Chad Stage and Dr. Ross Simpson discuss UNC's SUDDEN project, as it relates to Mental Health and SDOH in NC

North Carolina’s Medicaid beneficiaries represent some of the state’s most vulnerable population. In his work with primary care providers, Emtiro’s Behavioral Health Programs Manager Chad Stage attempts to better understand this population, while also attempting to understand provider needs as they encounter and treat these patients. Additionally, not all vulnerable citizens utilize the resources available to them, including obtaining Medicaid coverage or establishing a relationship with a local provider, putting them at greater risk of adverse health events and outcomes. In the video below, Chad Stage interviews Dr. Ross Simpson, a cardiologist working with UNC Chapel Hill on the SUDDEN Project- a project focused on collaborating and studying the correlation between social factors, mental health, and sudden death in people under age 65 in North Carolina. See the transcription of the interview below, following the video.

Interview Transcription

Stage: Welcome everyone. My name is Chad Stage, I’m the Behavioral Health Programs Manager for Emtiro Health and today I’m joined by Dr. Ross Simpson. Dr. Simpson is a professor of Cardiology and Epidemiology at the University of North Carolina at Chapel Hill. He is the acting chair of the UNC School of Medicine’s Data, Safety, and Monitoring Board. He has an extensive portfolio of peer reviewed publications that we could spend our entire conversation going through today. But most recently he has been acting as the Project Lead for the UNC SUDDEN Project, which is going to be sort of a topic of discussion that Dr. Simpson is here with us today. So, Dr. Simpson, thank you for taking the time to meet with us and discuss your work as it relates to the SUDDEN Project.

Simpson: Thank you Chad. I think it’s an opportunity for me and I look forward to talking to you more about it.

Stage: Sure. So, I guess for the most part of last year, I had the pleasure of participating in a lot of your weekly meetings with the SUDDEN Project. And I really found a lot of the work you all have done quite fascinating and really an area of healthcare that does deserve attention.

So, for those joining us who have no idea what the SUDDEN Project is, could you tell us what the goal of that work is and the area of focus?

Simpson: Well, thank you Chad. The SUDDEN Project actually is an acronym, stands for Sudden Unexpected Death in North Carolina and the purpose of our work is to understand why young people, young is under age 65, why young working age adults die suddenly and unexpectedly. And our vision was to understand why this is happening and then to work towards prevention programs to reduce these really horrible events. I could expand that a little bit. It’s really always a tragedy when someone dies but it’s really a horrible event when a young person dies unexpectedly. It’s horrible for the family, obviously horrible to the person.

In fact, families sometimes never get over a sudden death in a young adult. And so we got together with many of our students as well as other faculty members and we worked with emergency medical services in Wake County. And our goal was simply to understand how many people were dying suddenly and figure out why they were doing that. Like I said, with the goal being to develop a program to prevent some of these deaths.

Stage: It’s my understanding, Dr. Simpson, that you’re not the first leader of this effort. How long has this project been in existence?

Simpson: Well, it’s been in existence probably about six years. I was recruited to help with managing the project because as the project started, I think the initial people that began the project thought that this would be kinda simple, it would be a genetic problem and I was brought in to help because it became very clear that this is much more complex than someone dying because of a bad gene in their family. And so I’ve been working with the project really well over four years, almost five years now. I brought an epidemiology focus to the project which really was, in plain language, to understand the incidence of sudden death and risk factors from sudden death.

Stage:  So with that being said, it seems like the initial genetic component was not necessarily the answer. That being said, could you provide us with some insights into what your group has found as it relates to comorbidities or potentially social needs?

Simpson: Well, I mean it was kind of a surprise to me. I’m a cardiologist and we always thought of sudden death as primarily a heart problem. And of course, when the heart stops, you die but it was much more complicated than that.

There certainly are genetic components to sudden death but those were really minor compared to the major social problems we found. To put it in context, one of our key findings was that about 15% of all deaths under age 65 are sudden and unexpected. This is a real public health problem. It’s not a rare event. That was the first discovery that surprised us. The second was not a huge surprise, what we saw was a lot of people had heart disease, they had undiagnosed or untreated heart disease, a lot of hypertension, diabetes, respiratory disease. Not a big surprise, but it was surprising in the sense that we always think of a sudden death as somebody not seeing the doctor, just dying unexpectedly.

That was not the case. We saw that a lot of our victims, most of our victims actually, saw the doctor a lot. That was a surprise, that was new information. Yet the people were often not on the best medicines to treat their diabetes, their coronary disease, or their respiratory disease. But the real surprise, and this came kinda late in the project, was the social burden that was going on here and the psychological burden. We found that almost 70% of the victims had anxiety, depression, and schizophrenia, some major psychiatric illness and/or problems at least. That they weren’t on good treatments for their psychological illness and the last part, again kinda came a little later. As a cardiologist was not expecting this, the social determinants were just huge. It was a real disparity, African Americans were twice as likely to have sudden death as whites, men three times as likely compared to women. But then the real strong association with poor insurance status, not using the SNIP program, the available food stamps kind of program. Poverty was an associate of it. And so actually we were finding that the social determinants, the social predictors of sudden death really outweighed the chronic disease problems. The chronic disease problems were there, there’s no question but these were people with hypertension, maybe a little diabetes and yet suddenly they die. And we went back and looked at their records, they weren’t on evidence based medicines to prevent their deaths. So what we concluded at the end of this was that there was tremendous opportunity to help prevent sudden death. We’ll never completely prevent it but there’s a tremendous opportunity to mitigate this tragedy.

