Integrated medical care for patients with serious psychiatric illness: a randomized trial

Early Health Impacts of a Primary Care Consultation Model for People Served by Assertive Community Treatment teams

The cardiometabolic health outcomes and life expectancy of people living with serious mental illness (SMI) continue to significantly flag behind that of the general population. This study explores the possibility of using the evidence-based Assertive Community Treatment (ACT) model and infrastructure to increase access to primary care and improve cardiometabolic outcomes of people with SMI. Four ACT teams in a large urban area received the services of a primary care consultant who was co-located at a Federally Qualified Health Center (FQHC), met regularly with ACT team clinicians to review a cardiometabolic registry of participants, and engaged participants in primary care services. Health screening rates, primary care utilization, and cardiometabolic outcomes-body mass index, blood pressure, hemoglobin A1c, cholesterol, and tobacco smoking status-were monitored over the course of a year. The efficacy of this integrated care model was also explored through focus groups with ACT team staff and participants. Significant improvements in screening rates were found for the ACT teams that received this integrated care intervention; however, only modest improvements in cardiometabolic outcomes were found. Future longitudinal, multi-site studies are needed to fully determine the impact of integrated care models on the physical health outcomes of this vulnerable population.

Strengthening the Delivery of Physical Healthcare for Adults Living With Serious Mental Illness - A Qualitative Description of Patient and Family Member Perspectives

BACKGROUND

Individuals with serious mental illness (SMI) have higher rates of comorbid physical health conditions, poorer associated health outcomes, and die on average 10-20 years earlier than the general population. This qualitative study aimed to explore the perspectives and experiences of adults living with SMI and family members with accessing physical healthcare within primary and mental health settings in Canada.

METHODS

We conducted a qualitative descriptive study using semi-structured interviews with 20 adults living with SMI and five focus groups with 18 family members between July 2023 and April 2024. After coding by two authors, thematic analysis was completed with the support of a data analysis team to identify overarching themes capturing participant experiences with accessing physical healthcare, care needs and preferences.

RESULTS

Four main themes emerged from participant narratives: (1) The centrality of mental health problems in the lives of people with SMI; (2) Challenges in accessing physical healthcare; (3) The role of families in supporting access to care; (4) Perceived health priorities and preferences. There was a high degree of congruence between the perspectives of individuals living with SMI and family members. Both participant groups described challenges accessing primary care settings, fragmented health services, and a desire for person-centred, whole-person health within mental health settings, with family member support where available.

CONCLUSIONS

Findings from this study highlight the need for advancing the integration of physical healthcare within mental health settings for adults living with SMI, who are less likely to engage with community-based primary care services. Enhanced access to physical healthcare could leverage multidisciplinary resources in these settings and partnerships with families. These findings can inform efforts to provide whole-person healthcare for individuals experiencing SMI.

PATIENT OR PUBLIC CONTRIBUTION

The study team collaborated closely with community organizations and individuals with lived experience at every stage of this research. This included contributions to the funding proposal, the study protocol, participant recruitment, study materials, data analysis and preparing the manuscript. Individuals with lived experience and family members actively participated in management and project meetings for the duration of the study.

Strengthening the delivery of integrated care for individuals experiencing serious mental illness within mental health settings: a qualitative description of health provider perspectives

BACKGROUND

Individuals experiencing serious mental illness (SMI) have higher rates of comorbid physical health conditions, poorer associated health outcomes, and die on average 10-20 years earlier than the general population. They encounter multiple barriers to accessing appropriate physical health care in many countries, including Canada, where policies and practices to promote integrated care delivery to this population remain scant. This qualitative study aimed to explore health provider perspectives and experiences with integrated physical and mental health care within mental health settings in Canada, in efforts to address the health needs of this population.

METHODS

This qualitative descriptive study involved conducting individual semi-structured interviews with 13 health administrators and four focus groups with 15 clinicians between July 2023 and April 2024. The data analysis team, inclusive of individuals with SMI, used thematic analysis to identify overarching themes that capture participants' perspectives on and experiences with delivering integrated physical and mental health care within mental health settings in Canada, including their clinical practices and organizational contexts.

RESULTS

We identified four themes in participant narratives: (1) the need for integrated care delivery within mental health settings; (2) organizational readiness for integrated care; (3) moving integration forward: addressing challenges; and (4) leveraging opportunities to advance integrated care. Both participant groups highlighted challenges with fragmented healthcare services, emphasized the urgent need for policies, practices and guidelines that support person-centered, comprehensive care within mental health settings, and called for engaging people with living/lived experience and family members in service redesign.

CONCLUSION

Findings underscore the importance of accelerating efforts to promote integrated health care delivery for adults with SMI within mental health settings, and of implementing policies that address health disparities for this population in the Canadian context.

CLINICAL TRIAL NUMBER

Not Applicable.

Enhanced Primary Care for Severe Mental Illness Reduces Inpatient Admission and Emergency Room Utilization Rates

Cardiovascular disease (CVD) is a leading cause of premature mortality among patients with severe mental illness (SMI). Effective care delivery models are needed to address this mortality gap. This study examines the impact of an enhanced primary care (PC) program that specializes in the treatment of patients with SMI, called Medicine in Psychiatry Service-Primary Care (MIPS-PC). Using multipayer claims data in Western New York from January 1, 2016 to December 31, 2021, patients with SMI and CVD were identified using International Classification of Diseases, Tenth Revision codes. National Provider Identification numbers of MIPS-PC providers were then used to identify those patients who were treated by MIPS-PC during the period. These MIPS-PC-treated patients were compared against a cohort of one-to-one propensity score matched contemporaneous comparison group (ie, patients receiving PC from providers unaffiliated with MIPS-PC). A difference-in-difference approach was used to identify the treatment effects of MIPS-PC on all-cause emergency department (ED) visits and hospitalization rates. The MIPS-PC group was associated with a downtrend in the acute care utilization rates over a 3-year period following the index date (ie, date of first MIPS-PC or other PC provider encounter), specifically a lower hospitalization rate in the first year since the index date (25%; P < 0.001). ED visit rate reduction was significant in the third-year period (18%; P = 0.021). In summary, MIPS-PC treatment is associated with a decreasing trend in acute care utilization. Prospective studies are needed to validate this effect of enhanced PC in patients with SMI and CVD.

