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Improving Outcomes for Persons with Co-Occurring Developmental Disability and Mental Illness

Prevelance of co-occurring DD, MI and related conditions, survey results on screening/assessment

Josh Hagedorn

on 24 April 2012

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Transcript of Improving Outcomes for Persons with Co-Occurring Developmental Disability and Mental Illness

Prevalence: People are: Complex unique mysterious irreducible beautiful 296.80
disorder "How common is co-occurring MI/DD?" Myrbakk E, von Tetzchner S. Am J Ment Retard. 2008; 113(1): 54-70. A strong relationship between behavior problems and psychiatric disorders. Participants with mild and moderate ID were more likely to show symptoms of psychosis and depression than those with severe and profound ID People with intellectual and/or developmental disabilities are 3-5 times more likely than those without to have psychiatric disorders. Around 40% of people with intellectual or developmental disabilities have a co-occurring mental illness. Review of multiple abstracts Russell AT, Hahn JE, and Hayward K. “Psychiatric Services for Individuals with Intellectual and Developmental Disabilities: Medication Management.” J of Mental Health Research in Intellectual Disabilities, (2011) 4:4, 265-289. Dual DD MI * * Approximate number of unique persons served in Michigan public health system, after reconciling disability designation with sample encounter diagnoses. (32,731) (25,043) (162,832) Service Use: "What types of services do people use?" Characteristics: "What are the most common conditions?" Among the MI/DD disability designation sample, the following diagnoses were most common:
bipolar/mood disorders (27%, 1159)
psychotic disorders (23%, 985)
depressive disorders (21%, 866)
anxiety disorders (12%, 494).

