Jackson Health Network

Behavioral Health Care: Issues in Management 2014

Jackson County, Michigan

March 24, 2015

Prepared by:

Richard J. Thoune, RS, MS, MPH Health Officer

Michael S. Klinkman, MD, Medical Director, Jackson Health

Network

Al Pheley, PhD, Director, Research Department, Allegiance Health System

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Introduction.

Mental illness is defined as “collectively all diagnosable mental disorders” or “health conditions

that are characterized by alterations in thinking, mood, or behavior (or some combination

thereof) associated with distress and/or impaired functioning.” (1)

Depression is the most common

type of mental illness, affecting more than 26% of the U.S. adult population. (2)

It has been

estimated that by the year 2020, depression will be the second leading cause of disability

throughout the world, trailing only ischemic heart disease. (3)

Serious mental illness is defined by

the Substance Abuse and Mental Health Services Administration (SAMHSA) as having a

diagnosable mental, behavioral, or emotional disorder that met the criteria found in the 4th

edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and resulted in

functional impairment that substantially interfered with or limited one or more major life

activities. Evidence has shown that mental disorders, especially depressive disorders, are

strongly related to the occurrence, successful treatment, and course of many chronic diseases

including diabetes, cancer, cardiovascular disease, asthma, and obesity (4) and many risk

behaviors for chronic disease, such as, physical inactivity, smoking, excessive drinking, and

insufficient sleep.

Background.

A 2013 assessment of the burden of mental illness report completed by the Jackson County

Health Department identified the need for an assessment of area providers to determine the

current status of behavioral health care. The assessment was completed to support the clinical

integration efforts of the Jackson Health Network (JHN). The assessment report focused on

adults aged ≥18 years residing in Jackson County, Michigan. The network has developed and is

implementing a comprehensive health assessment tool through care coordination/management

that will assess the health needs of patients across 5 domains: social (social problems), biological

(medical), psychological (mental health), functional status, and self-management. Understanding

the burden of mental illness present in the community is essential for service delivery system

planning, clinically integrated care coordination efforts, treatment at the primary care provider

level, and any necessary capacity building. Determining provider training and comfort in

identifying and managing behavioral health diagnoses and access to mental health treatment will

help guide the development of resources to improve care. This report analyzes the data received

through a provider survey. The findings in this report can be used by the local health system,

Jackson Health Network, mental health providers, community mental health agencies, primary

care and specialty providers to help guide the development of resources to improve care at the

practice level.

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Methods

To assess provider training and comfort level, JHN developed a 50 question cross-sectional

design survey for the purpose of obtaining input on issues and challenges that providers

may encounter in treating people with behavioral health diagnoses. The survey was

targeted to 78 primary care physicians (family medicine, internal medicine and pediatrics),

149 specialty care physicians, and 23 midlevel providers (nurse practitioners and physician

assistants) in the JHN from September 24 to November 26, 2014.

The goals of the survey were to identify 1) behavioral health diagnoses that are most

prevalent in the provider’s patient population and resources currently used to manage these

patients, 2) barriers providers face in treating patients with behavioral health diagnoses, and

3) the types of resources providers feel would be most valuable in managing patients with

behavioral health diagnoses.

A blast email to providers was initiated on September 24, 2014 with an embedded link to an

electronic survey. Completion of the survey was also promoted by network provider

servicing specialists during their routine support visits to individual practices. Hard copies

of the survey were also made available upon request, and were entered by JHN staff into the

electronic survey. If providers answered yes to a question about whether they screen for a

given disorder in their practice, follow on questions were posed to them on how they

manage patients with this diagnosis in their practice.

Results

Demographics and Practice Structure

During the approximately 60 day response window, a total of 51 providers completed the

survey for a 20% response rate. Eighty percent of the respondents were physicians (Table

1). Family or general practitioners were the largest group responding (24), with specialists

the second largest response group at 14. Within practice structures, the highest number (17)

of responses received was from small group single specialty practices.

Patient Management

Providers were asked to respond to a series of questions about how behavioral health conditions

are managed at the practice level for both adult and pediatric patients. The questions focused on

whether patients are routinely screened for behavioral health conditions and how patient care is

usually managed. Providers were also asked about the degree of help they might need for

managing each behavioral health diagnosis in their patients, and asked to prioritize the

development of assistive resources for their patient population.

Adult Patients

Forty seven (92%) responding providers indicated that they treat adult patients (Table 1). Three

practices see only pediatric patients.