Stage: Yeah, that’s interesting. Having a behavioral health background though, it doesn’t surprise me that…

Simpson: Well, I should have listened to you earlier Chad, I didn’t. I do listen to you now in your meetings but this was something we did not expect. But we are at least open enough to realize when we saw it that it was important. And that’s become one of our major focuses now.

Stage: Yeah and our history at Emtiro, we are focused on that vulnerable population of the Medicaid patient. And Medicaid in North Carolina is moving toward a major transformation this coming July where providers, family practice, primary care physician practices are going to have to really find ways to better address the behavioral health needs of a lot of their patients as well as some of these social determinants of health. And I think Emtiro, we’ve done a very good job of making sure those things are part of the conversation when we’ve developed our care management model, when we’ve developed our provider services line of services, as well as our data analytics platforms.  

As disturbing at some of your findings are, I’m glad to hear I think that we’re on the right track to really be able to help practices as their expectations of addressing these things is really going to be escalated come July.

Simpson: Well Chad, I think you are in a great position to really have a real impact. It’s clear that the management model we’re working with right now in terms of insurance and coverage for Medicaid and for uninsured people is not adequate. And that’s what our data shows, there’s a real potential here to reduce the instances of sudden death. And I think you’re gonna have an impact on that.

Stage: Well Dr. Simpson, if given that audience is probably who is watching this, highly primary care practitioners, are there any points of advice from your research that you might give a practicing physician best practices to help address some of these issues?

Simpson: Well I think right now, we’re working trying to develop a risk model. Something we can use that we can give primary care physicians that would help them identify a vulnerable adult. I think though right now in plain language and just to say it directly, I mean most of us know who these people are. We talk to Rescue Squad workers, they said “Oh we know, we go to these houses all the time, we know who’s at risk.” And I think physicians will have a pretty good sense of what’s or who is somebody at risk. The real risk factor I think is social isolation. I know as you’re a Behaviorist, you want me to define that precisely. I won’t do it, I could just tell you though it’s a person who is not fully engaged with their community. They’re not taking advantage of food stamps, their often, they come to clinic a lot sometimes but they often don’t take the medicines you’re prescribing.

Stage:  Yeah

Simpson: And they often have chronic diseases that are treatable- hypertension, diabetes. We shouldn’t be dying of hypertension these days or heart attacks given we really have good medicines for these problems. But the issue turns out is, how do you identify that person? I would bet you see someone who’s not involved- and I’m just making this list up- not involved with church, not involved with their fishing club, they’re not involved with their community. And there’s often some mental illness like an anxiety or depression. I mean not life threatening mental illness, but a type of mental illness primary physicians see all the time. Those are people vulnerable and those are people at risk.

Stage: Well with all of that being said, Dr. Simpson, if there’s someone out there who is watching us today and is interested in being a part of the SUDDEN Project, or feels like they may have something to contribute, what’s the best way someone can reach out?

Simpson: Well, we’d love to have people join our group. It’s very inclusive, there’s about maybe twenty students and faculty a part of the team, including you Chad.

Stage: Oh yes

Simpson: I’m gonna hold you to that. So I would love to have people from the community to work with us. We really are beginning to design and think about what’s an intervention that would work. We don’t want to waste people’s time but on the other hand we do want to do something.

Stage: Yeah

Simpson: So the best to answer your question, the best way is to send me an email. Its rsimpson@med.unc.edu and I’ll reach out and I’ll return the email and we could have a conversation. And if you don’t want to join the group but you have some ideas, we’d appreciate that too.

Stage: Right

Simpson: There’s a lot things that can be done to help people but we don’t want to, the last thing we want to do is burden primary care physicians with unnecessary or cumbersome tools or interventions. And so we’d like your input, and we’d like your help if you feel you want to work with us. One thing I will say about the model we use for working with people, it’s really one where- I feel like sometimes like a manager and not a scientist- and it’s really to have students do the work.

As one of my daughters pointed out to me, “dad do you want all your kids to do all the work for you”, the answer’s yes, I want them to get the credit. So if someone has a good idea, they want to develop it, we’ll help them develop it. That I think is the best way to do any type of project that has meaning in the community.

Stage: Great. Well and that being said for anybody who’s watching us who is a provider of Medicaid, provides healthcare to Medicaid patients in North Carolina, our group Emtiro Health will be more than happy to discuss the coming changes in July and how that’s going to effect your practice and some of the expectations around care delivery.

We have a robust care management model that we are deploying and it will I think address the whole person very well. We have provider services that can work with practices around specific certifications, whether that be Patient Centered Medical Home, or my area is Behavioral Health Integration. And then we also have a very robust data analytics platform that we hope all of those things will help physicians do doctor stuff and not have to worry about the other many aspects of healthcare. And let them treat the patients and we can address some of these other things. So, if anybody needs or wants information about Emtiro Health, they can email info@emtirohealth.org and we’d welcome anyone who has questions. With that, I think this concludes the interview.

Dr. Simpson thank you so much again for taking the time to provide this information.

Simpson: Thank you Chad. It was a pleasure and I appreciate the opportunity to talk with you.

Stage: Thank you.

Simpson: Thank you.