Ron Geraty, MD

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	Today, there is increasing recognition of the need to address social and behavioral determinants of health to improve outcomes. Yet for members with chronic conditions, a behavioral health approach to care management often is lacking-and that’s a missed opportunity to improve value and outcomes.

	We know that members with behavioral health issues have higher-than-average rates of emergency department (ED) visits, hospitalizations and readmissions. That’s one reason why efforts to target high-risk populations with proactive, personalized care management have begun to include behavioral health components in recent years.

	But for those with chronic conditions-not just the typical Core 5 conditions of coronary artery disease, chronic obstructive pulmonary disease, heart failure, diabetes and asthma-the approach to care management still is largely focused on condition-specific regimens. This simplistic approach to care management often fails to consider behavioral health issues that can interfere with members’ ability to comply with their treatment plans or that exacerbate their health conditions.

	The result: members’ health status does not improve, leading to continued high utilization-including increased use of emergency care-and difficulties managing health effectively.

	When we treat chronic conditions by focusing exclusively on the medical components of these conditions, we miss one-third of the contributing costs and contributing factors.

	What is needed is an integrated approach to care management, one that seeks to incorporate behavioral health management into a comprehensive care plan based on the patient’s individual health needs.

	One-third of the conditions identified by the Institute of Medicine as having a significant impact on the nation’s economy are or include behavioral health disorders. Together, these nine conditions-arthritis, cancer survivorship, chronic pain, dementia, depression, type 2 diabetes, post-traumatic disabling conditions, schizophrenia, and vision and hearing loss-account for billions of dollars in healthcare spending annually. Understanding the ways in which behavioral health impacts physical health, particularly for members with chronic illness, is critical to achieving the Triple Aim: improving health outcomes, reducing costs, and boosting member satisfaction.

	Here are four of the top benefits of incorporating behavioral health management into care management plans for members with chronic conditions.

. Consider a patient with Crohn’s disease. Roughly 

one-third of chronic disease patients who end up in the ED

 are there not because they aren’t taking their medications or following their treatment plan, but because a behavioral health issue, such as depression or anxiety, has exacerbated their condition. But when a member who has Crohn’s disease presents with debilitating abdominal pain in the ED, the focus often is centered on evaluating the physical cause of pain, such as a flare up; identifying causes that require urgent or emergency intervention; and relieving or controlling the member’s pain.

	When we don’t consider the root-cause or antecedent behavioral factors that have exacerbated a Crohn’s patient’s physical condition, such as anxiety related to workload or relationships, medical treatment alone is unlikely to keep that patient from returning to the ED. This hinders the ability of payers and other risk-bearing entities to execute interventions that will simultaneously improve the member’s health and the organization’s bottom line.

	On the other hand, when care managers screen for behavioral health conditions that could prompt a flare up in members with Crohn’s disease and direct members to the appropriate resources for managing their behavioral health condition, physical symptoms of disease are better controlled, and quality of life improves dramatically.

More effective, personalized interventions

. Studies have shown that when members with chronic disease suffer from depression, there is an impact on the 

occurrence, treatment and outcome of their disease

, including heart disease, diabetes, hypertension, cancer and obesity. When we focus on the member’s complaint rather than seeking the underlying determinant of the reason for their visit, we miss the opportunity for a more effective, personalized intervention that can improve health outcomes while reducing costs.

	One of the best examples of organizations that are personalizing interventions for members with chronic disease is the Cleveland Clinic. For example, its Center for Functional Medicine asks patients to complete a 28-page questionnaire that takes into account not only the member’s medical, personal and family history, but also psychosocial, diet and lifestyle factors that could impact the ability to effectively manage chronic illness. Teams of caregivers take the time to listen to members to gain a total health view, including behavioral or mood-related issues that have the potential to aggravate chronic conditions if such issues are not also addressed. The result: a 50% to 70% drop in Patient Reported Outcomes Measurement Information System scores from initial visit to follow up.

	Researchers at the University of Rochester are pioneers in the study of the behavioral health impact on chronic illness. For example, researchers there were the first to study the health status of foster children in the United States. In 2006, they found that 30% of young foster children had chronic conditions such as asthma, failure to thrive, obesity and severe allergies. Based on these findings, the University of Rochester created a pediatric foster care clinic to meet the integrated health needs of children in foster care-and not only improved the overall health of these children, but also increased stability for these children by providing support for foster families and increasing communication among child welfare, family court and health professionals.

	Innovative companies also are shifting from a medical nurse model to a multidisciplinary approach, gleaning data from multiple sources around social and behavioral determinants of members’ health rather than relying predominantly on claims and pharmacy data.

Improved member engagement and satisfaction

. When members feel understood and appreciated, they are more likely to be engaged in managing their health. Yet a 2016 

 found that half of patients with chronic disease who were surveyed believe payers don’t engage them enough in chronic disease management. What are the implications of a lack of communication when members with chronic conditions are struggling not only with managing a chronic illness, but also the impact of behavioral health issues for which they haven’t received support? This is an instance where an integrated approach to care management is critical to member engagement, satisfaction and better health outcomes-and reduced costs.

	Consider that 50% of those diagnosed with mental illness in the United States will deal with this illness for the rest of their lives, according to the American Public Health Association (APHA). That’s nearly double the lifetime prevalence rate for mental illness in other developed nations, the APHA said in a November 2014 

, and it requires “an urgent and explicit public health response.”

	When payers and other risk-bearing entities take an integrated approach to managing chronic illness in members-one that incorporates behavioral health components-members are more likely to view these entities as partners in care. Engaging care supporters, such as family members, is also critical and has a significant impact on the ability to achieve positive outcomes through integrated care management.

. Research supports the need for a behavioral health component within chronic disease care management to improve health outcomes. For example, depression is associated with a 

	Often with chronic disease, it’s difficult to know which came first: the depression or the disease. Managing both is critical to improving health outcomes. For example, at Kaiser Permanente, a collaborative model that combines members’ diabetes and cardiovascular treatment with behavioral health treatment has reduced depression while lowering members’ glucose and blood pressure numbers.

	An integrated approach to chronic disease management is most successful when it incorporates data analytics to determine the social and behavioral determinants of health and their intricate interplay with chronic disease. This is an area where payers and healthcare organizations have made great strides in the past few years-but there is still the opportunity to do much better. Accessing data around behavioral components of health and using this data to develop personalized interventions should be an area of strategic focus for all care management programs.

Articles

Here are four of the top benefits of incorporating behavioral health management into care management plans for members with chronic conditions.

Ron Geraty, MD

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How to target high-risk populations with behavioral health