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Table 1. Number and percentage of providers by type, practice type, practice structure and percent of patients by payment category - Jackson Health Network, Jackson County, Michigan 2014

Variable No. (%)*

Provider Type

Physician 41 (80.4) PA 3 (5.8) NP 5 (9.8) Other 2 (3.9)

Total: 51 (100)

Practice Type Family/GP 24 (47.0) Internal Med 7 (13.7) Pediatricians 3 (5.8) OB/GYN 2 (3.9) Geriatrics 1 (1.9) Specialty 14 (27.4)

Total: 51 (100)

Practice Structure Solo 11 (22.9) Small Group (2-4) single specialty practice 17 (35.4) Large Group (>4) single specialty practice 12 (25.0) Small group (2-4) multi-specialty practice 2 (4.17) Large group (>4) multi-specialty practice 6 (12.5)

Total 48 (100)

Percent of patients by payment category

Commercial 34 (34)

Medicaid 33 (12)

Medicare 33 (28)

Uninsured/self-pay 22 (3)

Other Insurance types 12 (3)

Unsure 14 (21)

Total: (100)

*Total percent may vary from 100 due to rounding.

Among the 42-44 providers who are seeing adult patients that responded to survey questions

about screening, a high proportion are routinely screening patients for minor depression (93%),

major depression (90%), alcohol abuse/misuse (85%), and other substance abuse (76%) (Figure

1). Lower screening levels were observed for anxiety disorder (63%), bipolar disorder (46%),

post-traumatic stress disorder (38%), and attention deficit disorder (33%).

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Figure 1. Physician Management of Adult Patients by Behavioral Health Disorder, Routine Screening Practices - Jackson Health Network, Jackson County, Michigan 2014

The management approaches used with patients varies considerably by behavioral health

diagnosis (Figure 2).

Figure 2. Physician Management of Adult Patients by Behavioral Health Disorder, Percent Usual Management of Patients - Jackson Health Network, Jackson County, Michigan 2014

33

38

46

63

76

85

90

93

0 10 20 30 40 50 60 70 80 90 100

Attention Deficit Disorder

PTSD

Bipolar Disorder

Anxiety Disorder

Other SA

Alcohol Abuse/Misuse

Major Depression

Minor Depression

Percent Screening N=44

18

20

24

29

42

56

78

81

82

80

76

71

58

44

22

19

0 20 40 60 80 100

Other SA

Bipolar Disorder

PTSD

Alcohol Abuse/Misuse

Major Depression

ADD

Minor Depression

Anxiety Disorder

NA, routinelytreat most,ortreat some,refer others

Co-managewith MHP orrefer all toMHP

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Among providers who screen, when non-applicable, routinely treat most myself, and treat some,

refer other responses are combined, providers were very comfortable treating anxiety disorder

(81%) and minor depression (78%) and moderately comfortable treating ADD in the practice

setting. They prefer to manage the treatment of major depression (58%), alcohol abuse/misuse

(71%), PTSD (76%), bipolar disorder (80%), and other substance abuse, 82%) through co-

management or referral to a mental health provider.

Pediatric Patients

Twenty six (56%) providers responded that they treat pediatric patients. Among providers who

are seeing pediatric patients, a majority of providers are routinely screening patients for major

depression (81%), alcohol abuse/misuse (73%), other substance abuse (73%), minor depression

(69%), anxiety disorder (65%), and eating disorders (62%) (Figure 3). In general, screening

rates for these conditions among the pediatric patient population were approximately 10% lower

than screening rates for these matching conditions among adult patients. Lower screening levels

were observed for post-traumatic stress disorder (48%), attention deficit disorder (48%) and

bipolar disorder (23%),

Figure 3. Physician Management of Pediatric Patients by Behavioral Health Disorder, Routine Screening Practices - Jackson Health Network, Jackson County, Michigan 2014

23

48

48

62

65

69

73

73

81

0 10 20 30 40 50 60 70 80 90

Bipolar Disorder

ADD

PTSD

Anxiety Disorder

Eating Disorders

Minor Depression

Alcohol Abuse/Misuse

Other SA

Major Depression

Percent Screening N=26

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The management approaches used with pediatric patients also varied considerably by behavioral

health diagnosis, and were different than approaches used for adult patients (Figure 4). Providers

were comfortable treating pediatric patients themselves at levels of 84% and 48%, respectively,

for attention deficit disorder and minor depression. They were more likely to co-manage or

refer all patients to a mental health provider for treatment of major depression (76% vs. 58%),

anxiety disorder (76% vs. 19%) , and eating disorders (77%) than for adult patients.

