Addressing unmet screening and treatment needs of patients with comorbid conditions

Missouri’s Community Mental Health Centers utilize a cadre of highly trained Nurse Liaisons to manage the increasingly complex and demanding care needs of persons with serious mental illness plus other comorbid medical conditions such as diabetes, asthma/COPD, and cardiovascular conditions. To assist with this responsibility, CMT provides a quarterly Disease Management Report that flags patients with selected health conditions for whom appropriate screening and treatment activities appear to be lacking, based on a review of pharmacy and medical claims data. The report allows nurses to quickly identify patients for whom intervention is necessary in order to assure that medical needs are addressed, thus increasing patient health and reducing the costs associated with treating poorly managed conditions. Aggregated data provides agencies with snapshots of the proportion of their population that is receiving recommended screenings and treatment for each of a series of indicators, allowing agencies to target resources to critical areas, and to set goals and monitor progress as part of quality assurance operations.