Integrated primary and community mental health care for young adults with serious mental illness: A program evaluation

AIM

Young adults with serious mental illness (SMI) have poor physical health and high Emergency Department (ED) and hospital utilization. Integrating primary care into community mental health care may be an important form of early intervention.

METHODS

Adjusted multivariable regressions assessed changes in self-reported annual primary care, ED and hospital utilization for 83 young adults with SMI enrolled in integrated care.

RESULTS

Participants' mean annual per person utilization changed significantly as follows: primary care visits, from 1.8 to 3.6, p < .001; medical ED visits, from 1.0 to 0.6, p < .01; psychiatric ED visits from 0.6 to 0.2, p < .001; medical inpatient days, from 1.2 to 0.1, p < .001 and psychiatric inpatient days, from 6.3 to 2.6, p < .001.

CONCLUSIONS

Young adults with SMI receiving integrated care increased primary care and reduced ED and inpatient utilization. Future controlled research is warranted to further assess integrated care for young adults with SMI.

A feasibility study of a participatory designed program for preventing cardiovascular disease in mentally vulnerable patients

AIM

To test the feasibility of a participatory design intervention aimed at reducing the risk of cardio-vascular disease among patients suffering from alcohol use disorder (AUD) or severe mental illness (SMI).

METHODS

The intervention was developed by patients from the Community Mental Health Center and the Alcohol Treatment Facility in Odense, Denmark, and consisted of eight modules (health interviews, screening and treatment, introduction, diet/alcohol, physical activity, smoking, health app, and sleep problems). The intervention was tested using pre- and post-measurements of selected variables, patients' intervention attendance, and interviews and dialogue workshops at the end of the study.

RESULTS

A total of 21 out of 42 eligible patients from the Alcohol Treatment Facility and two out of 443 eligible patients from the Community Mental Health Center accepted participation in the study. The two patients from the Community Mental Health Center were not included in the analyses due to General Data Protection Regulation (GDPR). All patients accepted being screened for risk factors at inclusion, and the majority enrolled in at least one of the subsequent modules. The study indicated that the patients followed recommendations from their GPs.

CONCLUSIONS

There is a great need for focus on cardio-vascular disease in patients with SMI and those with AUD. Results indicate that the intervention is feasible for patients with AUD, but due to inclusion of too few patients with SMI, nothing can be concluded for this patient group. Patients and staff in the Alcohol Treatment Facility agreed that the intervention has future perspectives.

Variation in benefit among patients with serious mental illness who receive integrated psychiatric and primary care

PURPOSE

The population with serious mental illness has high risk for hospitalization or death due to unhealthy behaviors and inadequate medical care, though the level of risk varies substantially. Programs that integrate medical and psychiatric services improve outcomes but are challenging to implement and access is limited. It would be useful to know whether benefits are confined to patients with specific levels of risk.

METHODS

In a population with serious mental illness and increased risk for hospitalization or death, a specialized medical home integrated services and improved treatment and outcomes. Treatment quality, chronic illness care, care experience, symptoms, and quality of life were assessed for a median of 385 days. Analyses examine whether improvements varied by baseline level of patient risk.

RESULTS

Patients with greater risk were more likely to be older, more cognitively impaired, and have worse mental health. Integrated services increased appropriate screening for body mass index, lipids, and glucose, but increases did not differ significantly by level of risk. Integrated services also improved chronic illness care, care experience, mental health-related quality of life, and psychotic symptoms. There were also no significant differences by risk level.

CONCLUSIONS

There were benefits from integration of primary care and psychiatric care at all levels of increased risk, including those with extremely high risk above the 95th percentile. When developing integrated care programs, patients should be considered at all levels of risk, not only those who are the healthiest.

Collaborative care approaches for people with severe mental illness

BACKGROUND

Collaborative care for severe mental illness (SMI) is a community-based intervention that promotes interdisciplinary working across primary and secondary care. Collaborative care interventions aim to improve the physical and/or mental health care of individuals with SMI. This is an update of a 2013 Cochrane review, based on new searches of the literature, which includes an additional seven studies.

OBJECTIVES

To assess the effectiveness of collaborative care approaches in comparison with standard care (or other non-collaborative care interventions) for people with diagnoses of SMI who are living in the community.

SEARCH METHODS

We searched the Cochrane Schizophrenia Study-Based Register of Trials (10 February 2021). We searched the Cochrane Common Mental Disorders (CCMD) controlled trials register (all available years to 6 June 2016). Subsequent searches on Ovid MEDLINE, Embase and PsycINFO together with the Cochrane Central Register of Controlled Trials (with an overlap) were run on 17 December 2021.

SELECTION CRITERIA

Randomised controlled trials (RCTs) where interventions described as 'collaborative care' were compared with 'standard care' for adults (18+ years) living in the community with a diagnosis of SMI. SMI was defined as schizophrenia, other types of schizophrenia-like psychosis or bipolar affective disorder. The primary outcomes of interest were: quality of life, mental state and psychiatric admissions at 12 months follow-up.

DATA COLLECTION AND ANALYSIS

Pairs of authors independently extracted data. We assessed the quality and certainty of the evidence using RoB 2 (for the primary outcomes) and GRADE. We compared treatment effects between collaborative care and standard care. We divided outcomes into short-term (up to six months), medium-term (seven to 12 months) and long-term (over 12 months). For dichotomous data we calculated the risk ratio (RR) and for continuous data we calculated the standardised mean difference (SMD), with 95% confidence intervals (CIs). We used random-effects meta-analyses due to substantial levels of heterogeneity across trials. We created a summary of findings table using GRADEpro.