Figure 4. Physician Management of Pediatric Patients by Behavioral Health Disorder, Percent Usual Management of Patients - Jackson Health Network, Jackson County, Michigan 2014

Assistance in Managing Behavioral Health Disorders

Adult Patients

All providers, including those who did not report routine screening, were also asked to respond

to questions designed to determine the degree of help they might need to manage behavioral

health diagnoses in their patients. As previously discussed, providers caring for adult patients

seem to be comfortable treating minor depression and anxiety disorders (Figure 5).

However, a majority of providers felt they could use help or definitely needed help to manage

patients for most disorders. Seventy percent of providers could use some help or definitely need

help for attention deficit disorder, 78% for major depression, 81% for PTSD, 85% for other

substance abuse, 86% for alcohol abuse/misuse, and 88% for bipolar disorder.

23

25

24

24

24

31

33

48

84

77

75

76

76

76

69

67

52

16

0 20 40 60 80 100

Eating Disorders

Other SA

Anxiety Disorder

Major Depression

PTSD

Alcohol Abuse/Misuse

Bipolar Disorder

Minor Depression

ADD

NA, routinelytreat mostor treatsome, referothers

Co-managewith MHP orrefer all toMHP

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Figure 5. Percent of Physicians Responding to Degree of Help Needed to Manage Behavioral Health Diagnoses in Adult Patients - Jackson Health Network, Jackson County, Michigan 2014

Pediatric Patients

Similar to providers caring for adult patients, providers caring for pediatric patients also were

comfortable treating minor depression (Figure 6). A strong majority of providers again felt they

could use help or definitely needed help to manage all other disorders, ranging from 59% for

ADD to 100% for eating disorders.

Figure 6. Percent of Physicians Responding to Degree of Help Needed to Manage Behavioral Health Diagnoses in Pediatric Patients - Jackson Health Network, Jackson County, Michigan 2014

12

14

15

19

21

28

45

79

88

86

85

81

79

72

55

21

0 10 20 30 40 50 60 70 80 90 100

Bipolar Disorder

Alcohol Abuse/Misuse

Other SA

PTSD

Major Depression

ADD

Anxiety Disorder

Minor Depression

Don't see, don't or probably don't need help Could use/definitely need help

0

4

4

4

8

8

20

41

64

100

96

96

96

92

92

80

59

36

0 10 20 30 40 50 60 70 80 90 100

Eating Disorders

PTSD

Bipolar Disorder

Major Depression

Other SA

Alcohol Abuse/Misuse

Anxiety Disorder

ADD

Minor Depression

Don't see, don't or probably don't need help Could use/definitely need help

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Limiting Practice, Patient and System Factors

All providers were asked to respond to a series of practice, patient or system factors that might

limit their ability to recognize or successfully treat behavioral health conditions in their adult or

pediatric patient populations. Figures 7 and 8 characterize the responses for all providers

combined for limiting practice or patient factors and system factors, respectively. Providers did

not feel that a lack of training in management of behavioral health problems was a substantial or

severe limitation. When substantial and severe limitation responses were combined, less than

50% of responding providers felt that any of the potential practice or patient factors listed were a

substantial or severe limitation to their ability to recognize or successfully treat behavioral health

conditions in their patient population.

Limiting Practice and Patient Factors

Figure 7. Percent of Physicians Responding to Limiting Practice and Patient Factors for Managing Behavioral Health Diagnoses in Adult and Pediatric Patients - Jackson Health Network, Jackson County, Michigan 2014

Limiting System Factors

When substantial and severe limitation responses were combined, more than 50% of responding

providers felt that system factors involving difficulties in sharing clinical information with

MHPs, complicated or confusing referral systems for BH/mental health care, limited or poor

access to MHPs due to insurance plan restrictions, and lack of availability of mental/behavioral

health professionals were a problem.

