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Report from the Chairs
Penny Knapp, M.D. & Barry Handon, M.D.
We are pleased to see that CalMEND continues to expand, refine and disseminate successful models of mental health care—consistent with MHSA goals while fostering interagency collaborations that include data-sharing between DHCS and DMH and gap analysis of reimbursement for services. CalMEND’s efforts to transform care by combining evidence-driven pharmacotherapy and non-medical treatment, as well as identifying opportunities for clinically appropriate cost-containment in the use of new generation antipsychotic medications are very promising.
The recently completed alpha version of the Clinical Guide successfully adapts established illness management strategies to persons with mental disorders. Along with this, we are working to identify anchor points for quality improvement of clinical care, as well as key outcomes by which to monitor improvement efforts. We are also developing decision aids to assist clients and providers—the first will focus on the use of antipsychotic medications as part of an overall recovery plan.Research is also part of the CalMEND agenda: In partnership with UC Berkeley, we are supporting pharmaco-economic studies on health status and severe mental illness, while research at UCLA is focused on safety factors in child and adolescent pharmacotherapy of children. CalMEND will be presenting a symposium at the May 2008 meeting of the American Psychiatric Association that will showcase our work to date on shared decision-making models, performance improvement projects to reduce inappropriate antipsychotic polypharmacy, decision aid development, and the inclusion of both family support and evidence-based practices in treatment for children and adolescents.
Project Highlights
Karin Kalk, CalMEND Project Manager
Probably the most frequently asked question about CalMEND is “what the heck is it?” – which is not surprising, given its name is not an immediately obvious acronym and the nature of its charge is perhaps different than many projects sponsored by either DMH or DHCS, or supported by CiMH. The quick answer is “CalMEND is a project to develop a care model that will better serve individuals with mental illness.” However, this rarely suffices to explain what CalMEND is actually producing or why it exists – particularly because the reference to a “care model” is fairly vague and doesn’t readily translate into the every day work of mental health agencies. So here’s an overview of what we mean when we reference “care model.”
Early in the CalMEND project, we identified Wagner’s “Chronic Care Model” as a good framework for our effort. With some minor modifications to better to suit the mental health care field, this model very clearly illustrates that improved outcomes result from productive interactions between clients and providers.
To routinely and reliably bring about this hopeful partnership, Wagner also identified four very important components:
Self-Management: Consumers must have a central role in determining their recovery, one that fosters a sense of responsibility for their own well being.
Decision Support: Decisions about supports and services should as much as possible be informed by available evidence as well as with sensitivity to issues of culture and personal preference.
Delivery System Design: Providing service and supports effectively needs to consider roles and tasks to ensure the individual and family receive what they want in the way they prefer.
Clinical Information System: An information system should serve consumer, family and provider needs.The term “care model” encompasses all the processes, practices, and other supports that are called for in these four components.
Over time, CalMEND aims to provide detailed descriptions, practical strategies and user-friendly tools to help mental health policy makers and care agencies better design and operate their service delivery system, enhance support of self-management, adopt meaningful decision supports, and participate in the development of an integrated information system.
Health Economics Analysis May Lead to Better Care
Cheryl Cashin, PhD
There is overwhelming evidence that individuals with serious mental illness (SMI) have higher rates of physical illness and reduced life expectancy compared with the general population. The complex psychological, social, and physical impacts of SMI often lead to multiple co-occurring chronic conditions, such as diabetes and cardiovascular disease. Individuals with SMI also may have poor access to primary health care or receive care that is fragmented or not adapted to their particular needs. Untreated medical conditions result in lower quality of life, barriers to recovery, and overuse of more costly health care services.
To understand the scope of this in California, CalMEND is conducting a study of Medi-Cal claims to identify inefficiencies related to inappropriate or fragmented care for individuals with SMI. Preliminary results suggest that individuals with SMI have more than a 30% increase in the chance of being hospitalized for an acute physical health problem each year, even compared to a high-need population of disabled beneficiaries. Poor management of specific chronic conditions, such as diabetes, may be largely to blame. Preliminary estimates suggest that individuals with SMI have more than a 50% increase in the chance of being hospitalized for avoidable complications of diabetes, which is further evidenced in the nearly double per capita Medi-Cal costs.
There are also significant ethnic and gender differences. In particular, Latino females appear to be most vulnerable to the impact of SMI on potentially avoidable hospitalization for physical health problems overall, and African American women with SMI have the highest rates of hospitalization for avoidable diabetes complications. Further research will estimate the potential cost savings that could be achieved through better integrated care for individuals with SMI, making the economic case for intervention.
Transforming Care to Promote Wellness and Recovery
Neal Adams, MD, MPH
In January, following many months of work, the CalMEND Clinical Practice Subcommittee released the “alpha” draft of the Guide for Person-Centered Mental Health Services and Supports: Transforming Care to Promote Wellness and Recovery. Copies of the guide are available for review and comment at www.CalMEND.org. Forms for providing feedback and suggestions are also available.