MAIN RESULTS

Eight RCTs (1165 participants) are included in this review. Two met the criteria for type A collaborative care (intervention comprised of the four core components). The remaining six met the criteria for type B (described as collaborative care by the trialists, but not comprised of the four core components). The composition and purpose of the interventions varied across studies. For most outcomes there was low- or very low-certainty evidence. We found three studies that assessed the quality of life of participants at 12 months. Quality of life was measured using the SF-12 and the WHOQOL-BREF and the mean endpoint mental health component scores were reported at 12 months. Very low-certainty evidence did not show a difference in quality of life (mental health domain) between collaborative care and standard care in the medium term (at 12 months) (SMD 0.03, 95% CI -0.26 to 0.32; 3 RCTs, 227 participants). Very low-certainty evidence did not show a difference in quality of life (physical health domain) between collaborative care and standard care in the medium term (at 12 months) (SMD 0.08, 95% CI -0.18 to 0.33; 3 RCTs, 237 participants). Furthermore, in the medium term (at 12 months) low-certainty evidence did not show a difference between collaborative care and standard care in mental state (binary) (RR 0.99, 95% CI 0.77 to 1.28; 1 RCT, 253 participants) or in the risk of being admitted to a psychiatric hospital at 12 months (RR 5.15, 95% CI 0.67 to 39.57; 1 RCT, 253 participants). One study indicated an improvement in disability (proxy for social functioning) at 12 months in the collaborative care arm compared to usual care (RR 1.38, 95% CI 0.97 to 1.95; 1 RCT, 253 participants); we deemed this low-certainty evidence. Personal recovery and satisfaction/experience of care outcomes were not reported in any of the included studies. The data from one study indicated that the collaborative care treatment was more expensive than standard care (mean difference (MD) international dollars (Int$) 493.00, 95% CI 345.41 to 640.59) in the short term. Another study found the collaborative care intervention to be slightly less expensive at three years.

AUTHORS' CONCLUSIONS

This review does not provide evidence to indicate that collaborative care is more effective than standard care in the medium term (at 12 months) in relation to our primary outcomes (quality of life, mental state and psychiatric admissions). The evidence would be improved by better reporting, higher-quality RCTs and the assessment of underlying mechanisms of collaborative care. We advise caution in utilising the information in this review to assess the effectiveness of collaborative care.

Oral Health Recovery: A Peer Support Specialist-Led Health Education Program for People With Serious Mental Illness

Oral health affects whole health and quality of life. This is especially true for people with serious mental illness, a population with heightened risks for oral disease and needs for oral treatment. Studies have previously shown the effectiveness of peer support specialist (PSS)-led wellness interventions. Oral health educational materials and a health education approach were collaboratively developed by a multidisciplinary team and then implemented at one community mental health center and three PSS-run drop-in centers. PSSs provided health education and linked consumers to dental care. Program evaluation (N=41 respondents) indicated the approach's acceptability, feasibility, and sustainability.

Establishing a Care Continuum for Cardiometabolic Conditions for Patients with Serious Mental Illness

PURPOSE OF REVIEW

Addressing cardiometabolic risk factors in persons with serious mental illness requires early screening and proactive medical management in both medical and mental health settings.

RECENT FINDINGS

Cardiovascular disease remains the leading cause of death for persons with serious mental illness (SMI), such as schizophrenia or bipolar disorder, much of which is driven by a high prevalence of metabolic syndrome, diabetes, and tobacco use. We summarize barriers and recent approaches to screening and treatment for metabolic cardiovascular risk factors within physical health and specialty mental health settings. Incorporating system-based and provider-level support within physical health and psychiatric clinical settings should contribute to improvement for screening, diagnosis, and treatment for cardiometabolic conditions for patients with SMI. Targeted education for clinicians and leveraging multi-disciplinary teams are important first steps to recognize and treat populations with SMI at risk of CVD.

Integrated Care as a Model for Interprofessional Disease Management and the Benefits for People Living with HIV/AIDS

INTRODUCTION

Today, antiretroviral therapy (ART) is effectively used as a lifelong therapy to treat people living with HIV (PLWH) to suppress viral replication. Moreover, PLWH need an adequate care strategy in an interprofessional, networked setting of health care professionals from different disciplines. HIV/AIDS poses challenges to both patients and health care professionals within the framework of care due to frequent visits to physicians, avoidable hospitalizations, comorbidities, complications, and the resulting polypharmacy. The concepts of integrated care (IC) represent sustainable approaches to solving the complex care situation of PLWH.

AIMS

This study aimed to describe the national and international models of integrated care and their benefits regarding PLWH as complex, chronically ill patients in the health care system.

METHODS

We conducted a narrative review of the current national and international innovative models and approaches to integrated care for people with HIV/AIDS. The literature search covered the period between March and November 2022 and was conducted in the databases Cinahl, Cochrane, and Pubmed. Quantitative and qualitative studies, meta-analyses, and reviews were included.

RESULTS

The main findings are the benefits of integrated care (IC) as an interconnected, guideline- and pathway-based multiprofessional, multidisciplinary, patient-centered treatment for PLWH with complex chronic HIV/AIDS. This includes the evidence-based continuity of care with decreased hospitalization, reductions in costly and burdensome duplicate testing, and the saving of overall health care costs. Furthermore, it includes motivation for adherence, the prevention of HIV transmission through unrestricted access to ART, the reduction and timely treatment of comorbidities, the reduction of multimorbidity and polypharmacy, palliative care, and the treatment of chronic pain. IC is initiated, implemented, and financed by health policy in the form of integrated health care, managed care, case and care management, primary care, and general practitioner-centered concepts for the care of PLWH. Integrated care was originally founded in the United States of America. The complexity of HIV/AIDS intensifies as the disease progresses.

CONCLUSIONS

Integrated care focuses on the holistic view of PLWH, considering medical, nursing, psychosocial, and psychiatric needs, as well as the various interactions among them. A comprehensive expansion of integrated care in primary health care settings will not only relieve the burden on hospitals but also significantly improve the patient situation and the outcome of treatment.

The Effectiveness of a Specialized Primary Care Medical Home for Patients with Serious Mental Illness

BACKGROUND

There are unmet primary care needs among people with serious mental illness that might be improved with integrated care and medical care management. Many healthcare organizations have attempted to address this problem, but few interventions have been rigorously studied and found to be effective.

OBJECTIVE

Study the implementation and effectiveness of a novel, specialized primary care medical home designed to improve the healthcare of patients with serious mental illness.

DESIGN, SETTING, AND PARTICIPANTS

Clustered controlled trial for a median of 401 days. One Veterans Health Administration medical center was assigned to intervention and two were assigned to usual care (control). Thirty-nine clinicians and managers were included in the study, as well as 331 patients who met eligibility criteria.

INTERVENTION

A specialized medical home with systematic patient engagement, proactive nurse panel management, a collaborative care psychiatrist, and a primary care physician providing care that included psychiatric treatment.

