1. 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, routinely
treat most,or
treat some,
refer others
Co-manage
with MHP or
refer all to
MHP

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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, routinely
treat most
or treat
some, refer
others
Co-manage
with MHP or
refer all to
MHP

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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 plan
restrictions
Complicated or confusing referral systems for
BH/mental health care
Difficulties in sharing clinical information with MHPs
Inadequate time to address the problem during
routine office visits
Problems in prescribing preferred medication(s) due to
insurance 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
Pediatric
Pts
Adult Pts
83
71
70
65
0 10 20 30 40 50 60 70 80 90
Trained Professional (e.g. care manager) to
connect 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 information
exchange 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 health
coverage, including parity
More MH professionals
Real time access to outpatient psychiatry
services
Prompt, and greater access to, existing MH
professionals

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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.