Collectively, these account for 83% of the diagnoses within the sample data. System Survey: "What is the current state of the public health system?" Screening: Recommended Practices Assessment: Recommended Practices and Tools changing BP = 146/98 mmHg 319.00
disabilities 278.00 Obesity 250.8 Diabetes with other specified manifestations V60 Housing, household and economic circumstances V62 Other psychosocial circumstances BMI = 34 LDL = 171 mg/dL 338.2 Chronic Pain Process 35% of respondents indicated that they did not have a standard procedure for follow-up when a screen identifies the presence of possible conditions. Once a person is receiving service, over 30% of respondents did not have a defined process to identify/respond to new symptoms that might suggest co-occurring conditions. Nearly 30% of respondents do not have a written process for screening/ identification of co-occurring MI/DD. Access Presence of co-occurring conditions was perceived to decrease access to the following services:
psychiatric hospitalization
peer supports
outpatient services
family psychoeducation
crisis residential
assertive community treatment (ACT) Tools From a 11/2011 web-based survey of Michigan’s 46 CMHSPs. 37 of the 46 CMHSPs responded to the survey. Most commonly used:
“Other” (primarily locally-designed tools). Multiple respondents identified level-of-care determination tools being used for screening and assessment, though these tools are not typically intended for clinical use. Over 40% do not believe that the tools they use adequately identify co-occurring conditions. 995.20 Adverse effect of drug MI MI/DD Inpatient Days per 1,000 Population, 2009 State psychiatric hospital Community psychiatric hospital DD 1,034.2 1,239.8 763.9 806.4 537.1 139.4 As a point of reference, consider that medical hospital use during 2009 in Michigan measured 635 inpatient days per 1,000 served for the general population (Kaiser Health Facts). Prevalence Characteristics System Survey Service Use Screening Assessment ? ? How many of these conditions can change? Schizophrenia
(CGI-SCH©) 5-item tool (using SI category only)
5 symptom domains (positive, negative, depressive, cognitive and global) evaluated using a 7-point scale.
Used in multiple studies, including Worldwide-Schizophrenia Outpatient Health Outcomes (W-SOHO).
Linear relationship to the BPRS and PANSS.
Used in clinical effectiveness trials for multiple medications Social Functioning
SLOF Personal and Social Performance Scale (PSP)
Four domains collapsed into a single score.
A difference of eight points can be classified as a clinically relevant difference.
Describes the course of treatment of patients in the short, medium and long term.
Primarily tested with schizophrenia, but also used with organic, neurotic, affective and personality disorders, as well as developmental disabilities.
Good inter-rater reliability even with nonmedical personnel.
Used in clinical trials for Invega (paliperidone) *Morosini P., Magliano L., Brambilla L., Ugolini S., Pioli R. (2000) Development, reliability and acceptability of a new version of the DSM-IV Social and Occupational Functioning Assessment Scale (SOFAS) to assess routine social functioning. Acta Psychiatrica Scandinavica, 101: 1-7.
Additional Versions:
(MoCA©) Montreal Cognitive Assessment (MoCA)
11-item tool
Screening instrument for mild cognitive dysfunction, Alzheimer’s, Huntington’s, Parkinson’s.
Assesses cognitive domains: attention and concentration, executive functions, memory, language, visuoconstructional skills, conceptual thinking, calculations, and orientation.
Time to administer: approximately 10 minutes. ?
CGI-BP© Clinical Global Impressions-Bipolar (Severity Index)
3-item tool (3 scales: depressive, manic, overall)
Proposed for use in DSM-V We are here Understanding... Improving understanding What next? Nora Barkey Josh Hagedorn Andrea Sarto Current: Quality Improvement and Planning BHDDA
Led implementation for 19 million dollar pilot of Michigan’s Long Term Care Connection sites.  
Previous experience
Area Agency on Aging of Western Michigan: Contract coordinator and project director
Creating Community for a Lifetime.  
Long term care ombudsperson
Congressional office a social worker and has a degree in Public Affairs from Wayne State University.
Director of Informatics for Hope Network, a statewide provider of services for people with mental illness, developmental disabilities, substance use disorders and traumatic brain injury.
Formatting data and workflows for clinical use, including automated performance measures.
National Council's Psychiatric Leadership Program to map of metabolic monitoring process for second-generation antipsychotics..
Contributing member of the Performance Measurement Workgroup for MDCH's Integrated Care for Dual Eligibles project
Developing an adaptive suite of brief, researched tools for cross-dimensional assessment. 34 years of experience in field of developmental disabilities.
Current: North Country Community Mental Health Program Director for Persons with Developmental Disabilities with responsibility over all services provided which includes individuals that present with co-occurring conditions of a mental illness and a developmental disability.
Plymouth Center for Human Development Northville Residential Training Center
Alpine Center as psychologist. Recovery Self-directed Cost of Care Cost Data: Multimorbidity Patterns Annual Hospitalization Rate Per Capita DD
+ Antipsychotic/mood stabilizer
+ Anxiety disorder/benzodiazepam
+ Depressive disorders
+ Schizophrenia DD
+ Antipsychotic/mood stabilizer
+ Depressive disorders
+ Schizophrenia DD
+ Antipsychotic/mood stabilizer
+ Anxiety disorder/benzodiazepam
+ Depressive disorders DD
+ Schizophrenia DD
+ Gastrointestinal bleed
+ Schizophrenia High-Cost Prevalence, % Very
High-Cost Prevalence, % 1.85 0.79 0.54 0.41 0.48 49% 47% 40% 35% 33% Pattern 23% 11% 7% 5% 8% The proportion of beneficiaries with this specific multimorbidity pattern who are represented among beneficiaries in the top 5.01st to 20th percentile of costs in the overall population of Medicaid-only adult beneficiaries with disabilities. The proportion of beneficiaries with this specific multimorbidity pattern who are represented among beneficiaries in the top 1st to 5th percentile of costs in the overall population of Medicaid-only adult beneficiaries with disabilities. Function Social Cognitive Symptoms Psychiatric Physical Mood Thought Engagement Biomarkers Side Effects Domains Presenters Processes should:
(1) allow time for conversation,
(2) support informed choice
(3) be adaptable to change.
Individuals reported improvements in feeling good about self, getting on the right medications,
Consistently individuals reported a desire to be asked and to be provided answers to their questions. Why measure? Provide technical guidance and assistance to promote and support use of a limited number of common standardized screening tools that will assist in identification of individuals with co-occurring DD/MI.
Develop process measures to identify inconsistency or gaps in screening and support and participate in related cross system quality improvement activities. MDCH Map clinical pathways that outline responses to positive screen, define responsibility for communication and follow-up regarding all risks/conditions identified as part of the intake process across relevant providers (e.g. access, specialty providers, and physical health care, residential and other relevant providers)
Implement practices so staffs who work primarily with persons with a primary diagnosis of MI and those who work primarily with persons with a developmental disability have access to expertise needed to address the needs of persons with a co-occurring diagnosis. PIHP/CMHSP Systemic Practices Materials: Improving Outcomes for Persons with Co-Occurring Developmental Disability and Mental Illness Survey: Focus Groups: Screening Practices Rationale: Prevalence and Ability to Treat

• Based on prevalence rates, impact and available treatments for depression the workgroup recommends routine screening for depression in all individuals with intellectual disabilities.

• Based on the prevalence of anxiety and trauma the workgroup recommends routine screening for anxiety, including trauma-related disorders (e.g. ASD, PTSD, etc.) for all propulations.