MAIN MEASURES

Quality of care, chronic illness care and care experience, symptoms, and quality of life.

KEY RESULTS

Sixty-five intervention patients (40%) moved all psychiatric care to the primary care team. No adverse events were attributable to the intervention. Compared with control, intervention patients had greater improvement over time in appropriate screening for body mass index, lipids, and glucose (χ2 = 6.9, 14.3, and 3.9; P's < .05); greater improvement in all domains of chronic illness care (activation, decision support, goal-setting, counseling, coordination) and care experience (doctor-patient interaction, shared decision-making, care coordination, access; F for each 10-24, P's < .05); and greater improvement in mental health-related quality of life (F = 3.9, P = .05) and psychotic symptoms (F = 3.9, P = .05).

CONCLUSION

A primary care medical home for serious mental illness can be feasible to implement, safe, and more effective than usual care.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01668355.

Collaboration between Psychiatrists and Other Allied Medical Specialists for the Treatment of Delusional Disorders

Background: There is increasing evidence that individuals with psychosis are at increased risk for cardiovascular disease, diabetes, metabolic syndrome, and several other medical comorbidities. In delusional disorder (DD), this is particularly so because of the relatively late onset age. Aims: The aim of this narrative review is to synthesize the literature on the necessity for medical collaboration between psychiatrists and other specialists. Methods: A non-systematic narrative review was carried out of papers addressing referrals and cooperation among specialists in the care of DD patients. Results: Psychiatrists, the primary care providers for DD patients, depend on neurology to assess cognitive defects and rule out organic sources of delusions. Neurologists rely on psychiatry to help with patient adherence to treatment and the management of psychotropic drug side effects. Psychiatrists require ophthalmology/otolaryngology to treat sensory deficits that often precede delusions; reciprocally, psychiatric consults can help in instances of functional sensory impairment. Close collaboration with dermatologists is essential for treating delusional parasitosis and dysmorphophobia to ensure timely referrals to psychiatry. Conclusions: This review offers many other examples from the literature of the extent of overlap among medical specialties in the evaluation and effective treatment of DD. Optimal patient care requires close collaboration among specialties.

Staff Perceptions of Barriers and Facilitators to Implementation of Behavioral Health Homes at Community Mental Health Provider Settings

Individuals living with a serious mental illness are disproportionately affected by preventable and/or manageable chronic conditions. Integrated care and support for behavioral and physical health within community mental health provider (CMHP) settings, also known as behavioral health homes (BHH), can lead to improvements in care and cost outcomes. This study explored staff perceptions of barriers and facilitators to BHH implementation. We conducted semi-structured interviews with CMHP staff at baseline, 1, and 2 years after the start of implementation. We analyzed interviews to identify major themes. We conducted 65 total interviews with 30 unique staff members. Common barriers included staff turnover, hesitation to change care processes, and acute service user needs. Facilitators included agency-wide culture change, intervention champions, and integration of intervention processes into daily workflows. Despite common barriers, CMHP staff identified several elements related to successful BHH implementation, including the CMHP-wide cultural shift to comprehensively address health/wellness that benefitted service users and staff alike.

Patient Service Utilization Among Individuals with Co-occurring Disorders: A Comparison of Two Models of Care Coordination

Healthcare systems have increasingly adopted integrated care models with demonstrated effectiveness. However, few studies examine integrated care for individuals with co-morbid mental illness and medical conditions. This quasi-experimental study compared service use for two integrated care models for patients with co-occurring conditions. We used hierarchical negative binomial and logistic regressions with random effects to test the relationship between integration and service use. Patients treated at co-located agencies had significantly higher odds of inpatient hospitalization compared to those in fully integrated settings. Additionally, some comorbidities had significantly different levels of service use. Patients at co-located agencies had more outpatient and emergency visits, but was not statistically significant. Our findings provide evidence that the model of care may impact service use for patients experiencing co-occurring conditions, however, variations in service use for specific co-morbid conditions highlight the need to examine the specific needs and characteristics of this population.

Results of a Qualitative Study Aimed at Building a Programme to Reduce Cardiovascular Risk in People with Severe Mental Illness

People with severe mental illness (PSMI) have a shorter life expectancy and are more likely to have cardiovascular disease than the general population. Patients, carers, psychiatric professionals and primary care providers can all play a role in increasing PSMI physical health. The present qualitative exploratory study aimed to explore the views of these four populations as part of the multi-phase COPsyCAT project, whose objective is to build and test a cardiovascular risk prevention programme for PSMI. Overall, 107 people participated in the study's 16 focus groups, which were transcribed and analysed in a thematic analysis. With a view to building the health promotion programme, major themes identified in the corpus were translated into a list of needs as follows: communication, information, training and support. Results show that it is essential to improve communication between all the different stakeholders in mental health. The greatest challenge facing this programme will be to adapt it to the needs and expectations of PSMI while facilitating work between the various mental health stakeholders. Simple and inexpensive actions could be taken to improve the cardiovascular health of PSMI and will be experimented with during the programme's feasibility study which will start in September 2022.

Non-Pharmacological Integrated Interventions for Adults Targeting Type 2 Diabetes and Mental Health Comorbidity: A Mixed-Methods Systematic Review

Objective

Adults living with Type 2 diabetes (T2D) and severe mental illness (SMI) disproportionally experience premature mortality and health inequality. Despite this, there is a limited evidence-base and evaluation of non-pharmacological integrated interventions that may contribute to improved patient experience and outcomes. To improve our understanding of how to optimise integrated care for this group, this review evaluates the effectiveness, acceptability, and feasibility of non-pharmacological integrated interventions for adults with SMI and T2D.

Methods

Studies from nine electronic databases were searched. Of the 6750 papers retrieved, seven papers (five quantitative and two qualitative) met the inclusion/exclusion criteria. A convergent integrated approach was used to narratively synthesise data into four main themes: effectiveness, acceptability, feasibility, integrated care.

Results

There is moderate evidence to suggest non-pharmacological integrated interventions may be effective in improving some diabetes-related and psychosocial outcomes. Person-centred integrated interventions that are delivered collaboratively by trained facilitators who exemplify principles of integrated care may be effective in reducing the health-treatment gap.

