State Mental Health Policy: Physical Health Screening in State Mental Health Clinics: The New York Health Indicators Initiative

A recent study of adults with serious mental illnesses who received care in the public mental health sector revealed that, on average, these consumers die 25 years earlier than the general population ( 1 , 2 ). Although they are subject to the same diseases that affect the general population, including heart and vascular disease, diabetes, and cancer, the key difference is that these individuals get sick earlier and die far sooner. Poor diet, sedentary lifestyle, smoking, and lack of preventive health care all appear to contribute to this increased risk of early death, as do some of the medications prescribed for mental illnesses.

To improve the quality and duration of life for mental health consumers in New York State, the New York State Office of Mental Health (NYS OMH) implemented a variety of wellness programs in OMH outpatient clinics. To be effective, these programs require regular monitoring of specified health indicators. Underlying the NYS OMH outpatient health indicators initiative is the goal of enabling consumers to better understand their health and well-being, join with their health care providers in improving their health, and track their status and improvements through the use of these measures. Our premise was that what gets measured gets managed.

On January 20, 2009, NYS OMH mandated that all 66 OMH-run adult outpatient clinics (not including community not-for-profit clinics), which provide care to an estimated 15,000 unique patients, begin monitoring three health indicators at three-month intervals for all adult patients (a separate project was undertaken for youths but is not the subject of this column). The three indicators are body mass index (BMI), blood pressure, and smoking status. They were selected because they are robust measures of health and predictors of risk; are understandable by consumers, families, clinicians, and policy makers; and can be feasibly obtained at a mental health clinic without reliance on other caregivers or laboratory reports. The more comprehensive recommendations made by the National Association of State Mental Health Program Directors were not adopted at the outset of this initiative and will be considered as a next step after these three measures are successfully achieved ( 3 ).

Although these three indicators are both important and understandable, reliably collecting data and responding to the results require considerable attention, determination, and collaboration among consumers (and at times their families), physicians, nurses, information technology offices, and quality improvement personnel. This column outlines the process by which NYS OMH undertook this initiative. It also describes the notable uptake by clinics after only four months.

The implementation effort

This initiative required significant organization and administrative support and was orchestrated through the Office of the Medical Director, with the strong support of the commissioner and in conjunction with the Division of Mental Health Services Policy and Research at NYS Psychiatric Institute-Columbia Department of Psychiatry. To move this initiative forward, a workgroup consisting of the OMH medical director, the OMH medical director of adult services, representatives from the OMH Office of Performance Measurement and Evaluation, personnel from the OMH Information Technology Department, and researchers met monthly. Implementation efforts were focused on five main areas: defining the scope of the population; providing necessary medical equipment; using an electronic database; defining, measuring, and monitoring the three health indicators; and providing support to the participating clinics by establishing a learning collaborative.

First, our workgroup found that it was important to exactly specify the target patient population for this initiative, so that it could coordinate and focus our implementation strategy. Second, to ensure that lack of equipment would not be an impediment to the initiative, NYS OMH purchased scales (with a capacity of more than 450 pounds) and sphygmomanometers (with varied cuff sizes) for clinics that needed them.

Third, clinics were mandated to record data for the three indicators into a newly constructed Metabolic Monitoring Tool (MMT), which was incorporated into the NYS OMH digital record system. Training sessions for this tool were provided in January 2009 at the time of the implementation and twice thereafter. Fourth, OMH Central Office, with the assistance of the New York State Psychiatric Institute, developed definitions for each indicator, including a critical value for blood pressure, and suggested means of acquiring them. [The definitions are included in an online supplement to this column at ps.psychiatryonline.org .] In addition, the clinical directors overseeing each of these clinics were provided performance graphs that measured adoption. The information gathered in the graphs was disseminated monthly and reviewed quarterly in a group that included the OMH medical director and other OMH clinical leadership. These summary reports showed the rates of capture of information for each of the three measures by facility, as well as the values of the measures themselves. Facilities were deidentified in these aggregate reports, with each psychiatric facility assigned a letter (A through P). Clinical directors of individual facilities were aware of their letter designation so they could compare their facility's performance with the others and with a statewide average. Trend graphs showing collection of these indicators at each facility over time were also presented and discussed at the quarterly clinical director meetings in Albany to encourage improved performance.

Finally, after an initial two-month "debugging" phase to identify and fix challenges to collecting this information and to promote adoption of successful solutions, a monthly, learning collaborative conference call was conducted with the clinical directors and staff at individual clinics along with some members of the workgroup to discuss common problems and share creative solutions.

Implementation outcomes

Implementing a large-scale health screening initiative throughout a diverse and geographically dispersed state mental health system was complicated. Many important challenges were encountered, and solutions were developed to overcome these barriers.