53

57

66

73

78

78

82

47

43

34

27

22

22

18

0 10 20 30 40 50 60 70 80 90 100

Patients failing to follow up with ongoing care

Lack of health insurance coverage

Patient reluctance to accept recommended treatment

Patient or family reluctance to accept a BH diagnosis

Poor reimbursement for tx of BH conditions

Lack of training in mgt of BH problems

Medical problems have a higher priority

No, Minor or Moderate Limitation Substantial, Severe Limitation

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Figure 8. Percent of Physicians Responding to Limiting System Factors for Managing Behavioral Health Diagnoses in Adult and Pediatric Patients - Jackson Health Network, Jackson County, Michigan 2014

Prioritizing Resource Development

The Jackson Health Network is committed to providing assistance in managing behavioral health

disorders and addressing limiting practice, patient and system factors. To facilitate achieving

this goal, providers were asked to prioritize resource developments by diagnosed behavioral

health condition that would be most valuable in helping to manage patients. When moderately

high and highest priority were combined, Figure 9 indicates at least 50% of providers treating

adult or pediatric patients would prioritize resource development for eating disorders, PTSD,

major depression, other substance abuse, alcohol abuse/misuse and bipolar disorder.

30

35

44

45

57

72

70

65

56

55

43

28

0 10 20 30 40 50 60 70 80 90 100

Lack of availablility of mental/BH professionals

Limited or poor access to MHPs due to insurance planrestrictions

Complicated or confusing referral systems forBH/mental health care

Difficulties in sharing clinical information with MHPs

Inadequate time to address the problem duringroutine office visits

Problems in prescribing preferred medication(s) due toinsurance plan pharmacy restrictions

No, Minor, Moderate Limitation Substantial, severe limitation

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Figure 9. Percent of Physicians Responding to Prioritization of Resource Development for Managing Behavioral Health Diagnoses in Adult and Pediatric Patients - Jackson Health Network, Jackson County, Michigan 2014

Value of Potential Supports

Providers were also asked in aggregate to respond to the value of potential supports that could be

provided to help manage and treat patients with behavioral health/mental health conditions

(Figure 10). More than 50% of providers rated four key supports as very to extremely helpful.

Figure 10. Percent of Physicians Responding to the Value of Potential Support in Treating Patients with Behavioral Health/Mental Health - Jackson Health Network, Jackson County, Michigan 2014

0 20 40 60 80 100

Bipolar Disorder

Alcohol Abuse/Misuse

Other SA

Major Depression

PTSD

Eating Disorder

Percent

Percent Prioritizing Resource Development Moderate/Highest Priority

PediatricPts

Adult Pts

83

71

70

65

0 10 20 30 40 50 60 70 80 90

Trained Professional (e.g. care manager) toconnect with pts and help with treatment

List of MHPs in area, conditions they treat,insurance accepted

MHP availablity for "curbside consults"

Standard communication tool for informationexchange between providers

Very/Extremely Helpful

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The One Thing of Most Help

Providers were also asked to respond to a final open -ended question: What is the one thing

that you believe would be of most help in providing better care for your patients with

behavioral health/mental health disorders? Thirty four providers responded. Figure 11

captures the top 6 response categories. The top three responses (prompt, and greater access

to, existing mental health professionals; real time access to outpatient psychiatry services;

and more mental health professionals) are consistent with the prioritized order of potential

supports in Figure 10.

Figure 11. Number of Physicians Responding to question What is the One Thing That You Believe Would be of Most Help in Providing Better Care for Your Patients with Behavioral Health/Mental Health Disorders - Jackson Health Network, Jackson County, Michigan 2014

V. Discussion:

The goals of this survey were to identify 1) behavioral health diagnoses that are most

prevalent in the provider’s patient population and resources currently used to manage these

patients, 2) barriers providers face in treating patients with behavioral health diagnoses, and

3) the types of resources providers feel would be most valuable in managing patients with

behavioral health diagnoses.

Questions that would have helped to determine which behavioral health diagnoses were

most prevalent in the provider's patient population were not included in the survey;

therefore a prevalence estimate is not possible. However, data was obtained that

characterized the extent to which screening for behavioral health diagnoses is occurring.

Among providers screening adult and pediatric patients, high screening rates (60% or

2

3

3

5

9

12

0 2 4 6 8 10 12 14

Trained case manger/care coordinator access

Access to inpatient psychiatry services

Increase resources for clients w/o mental healthcoverage, including parity

More MH professionals

Real time access to outpatient psychiatryservices

Prompt, and greater access to, existing MHprofessionals

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higher) were noted for minor and major depression, alcohol abuse/misuse, other substance

abuse, eating disorder, and anxiety disorder. Screening rates were less than 50% for

bipolar disorder, PTSD and attention deficit disorder. The estimated prevalence of these

disorders in the 18 and older adult population in Jackson County within any 12 month

period is 9,749.

