of regular exercise increases your risk of breathing problems, heart disease, diabetes, & cancer.

18

19

Synergistic effects cont’d

• Diabetes creates complications for all your internal organs including your heart and lungs, kidney, liver and makes it harder to heal from infections.

• Psychotropic Medications increase your risks of heart disease, obesity and diabetes.

• The combination of these factors increases your risk many times

19

20

Let’s focus now on the Power of Peers

20

21

What is the GOOD news?

• Adding years to life is possible! There are proven ways of doing just that

• Developing stress hardiness-ways that work

• Choices and strengths work in wellness just as they do in recovery

21

22

Who, What, Where, When & How?

• Who knows more about recovery and resiliency than we do?

• Who knows more about peer support, coaching and sponsorship than we do?

• We can lead the way.

22

23

Leadership characteristics

1. Leaders change things

2. Leaders act with humility

3. Leaders are not victimhood. Leaders do no blame others, they work with them

4. Leaders define reality through data. Helping people measure success

5. Leaders develop and test changes. What works?

6. Leaders are courageous

7. Leaders persuade by being honest, patient and persistent

8. Leaders are empowered by the people who believe in them. They are believable.

9. Leaders are not defeated by negativity

10. Leaders think outside the box

23

24

Elements to consider

• Wellness Dimensions

• Stress Hardiness (bouncing back in life)

• WRAP and Peer Support Principles

• Leadership Characteristics

24

25

Person-Centered: Choices Matter

25Used with permission from Peggy Swarbrick

26

Teaching Stress Hardiness

1. Challenge-threat v opportunity, self-determination, efficacy

2. Control—internal loci v. external loci, knowing which is which

3. Commitment- capacity and willingness to make a commitment

Reduces risk of developing stress related health problems by 50%

26

27

Some Principles of WRAP

• People develop hope by making their own plans

• Each encounter focuses on the person’s self-determination,

empowerment and choice.• Mutual respect and

unconditional acceptance are maintained

• ALL diversity is accepted and support (incl. mental diversity)

• All goals and plans are supported without judgment

• There are no pre-established limits to recovery.

• The focus is always on what people do well

• Informed choice is a primary ethical determinant. Questions are treated respectably as valuable

27

28

What Can We Act On?

• Many consumers have serious wellness and physical health challenges

• If we don’t do anything about them, many people will die at relatively young ages

• There are lots of activities and strategies that can help consumers get healthier and ADD years to their lives

• Peers can provide leadership in these efforts and help consumers to reach these goals

28

29

Resources

• Reinerstsen, J.L. (1998) Physicians as Leaders in the Improvement of Health Care Systems. American College of Physicians, 128(10), 833-838.

• Susan Kobasa, http://stresscourse.tripod.com/id106.html

• Swarbrick, M. (2006). A wellness approach. Psychiatric Rehabilitation Journal, 29,(4) 311- 314.

29