Conclusions

Recommendations from this review can provide guidance to healthcare professionals, commissioners, and researchers to inform improvements to non-pharmacological integrated interventions that are evidence-based, theoretically driven, and informed by patient and healthcare professionals' experiences of care.

Predictors of competitive employment in individuals with severe mental illness: results from an observational, cross-sectional study in Germany

BACKGROUND

Employment is of great importance as it is associated with various positive effects. Individuals with severe mental illness (SMI) are often excluded from competitive employment. Current data on employment of individuals with mental illness are rare, and influencing factors are under-researched. The present study examines possible predictors of competitive employment among individuals with SMI.

METHODS

This was a cross-sectional and multicentered study of 300 individuals with SMI aged 18 to 65 years. The following inclusion criteria were used: (I) diagnosis of schizophrenia, schizotypal and delusional disorders (ICD-10 F2x), or affective disorders (ICD-10 F3x), (II) duration of psychiatric illness ≥ 2 years, and (III) substantial impact of illness on social functioning. Participants were interviewed by trained staff using standardised instruments. The relationship between potential predictors (age, sex, education, marital status, living situation, migration background, psychosocial functioning, age at first mental problem, physical illness, work ability) and employment was analysed using a hierarchic binary logistic regression model.

RESULTS

Only one-third (34%) of participants were competitively employed. Almost one-third were unemployed (30%), and 28% reported early retirement due to mental illness. Psychosocial functioning was positively associated with competitive employment (OR = 1.09, 95% CI: 1.05 - 1.13, p < 0.001); concurrent chronic physical illness was negatively associated with competitive employment (OR = 0.38, 95% CI: 0.21 - 0.71, p = 0.002).

CONCLUSIONS

Findings confirm a high risk of exclusion from competitive employment among individuals with SMI. Nonetheless, a substantial proportion of individuals are employed. Findings call for efforts to maintain or enhance workforce participation among individuals with SMI. A special focus should be placed on improving physical health and strengthening psychosocial functioning.

TRIAL REGISTRATION

The study was registered in the German Clinical Trials Register (DRKS) under the registration number DRKS00015801 before the start of recruitment (Registration date: 21.02.2019).

Improving Physical Health Among People With Serious Mental Illness: The Role of the Specialty Mental Health Sector

People with serious mental illness die 10-20 years earlier, compared with the overall population, and the excess mortality is driven by undertreated physical health conditions. In the United States, there is growing interest in models integrating physical health care delivery, management, or coordination into specialty mental health programs, sometimes called "reverse integration." In November 2019, the Johns Hopkins ALACRITY Center for Health and Longevity in Mental Illness convened a forum of 25 experts to discuss the current state of the evidence on integrated care models based in the specialty mental health system and to identify priorities for future research, policy, and practice. This article summarizes the group's conclusions. Key research priorities include identifying the active ingredients in multicomponent integrated care models and developing and validating integration performance metrics. Key policy and practice recommendations include developing new financing mechanisms and implementing strategies to build workforce and data capacity. Forum participants also highlighted an overarching need to address socioeconomic risks contributing to excess mortality among adults with serious mental illness.

Intention to Use Behavioral Health Data From a Health Information Exchange: Mixed Methods Study

BACKGROUND

Patients with co-occurring behavioral health and chronic medical conditions frequently overuse inpatient hospital services. This pattern of overuse contributes to inefficient health care spending. These patients require coordinated care to achieve optimal health outcomes. However, the poor exchange of health-related information between various clinicians renders the delivery of coordinated care challenging. Health information exchanges (HIEs) facilitate health-related information sharing and have been shown to be effective in chronic disease management; however, their effectiveness in the delivery of integrated care is less clear. It is prudent to consider new approaches to sharing both general medical and behavioral health information.

OBJECTIVE

This study aims to identify and describe factors influencing the intention to use behavioral health information that is shared through HIEs.

METHODS

We used a mixed methods design consisting of two sequential phases. A validated survey instrument was emailed to clinical and nonclinical staff in Alabama and Oklahoma. The survey captured information about the impact of predictors on the intention to use behavioral health data in clinical decision making. Follow-up interviews were conducted with a subsample of participants to elaborate on the survey results. Partial least squares structural equation modeling was used to analyze survey data. Thematic analysis was used to identify themes from the interviews.

RESULTS

A total of 62 participants completed the survey. In total, 63% (n=39) of the participants were clinicians. Performance expectancy (β=.382; P=.01) and trust (β=.539; P<.001) predicted intention to use behavioral health information shared via HIEs. The interviewees (n=5) expressed that behavioral health information could be useful in clinical decision making. However, privacy and confidentiality concerns discourage sharing this information, which is generally missing from patient records altogether. The interviewees also stated that training for HIE use was not mandatory; the training that was provided did not focus specifically on the exchange of behavioral health information.

CONCLUSIONS

Despite barriers, individuals are willing to use behavioral health information from HIEs if they believe that it will enhance job performance and if the information being transmitted is trustworthy. The findings contribute to our understanding of the role HIEs can play in delivering integrated care, particularly to vulnerable patients.

Participant Experiences With a Peer-Led Healthy Lifestyle Intervention for People With Serious Mental Illness

OBJECTIVE

This study explored the experiences of individuals with serious mental illness who were predominantly Black, were living in supportive housing, and participated in the Peer-Led Group Lifestyle Balance (PGLB) intervention. The authors examined how participants engaged in the process of behavior change and applied intervention concepts.

METHODS

Focus groups and interviews with 63 participants explored their motivation for engaging with PGLB, challenges to behavior change, and how they integrated intervention strategies into their lives. Interviews were transcribed and analyzed with grounded theory.

RESULTS

A grounded model summarized the description of the cycle of behavior change and provided insight into participants' decision-making processes. Challenges to engaging in healthy lifestyle change were related to participants' general medical health, time constraints, lack of knowledge, difficulties breaking old habits and changing self-perceptions, mood state, and the social-physical environment. Participants applied many intervention strategies, such as addressing problematic social cues, contexts, and food associations; planning ahead; starting with smaller changes; portion control; food substitution; mindful eating; and integrating changes into their daily lives. They reported various behavior changes with respect to eating and physical activity and more limited shifts in self-monitoring.