Provider routine treatment of most disorders in their practice, or referral of some behavioral

health disorders to others, reflects comfort level and type of patient. Anxiety disorder and

minor depression in adults are effectively treated and managed within the practice setting.

Attention deficit disorder in adults is screened for at significantly lower levels (33%) than

for pediatric patients (84%), and may therefore not be treated as frequently in the practice

setting. Attention deficit disorder is routinely treated and managed by pediatric providers in

the practice setting. Less than half of 26 pediatric providers routinely treat and manage

minor depression in the practice setting. For all other disorders, both adult and pediatric

providers co-manage with a mental health professional or refer all patients to a mental

health professional, and are actively seeking help managing these patients.

All providers were asked to respond to a series of practice, patient or system factors that

might limit their ability to recognize or successfully treat behavioral health conditions in

their adult or pediatric patient populations. Although 47% of providers felt that patients'

failing to follow up with ongoing care was a substantial or severe limitation, all other

factors were well below the 50% level. In contrast, four specific system factors were rated

at 55% or higher as substantial or severe limitations.

A majority (more than 50%) of responding providers prioritized resource development for

six behavioral health disorders. These disorders are consistent with those for which

providers typically co-manage or refer to mental health providers. Providers also ranked

the value of potential supports in treating patients. Standard communication tools, curbside

consults, a list of MHPs in the area, and care managers are highly valued supports. These

are also consistent with the top listed things that providers feel would be of most help in

providing better care to their patients.

VI. Conclusions and Recommendations:

Screening

Given the estimated burden of mental illness in the community for bipolar disorder,

PTSD and attention deficit disorder, implement screening tools or evaluation of existing

screening tools used to screen for these disorders.

Treatment and Management

Develop tools that support the treatment and management of disorders and address the

high value supports identified in Figures 9 and 10 to facilitate successful health care

provider co-management and referral to MHPs for further behavioral health diagnosis,

evaluation, and treatment.

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Facilitate the implementation of system supports to address the list of those things that

would be most helpful to providers identified in Figure 11.

a. Define the identified valuable resources and prioritize development.

b. Launch a behavioral health provider survey in spring 2015, and initiate qualitative

interviews of community members to learn about their experience with the system in

spring-summer 2015.

c. Work with the Health Improvement Organization’s Behavioral Health Action Team,

and the major behavioral health providers (Allegiance Health Behavioral Health and

Lifeways) to create more options for support that are consistent with population

management, such as curbside consults, one-time visits, a care management support

program and, a list of MHPs in the area.

VII. Limitations

The results of this survey are only generalizable to the primary and specialty health care

providers of the Jackson Health Network.

The overall number of respondents (51 or 20%) is a limiting factor in this cross sectional study.

In addition, the conclusions drawn from smaller samples within the study, such as the number of

providers who provide care to pediatric patients are limiting. However, most pediatric providers

of care were also adult providers of care and their survey responses were similar in nature for the

same questions of either patient population.

Specialty care and mid-level provider representation in the survey was low compared to the

number of known specialists (149) and mid-level providers (23) in the community. The low

number of respondents prevented any additional analyses at the type of provider level.

VIII. Acknowledgments

The authors gratefully acknowledge the significant contribution made to the development,

fielding, distribution, collection and entry of the survey by Paula Pheley, RN, MPIA, Clinical

Program Manager, and Laurie Tarpley and Stephanie Longwell-Hickson, Provider Servicing

Specialists, Jackson Health Network.

IX. Bibliography

1. Department of Health and Human Serivces, U.S. Mental Health. A Report of the Surgeon Genral. U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health. Rockville, MD : National Institute of Mental Health, 1999.

2. Kessler, RC and Chiu WT, Demler O, Walters EE. Prevalnce, severity and co-morbidity of 12-month DSM-IV disorders in the National Co-morbiity Survey Replications. s.l. : Arch Gen Psychiatry, 2005. pp. 62:617-627.

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3. Murray, CJL and AD., Lopez. The Global Burden of Disease: A Comprehensive Assessment of Mortality and Disability from Diseases, Injuries, and Risk Factors in 1990 and Projected to 2020. Geneva, Switzerland : World Health Organization, 1996.

4. Chapman DS, Perry GS and TW, Strine. The vital link between chronic disease and depressive disorders. Prev Chronic Dis, 2005;2(1). p. A14.