This first full iteration of the guide reflects the best thinking of consumers, family members, providers, policy makers and other stakeholders about how best to organize a recovery-oriented service delivery system. It is an alpha version because it is a working draft that is ready for review--but not yet ready for implementation. The “beta” version will be created based on input from mental health providers and service recipients on how best to operationalize the CalMEND model.
We believe that many providers have had considerable experience with components of the process map and shared decision-making in a recovery framework, and so we do not want to “reinvent the wheel.” Rather, we want to build on existing proven and promising practices to improve the service system. To do this, we are calling for nominations of current practices and programs that can bring to life the CalMEND vision articulated in the guide.We encourage everyone to review these important CalMEND works-in-progress and to contribute your ideas and energy to making CalMEND a truly effective partner in system transformation.
Defining CalMEND’s Principles
Steve Leoni & Lea Nagy, on behalf of CalMEND’s Client and Family Members
A major strength of CalMEND is the inclusion of Client and Family Member viewpoints and expertise. Early on, CalMEND decided to define a set of philosophies and principles from these viewpoints to help guide and inform our work. Beginning with elements of SAMHSA's Consensus Statement on Mental Health Recovery, the definitions grew through many discussions into a larger document based - at its heart - on experiential knowledge and the accumulated understandings of our communities.
A draft of this document is now complete. In addition, slightly adapted versions of individual philosophies and principles have been incorporated as "verbal illustrations" in the recently completed Alpha version of the CalMEND Guide for Person-Centered Mental Health Services and Supports.
Here is one example from the definition of “Harmony:”
Harmony can be described as a state of spiritual, physical, communal and emotional balance for the individual, his/her family and community. This state of being can foster health, wellbeing, purpose and recovery.
Medication Therapy Management Teri Miller, PharmD and Pauline Chan, RPh
Pharmacists currently provide medication therapy management (MTM) services in a wide variety of clinical settings such as hypertension, anticoagulation, pharmacist-managed diabetic care and HIV clinics, to name a few. Drawing upon these successful approaches, CalMEND plans to pilot a program where pharmacists, working as an integral part of the client’s recovery team, foster the development of patient-centered, well-managed medication regimens through education, shared decision-making and self-care, ultimately leading to wellness and recovery.
MTM is a health service provided by a qualified health care provider - such as a pharmacist - to help clients and/or caregivers optimize the benefits of medication, minimize risks associated with medication use and maximize the cost-effectiveness of medication therapy. Ideally, MTM services are conducted one-on-one and face-to-face between client and health care provider.Clients benefit from MTM through: opportunities to address safe medication practices; promotion of appropriate use of medication through education and use of decision support tools; provision of continuous medication service during transitions of care; and promotion of coordination and continuity of physical and mental health care and related medication use.
MTM services provide a client with useful tools to get the most effective and safe results from medications by promoting collaboration with an individual’s family or caregiver of choice, psychiatrists, primary care physicians, pharmacists, and other health care providers, .
Integrating Care through Health Information Exchange
Julie Cheung, MPH
In recognition of the need to improve the quality of care provided to individuals with mental illness, policy makers around the country have turned their focus to integrative models of care. Unlike today’s health care system that separates the treatment of mental illness (“the head”) from physical illness (“the body”), an integrative care model is built upon a holistic philosophy that an individual’s physical and mental health care needs are interdependent and therefore must be addressed in a manner that enables the coordination of health care services. Although there are varying degrees of integration - from the fully integrated primary care setting to independent services that share health care data - all models of integrated health are intended to address the “wholeness” of the individual, rather than the body part or disease condition.
CalMEND has embarked on a mission to advance integrative care by facilitating the exchange of health information to support clinical decision-making. Last fall, we introduced the CalMEND Collaborative PIP undertaken by the Department of Health Care Services and county mental health plans to improve the efficiency and efficacy of medication use. By providing participating counties with utilization data specific to antipsychotic medications, the mental health plans have already identified opportunities to improve medication management, promote patient safety, and improve monitoring for metabolic disorders.
Building upon the success of this first venture, CalMEND is now exploring the feasibility of supporting the exchange of data between providers in the mental health community and primary care settings. CalMEND will spearhead a series of discussions with consumers, providers, and policy makers to investigate the legal, technological, and ethical issues surrounding the sharing of health care information. With an aim to develop operational strategies, CalMEND intends to identify practices that enable the systemic integration of health care services while preserving individuals’ rights of privacy and confidentiality.
Emergency Help:
If you or someone you know is facing a life-threatening emergency, please call 9-1-1.24-Hour Suicide Prevention Hotline 1-800-273-TALK
(1-800-273-8255)
http://www.suicidepreventionlifeline.org/For services and programs offered by the public mental health system:
http://www.dmh.ca.gov/Services_and_Programs/default.aspTo apply for Medi-Cal or contact your local county office:
http://www.dhcs.ca.gov/services/medi-Cal/Pages/CountyOffices.aspxFor assistance with your Medi-Cal mental health services:
http://www.dmh.cahwnet.gov/Ombudsman_Services/default.asp