Defining the exact target population was critical for implementation of this initiative. After much discussion, the workgroup decided to include only adult outpatients at nonforensic, noncorrectional facilities (OMH operates three forensic hospitals and 31 "clinics" in state prisons) who were being served in clinics rather than in clubhouses or residences. A detailed list of all 17 adult, civil psychiatric hospitals and their associated 66 adult outpatient clinics was created and distributed to all members of the workgroup. To establish local accountability for the project, the list contained the name and address of each participating clinic, as well as e-mail addresses and phone numbers of the clinical directors and community service leaders at each hospital and clinic.

Providing necessary equipment was also critical, but we encountered two problems in trying to do this. First, a delay in distribution of the equipment slowed implementation. Second, given financial constraints, only midgrade sphygmomanometers were ordered, and there was a concern that some of these might produce varied readings when used several times daily. This problem is currently being addressed and corrected. We believed that staff training sessions were important to ensure data entry of the indicators. Therefore, multiple training sessions for the MMT were provided when the initiative was launched. The coordinator of the workgroup and initiative (CM) also met monthly with personnel from the NYS OMH Information Technology Department to work on ways to improve the tool. Conference calls with clinic directors and staff were especially useful in generating feedback from frontline users to make the tool more clinically relevant and friendly. Responsibility for data collection and data entry was left up to individual clinics to determine. Some clinics chose nursing staff to do both, and others assigned both tasks to therapy aides.

Because of our performance-monitoring effort, we were able to show that four months after this initiative was launched, approximately 50% of NYS OMH outpatients had been screened for the three physical health indicators. The data also show the extent of the problem in the NYS OMH clinic population: 79% of the clients screened at the facilities were overweight or obese, 27% were hypertensive, and 50% were active smokers. [Graphs showing monitoring rates at the OMH facilities from March 1, 2009, through June 1, 2009, for each of the three indicators are presented in an online supplement to this column at ps.psychiatryonline.org . Additional graphs show, by facility, the proportions of patients who were obese or overweight, who had a stage I or stage II risk indicator for hypertension, and who were smokers.] Consistent monthly statewide improvement in collection of these indicators was found [see online supplement]. However, there were substantial performance differences between facilities. Quarterly presentation of the deidentified data was intended to improve performance without publically exposing facilities that fell below the mean and to enable supervisory staff to focus on quality improvements to enhance performance. We also used targeted support efforts for facilities below the 25th percentile.

During the first phase of the initiative, learning collaboratives were conducted via monthly conference calls with optional participation. The calls allowed staff and administrators at the facilities to share strategies on how to implement the initiative (for example, how to identify patients, train and assign staff, and ensure accurate data entry) and to provide feedback to the project coordinator (CM) about their needs (for example, for equipment or help with information technology). Some facilities struggled with organizing regular data collection, whereas others had more difficulty with finding staff time for data entry. These differences appeared to be influenced by a variety of factors, including clinic leadership, staffing, computer support, and enthusiasm for the project. The monthly conference calls were used as peer supervision, and facilities could discuss common problems they encountered as well as creative solutions. Since the project began in January 2009, 13 of the 17 facilities (76%) have joined the collaborative. In addition, NYS OMH information technology instructors have participated in the conference calls as needed to provide instruction on generating useful clinical reports.

Conclusions

The NYS OMH health indicator initiative serves 15,000 adults with serious mental illnesses throughout the state. Early data indicate that approximately 50% of NYS OMH adult outpatients with mental illnesses have been screened for three physical health indicators. By the end of 2009 we seek to have all clinic outpatients regularly monitored, counseled, and encouraged to engage in wellness activities as needed in regard to their BMI, blood pressure, and smoking status. Although the initiative began with adult outpatients, child health indicators have since been developed and are being implemented.

Elements essential to this rapid and robust implementation have been strong administrative leadership, direction, and support; the presence of a dedicated project coordinator with the aid of expert services research personnel; regular project meetings with key players; a reliable and simple electronic database; ongoing, open monitoring with clinical leadership; and regular feedback from frontline providers that was used to improve the operations of the initiative. Engagement of consumers is also critical for this initiative. The NYS OMH director of recipient affairs, a consumer, was invited to the monthly workgroup that has been planning this initiative. We hope that consumers will participate in future educational efforts and wellness programs. In addition, on the basis of this monitoring initiative, each NYS OMH clinic will be better able to determine the effects of existing evidence-based wellness interventions and improvements to them for consumers whose health indicators warrant prevention and intervention.

Acknowledgments and disclosures

The authors express special thanks to several collaborators at the NYS OMH and the Columbia University Department of Psychiatry, including but not limited to Shaofu Chen, M.D., Ph.D., Scott Derby, Sheila Donahue, Ph.D., Ralph Ellermann, Ph.D., Gerald Engel, Pharm.D., Miranda Herrington, Laura Kent, M.D., Jaime Martins, Ilana Nossel, M.D., Noah Peters, Anthony Salerno, Ph.D., and Tom Smith, M.D. They also thank Lisa Dixon, M.D., M.P.H., for her input on this project.

The authors report no competing interests.