CONCLUSIONS

Improving the health of people with serious mental illness will require expanding their access to healthy lifestyle interventions in community-based settings. The findings suggest that future interventions should expand support for self-monitoring, meal planning, tailored physical activity, and advocacy. Such interventions should also enhance participants' understanding of the corresponding impact of changes on weight loss and emphasize subjective wellness outcomes to maintain motivation.

Adapting the Comprehensive Unit Safety Program (CUSP) implementation strategy to increase delivery of evidence-based cardiovascular risk factor care in community mental health organizations: protocol for a pilot study

BACKGROUND

People with serious mental illnesses (SMI) such as schizophrenia and bipolar disorder experience excess mortality driven in large part by high rates of poorly controlled and under-treated cardiovascular risk factors. In the USA, integrated "behavioral health home" models in which specialty mental health organizations coordinate and manage physical health care for people with SMI are designed to improve guideline-concordant cardiovascular care for this group. Such models have been shown to improve cardiovascular care for clients with SMI in randomized clinical trials, but real-world implementation has fallen short. Key implementation barriers include lack of alignment of specialty mental health program culture and physical health care coordination and management for clients with SMI and lack of structured protocols for conducting effective physical health care coordination and management in the specialty mental health program context. This protocol describes a pilot study of an implementation intervention designed to overcome these barriers.

METHODS

This pilot study uses a single-group, pre/post-study design to examine the effects of an adapted Comprehensive Unit Safety Program (CUSP) implementation strategy designed to support behavioral health home programs in conducting effective cardiovascular care coordination and management for clients with SMI. The CUSP strategy, which was originally designed to improve inpatient safety, includes provider training, expert facilitation, and implementation of a five-step quality improvement process. We will examine the acceptability, appropriateness, and feasibility of the implementation strategy and how this strategy influences mental health organization culture; specialty mental health providers' self-efficacy to conduct evidence-based cardiovascular care coordination and management; and receipt of guideline-concordant care for hypertension, dyslipidemia, and diabetes mellitus among people with SMI.

DISCUSSION

While we apply CUSP to the implementation of evidence-based hypertension, dyslipidemia, and diabetes care, this implementation strategy could be used in the future to support the delivery of other types of evidence-based care, such as smoking cessation treatment, in behavioral health home programs. CUSP is designed to be fully integrated into organizations, sustained indefinitely, and used to continually improve evidence-based practice delivery.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04696653 . Registered on January 6, 2021.

Providing Health Physicals and/or Health Monitoring Services in Mental Health Clinics: Impact on Laboratory Screening and Monitoring for High Risk Populations

Providing physical health care in specialty mental health clinics is a promising approach to improving the health status of adults with serious mental illness, but most programs examined in prior studies are not financially sustainable. This study assessed the impact on quality of care of a low-cost program implemented in New York State that allowed mental health clinics to be reimbursed by Medicaid for provision of health monitoring and health physicals (HM/HP). Medicaid claims data were analyzed with generalized linear multilevel models to examine change over time in quality of physical health care associated with HM/HP services. Recipients of HM/HP services were compared to control clinic patients [Per protocol (PP)] and with non-recipients of HM/HP services from both intervention and control clinics [As-Treated (AT)]. HM/HP clinic patients, regardless of receipt of HM/HP services, were compared with control clinic patients [Intent-to-Treat (ITT)]. Analyses were conducted with adjustment for patient demographic and clinical characteristics and prior year service use. The PP and AT analyses found significant improvement in measure of blood glucose screening for patients on antipsychotic medication and HbA1C testing for patients with diabetes (AOR range 1.26-1.33) and the AT analysis found significant improvement in cholesterol screening for patients on antipsychotic medication (AOR 1.24). However, ITT analysis found no significant changes in quality of care in HM/HP clinic caseloads relative to control clinics. The low-cost HM/HP program has the potential to benefit patients who receive supported services, but its impact is limited by remaining barriers to service implementation.

"Being There" vs "Being Direct:" Perspectives of Persons with Serious Mental Illness on Receiving Support with Physical Health from Peer and Non-Peer Providers

Individuals with serious mental illness (SMI) face significant health disparities and multiple barriers to engaging in health behavior change. To reduce these health disparities, it is necessary to enhance the support individuals with SMI receive through the collaboration of different healthcare providers. This study explored how people with SMI living in supportive housing perceived receiving support from peer and non-peer providers for their physical health. Qualitative interviews were conducted with 28 participants receiving a peer-led healthy lifestyle intervention in the context of a randomized trial in supportive housing agencies. Interviews explored participants' experiences working with the healthy lifestyle peer specialist and a non-peer provider who assisted them with health. Interviews were audio recorded, transcribed, and analyzed using strategies rooted in grounded theory. Participants viewed their relationships with peer and non-peer providers positively, but described differences in the approach to practice, power dynamics present, and how they identified with each provider. Participants described peers as process-oriented while non-peer staff as task-oriented, focusing on accomplishing concrete objectives. Each provider sought to boost participants' motivation, but peers built hope by emphasizing the possibility of change, while non-peer providers emphasized the consequences of inaction. Participants related to peer staff through shared experiences, while identifying the importance of having a shared treatment goal with their non-peer provider. Overall, participants appreciated the unique roles of both peer and non-peer staff in supporting their health. Study findings have implications for integrating the use of peer-based health interventions to improve the health of people with SMI.

The Effect of Integrating Primary Care and Mental Health Services on Diabetes and Depression: A Multi-site Impact Evaluation on the US-Mexico Border

BACKGROUND

Health care delivery systems are increasingly integrating physical and mental health services to address patients' complex needs, contain costs, and improve satisfaction. Therefore, it is critical to understand whether adoption of integrated care models is effective in diverse settings.

OBJECTIVE

This study examined the effect of integrated care on physical and mental health outcomes among low-income Latino participants on the US-Mexico border.

RESEARCH DESIGN

In this quasi-experimental multisite study, individual-level data were pooled from 8 studies of locally adapted integrated care models.

SUBJECTS

Participants were 18 years or older and had 1 or more chronic conditions: diabetes, depression, hypertension, or obesity. The study enrolled 4226 participants with 2254 participants in the intervention group and 1972 in the comparison group.

MEASURES

Primary outcomes were depressive symptoms as measured by the Patient Health Questionnaire-9 score and blood glucose measured by hemoglobin A1c (HbA1c). Blood pressure, body mass index, and quality of life were secondary outcomes.