• Based on prevalence of dementia for those with ID the work group recommends a screen on the behaviorscreening of individuals at risk or suspected of evidencing changes associated with cognitive or functional decline. Provide technical guidance and assistance to promote and support use of a limited number of common standardized assessment tools that will assist in identification of co-occurring MI/DD and for use in the person centered planning process
Support efforts to increase communication and information sharing related to co-occurring mental illness and developmental disabilities across the provider types and systems. Support efforts to build efficiencies and communication through the adoption of common terminology, tools and data elements. MDCH Develop communication and practices to support an assessment process that provides information that is useful to making informed choices through the person centered planning process.
Provide for a comprehensive assessment process, which emphasizes the importance of working with individual, their chosen allies and support networks.
Review and adopt assessment tools that are in common with system practice , are standardized and that will assist in identification of individuals with co-occurring DD/MI PIHP/CMHSP Practices Trauma Behavioral Substance Use A recent study found that, after implementing similar tools, providers:
almost always used the information in the assessments,
found consumer-reported data useful,
highly recommended continued use of the tools Useful Zubkoff, et al. (2012) Usefulness of Symptom Feedback to Providers in an Integrated Primary Care-Mental Health Care Clinic. Psychiatric Services 63:91–93. Measurement is based on an intrinsic belief that change is possible.
Accurate diagnosis can increase access to evidence-based practices and personalize treatment
It can help make treatment goal-oriented
Changes in measurement highlight improvements and challenges for people receiving services Believe in Change Using multiple measurement domains provides a more complex, nuanced view of the person and can incorporate multiple perspectives:
Personal Perspective (Self-reported)
Direct Caregivers
Care Coordinators
Physicians Holistic Tools Function Social Cognitive Symptoms Psychiatric Physical Mood Thought Engagement Biomarkers Side Effects Trauma Behavioral Substance Use Symptoms Function Engagement Trauma Depression
PHQ-9© 9-items, widely used
Validated interview process - screens for both presence & frequency of depression symptoms
Provides a standardized severity & rating score
Important to identify signs & symptoms, causes & contributing factors as they are often treatable
Identify interventions and ensure safety Kroenke K, Spitzer RL, Psychiatric Annals 2002; 32:509-521 7-item screening and severity measure for generalized anxiety disorder
Identified cutpoints for mild, moderate, and severe anxiety, respectively.
Useful with various anxiety disorders – panic disorder, social anxiety disorder, and post-traumatic stress disorder.
When screening for anxiety disorders, a recommended cutpoint for further evaluation is a score of 10 or greater. Anxiety
GAD-7© PAS-ADD Aman, M., Burrow, W., Wolfrod, P. (1995). The ABC-Community: factor validity and effect of subject variables for adults in group homes. American Journal of Mental Retardation: 100 (3). 283-292. Aberrant Behavior
(ABC) Hsu, S., Fernhall, B., Hui, S., Halle, J. (2011). Psychosocial factors of stages of change among adults with intellectual disabilities. Intellectual and Developmental Disabilities: 49(1). 14-25. Davidson, L., Roe, D., Andres-Hyman, R., Ridgway, P. (2010). Applying stages of change models to recovery from serious mental illness: contributions and limitations. Isr. J. Psychiatry Relat. Sci.: 47 (3). 213-221. Stage of Change Moderate length, allowing for semi-frequent administration (e.g. q 90 days)
Easy to administer and score. Can be completed by family, direct care workers, etc.
Consumer and informant versions allow for administration with various degrees of functioning.
Items relate to specific services (i.e. CLS) Validating the measurement of real-world functional outcomes: phase I results of the VALERO study. Harvey PD, Raykov T, Twamley EW, Vella L, Heaton RK, Patterson TL. Am J Psychiatry. 2011 Nov 1;168(11):1195-201. Epub 2011 May 15. PSP© Multiple Domains http://ddi.wayne.edu/DDMI.php Symptom checklist for assessing problem behaviors in individuals ages 6-54 with mental retardation.
58 items, 10 – 15 minutes to complete.
5 subscales: a) Irritability and Agitation b) Lethargy and Social Withdrawal c) Stereotypic Behavior d) Hyperactivity and Noncompliance and e) Inappropriate Speech.
A sound measure of non-diagnostic or associated features of Autism Spectrum Disorder (Brinkley et al., 2006). Using the Information: Using Information Resources: Resources MI Silo DD Silo Case Management Supports Coordination Competencies
Pathways to Service
Person-Centered Goals Adopt validated tools
Train paraprofessional employees
Implement relevant clinical guidelines Clinical Staff Board Promote use of standardized screening and assessment tools and processes
Build community support for capacity building
Support efforts for meaningful use of EHR
Support increased communication and integration of MI, DD and acute care. Directors Share/implement recommendations
Incorporate competency needed into hiring, training and team approaches
Work with education/policymakers if shortage of skills needed Contact Info: BarkeyN@michigan.gov jhagedorn@hopenetwork.org asarto@norcocmh.org Questions? Bipolar/Mood
Disorders Schizophrenia/
Psychosis Depressive Disorders Anxiety Disorders Impulse Control Disorders Adjustment Disorders Personality Disorders Listening, observing & documenting
Participation in person-centered planning process
Key informant Direct Care Checklist (25 items) and Informant Inverview versions
Multiple scales: depressive, anxiety, hypo/mania, OCD, psychosis, unspecified, ASD
Widely used in intellectual disability mental health
Includes "Life Event Checklist" http://tinyurl.com/7urcr6d Presentation:
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