RESULTS

Multivariable linear regression analyses indicated intervention participants had significantly lower Patient Health Questionnaire-9 scores (β=-0.39, P=0.03) and HbA1c (β=-0.14, P=0.02) at 12 months compared with comparison group participants. Stratified analyses showed improvements in HbA1c were even greater among intervention participants who had diabetes, depression, severe and persistent mental illness, were older or female compared with their counterparts in the comparison group.

CONCLUSIONS

Health care is constantly transforming, making it critical to study these changes across populations and settings. Findings from this study indicate that integrated care can significantly improve mental and physical health in an underserved Latino population.

Striking a Balance between Program-Specific and Portfolio-Level Evaluation: Lessons Learned from a Multi-Site Evaluation on the Texas-Mexico Border

Funders are increasingly making strategic investments across multiple grantees, aiming for their portfolio to improve targeted outcomes in a specific issue area. To this end, funders might use multi-site evaluation (MSE) approaches to examine the impact of their collective investments. However, it is important to recognize that each program-and its own program evaluation-must be tailored to its setting, population, and local context to best meet the needs of its target population. Therefore, multi-site evaluations need to account for this complexity. This paper describes the Sí Texas project, a large initiative of eight grantees implementing different integrated behavioral health models to improve physical and mental health outcomes along the Texas-Mexico border. With over 4,200 MSE study participants, the evaluation for Sí Texas used a partnership-centered approach to both enhance the evidence base and build local organizational capacity. This paper describes this approach, the process of tailoring evaluation practices to the grantees' context, and the challenge of balancing consistency at the grantee-level for the portfolio multi-site evaluation. Successes, challenges, and lessons learned related to study design, data collection, grantee partnership, and capacity building are discussed.

Typology of organizational innovation components: building blocks to improve access to primary healthcare for vulnerable populations

BACKGROUND

Achieving equity of access to primary healthcare requires organizations to implement innovations tailored to the specific needs and abilities of vulnerable populations. However, designing pro-vulnerable innovations is challenging without knowledge of the range of possible innovations tailored to vulnerable populations' needs. To better support decision-makers, we aimed to develop a typology of pro-vulnerable organizational innovation components - akin to "building blocks" that could be combined in different ways into new complex innovations or added to existing organizational processes to improve access to primary healthcare.

METHODS

To develop the typology, we used data from a previously conducted a) scoping review (2000-2014, searched Medline, Embase, CINAHL, citation tracking, n = 90 articles selected), and b) environmental scan (2014, online survey via social networks, n = 240 innovations). We conducted a typological analysis of the data. Our initial typology yielded 48 components, classified according to accessibility dimensions from the Patient-Centred Accessibility Framework. The initial typology was then field-tested for relevance and usability by health system stakeholders and refined from 2014 to 2018 (e.g., combined similar components, excluded non-organizational components).

RESULTS

The selected articles (n = 90 studies) and survey responses (n = 240 innovations) were mostly from the USA, Canada, Australia and the UK. Innovations targeted populations with various vulnerabilities (e.g., low income, chronic illness, Indigenous, homeless, migrants, refugees, ethnic minorities, uninsured, marginalized groups, mental illness, etc.). Our final typology had 18 components of organizational innovations, which principally addressed Availability & Accommodation (7/18), Approachability (6/18), and Acceptability (3/18). Components included navigation & information, community health worker, one-stop-shop, case management, group visits, defraying costs, primary healthcare brokerage, etc. CONCLUSIONS: This typology offers a comprehensive menu of potential components that can help inform the design of pro-vulnerable organizational innovations. Component classification according to the accessibility dimensions of the Patient-Centred Accessibility Framework is useful to help target access needs. Components can be combined into complex innovations or added to existing organizational processes to meet the access needs of vulnerable populations in specific contexts.

The effectiveness of interventions to increase preventive care provision for chronic disease risk behaviours in mental health settings: A systematic review and meta-analysis

Clinical practice guidelines direct mental health services to provide preventive care to address client chronic disease risk behaviours, however, this care is not routinely provided. The aim of this systematic review was to synthesise evidence regarding the effectiveness of interventions to increase provision of preventive care by mental health services; by care element (ask, assess, advice, assist, arrange) and risk behaviour (tobacco smoking, poor nutrition, harmful alcohol consumption, physical inactivity). Electronic bibliographic databases, Google Scholar, relevant journals, and included study reference lists were searched. Eligible studies were of any design with a comparison group that reported the effectiveness of an intervention to increase the provision of at least one element of preventive care for at least one risk behaviour in a mental health setting. Twenty studies were included, most commonly examining smoking (n = 20) and 'ask' (n = 12). Meta-analysis found interventions involving task shifting were effective in increasing smoking 'advice' (n = 2 RCTs; p = 0.009) and physical activity 'advice' (n = 2 RCTs; p = 0.002). Overall, meta-analysis and narrative synthesis indicated that effective intervention strategies (categorised according to the Effective Practice and Organisation of Care taxonomy) were: task shifting, educational meetings, health information systems, local consensus processes, authority and accountability, and reminders. The most consistent findings across studies were with regard to preventive care for smoking, while conflicting or limited evidence was found regarding other risk behaviours. While further rigorous research examining key risk behaviours is recommended, the findings may inform the selection of strategies for future interventions and service delivery initiatives.

A systematic scoping review of interventions to integrate physical and mental healthcare for people with serious mental illness and substance use disorders

Integrated care approaches have been recommended to remove barriers to healthcare and improve the physical health outcomes of people living with serious mental illness (SMI) and/or substance use disorders (SUDs). The aim of this systematic scoping review was to describe empirical investigations of interventions designed to integrate physical, mental, and addiction healthcare for this population. An iterative and systematic search of five electronic databases (Medline (Ovid), PsycINFO, CINAHL, Embase (Ovid) and Scopus) was conducted to identify peer-reviewed articles published between January 2000 and April 2019. Two reviewers independently screened publications in two successive stages of title and abstract screening, followed by full-text screening of eligible publications. Data from each included publication were extracted independently by two reviewers using a standardised spreadsheet. A total of 28 eligible publications were identified, representing 25 unique studies. Over half of the included studies investigated the use of case managers to provide self-management skills or to coordinate mental and physical healthcare (n = 14). Other interventions examined the co-location of services (n = 9) and the implementation of screening and referral pathways to specialist treatment (n = 2). Less than half of the included studies described a framework, theory or model that was underpinning the intervention tested. While some aspects of integrated care have been identified and addressed by interventions, other key dimensions have not been considered, such as shared decision-making. Identification of a comprehensive model of integrated care is recommended to inform the development and evaluation of future interventions for people with SMI/SUDs.

Psychiatry NCHD referrals to the local emergency department in the context of an in-house primary care service

OBJECTIVES.

Patients with psychiatric illness are at increased risk of developing non-psychiatric medical illnesses. There have been positive reports regarding the integration of primary care services into mental health facilities. Here, we evaluate the appropriateness of psychiatry non-consultant hospital doctors (NCHD) transfers to the local emergency department (ED) in the context of an in-house primary care service.

METHODS.

We reviewed the inpatient transfers from St Patrick's University Hospital (SPUH) to the local ED at St James' Hospital (SJH) from 1 January 2016 to 31 December 2017. We used inpatient admission to SJH as our primary marker of an appropriate transfer.

RESULTS.

246 inpatients were transferred from SPUH to the SJH ED for medical review in the years 2016 and 2017. 27 (11%) of these were referred to the ED by the primary care service. 51% of those referred were admitted with similar rates of admission for both general practitioner (n = 27, 54% admitted) and NCHD initiated referrals (n = 219, 51% admitted). Acute neurological illness, concern regarding a cardiac illness, and deliberate self-harm were the most common reasons for referral.

CONCLUSION.

Our primary finding is that, of those transferred to ED by either primary care or a psychiatry NCHD, a similar proportion was judged to be in need of inpatient admission. This indicates that as a group, psychiatry NCHD assessment of acuity and need for transfer was similar to that of their colleagues in primary care.

Impact of Behavioral Health Homes on Cost and Utilization Outcomes

OBJECTIVE

This study evaluated the impact of two behavioral health home (BHH) approaches, provider-supported care and self-directed care, on health care utilization and cost outcomes among adult Medicaid recipients with serious mental illness.

METHODS

Eleven community mental health provider sites were randomly assigned to one of the BHH approaches, which each site implemented over a 2-year period. In both approaches, staff were trained in wellness coaching to support patients' progress toward general health and wellness goals. Provider-supported sites employed a full-time on-site registered nurse, who provided consultation to patients and wellness coaches. Each approach had a consistently enrolled treatment group (combined N=859) with a matched comparison cohort that was identified for analysis. Approaches were compared with each other and with baseline, and differences between each approach and its comparison cohort were examined by using analysis of covariance to determine impact on total health care cost, prescription costs, and use and cost of general medical and behavioral health services.

RESULTS

Relative to its comparison cohort, each approach achieved significant reductions in total cost (15% for provider-supported care and 26% for self-directed care) and increases in use of outpatient general medical services (43% for provider-supported care and 29% for self-directed care). Compared with self-directed care, provider-supported care resulted in approximately 28% lower use of general medical inpatient services and 26% lower related costs.

CONCLUSIONS

BHH approaches in community mental health settings can produce health care savings and decrease use of inpatient health care.

Randomized Trial of Reverse Colocated Integrated Care on Persons with Severe, Persistent Mental Illness in Southern Texas

BACKGROUND

Persons with severe, persistent mental illness (SPMI) are at high risk for poor health and premature mortality. Integrating primary care in a mental health center may improve health outcomes in a population with SPMI in a socioeconomically distressed region of the USA.

OBJECTIVE

To examine the effects of reverse colocated integrated care on persons with SPMI and co-morbid chronic disease receiving behavioral health services at a local mental health authority located at the US-Mexico border.

DESIGN

Randomized trial evaluating the effect of a reverse colocated integrated care intervention among chronically ill adults.

PARTICIPANTS

Participants were recruited at a clinic between November 24, 2015, and June 30, 2016.

INTERVENTIONS

Receipt of at least two visits with a primary care provider and at least one visit with a chronic care nurse or dietician, compared with usual care (behavioral health only).

MAIN MEASURES

The primary outcome was blood pressure. Secondary outcomes included HbA1c, BMI, total cholesterol, and depressive symptoms. Sociodemographic data were collected at baseline, and outcomes were measured at baseline and 6- and 12-month follow-ups.

KEY RESULTS

A total of 416 participants were randomized to the intervention (n = 249) or usual care (n = 167). Groups were well balanced on almost all baseline characteristics. At 12 months, intent-to-treat analysis showed intervention participants improved their systolic blood pressure (β = - 3.86, p = 0.04) and HbA1c (β = - 0.36, p = 0.001) compared with usual care participants when controlling for age, sex, and other baseline characteristics. No participants withdrew from the study due to adverse effects. Per-protocol analyses yielded similar results to intent-to-treat analyses and found a significantly protective effect on diastolic blood pressure. Older and diabetic populations differentially benefited from this intervention.

CONCLUSIONS

Colocation and integration of behavioral health and primary care improved blood pressure and HbA1c after 1-year follow-up for persons with SPMI and co-morbid chronic disease in a US-Mexico border community.

TRIAL REGISTRATION

clinicaltrials.gov , Identifier: NCT03881657.

[Management of cardiovascular co-morbidities in young patients with early onset psychosis: State of the art and therapeutic perspectives]

Patients with psychiatric disorders have a decrease in their life expectancy. Excess mortality of patients with schizophrenia was demonstrated by a meta-analysis in the late 1990s and has not decreased for the past 30years. A recent meta-analysis including nearly 250,000 patients with schizophrenia found an average decrease in life expectancy of 14.5years (CI95: 11,2-17,8), more important for men than for women: 15.9 (CI95: 13,8-18,0) vs 13.6 (CI95: 11,4-15,8). A closer look at the somatic comorbidities, including metabolic syndrome, and investigation of causes of death of these patients highlighted already well-known factors, namely late diagnosis and insufficient treatment of physical diseases, side effects of antipsychotics, unhealthy lifestyle (poor diet, smoking, excessive alcohol consumption and lack of exercise), and higher risk of suicide and accident. Concerning ultra-high risk (UHR) patients, a 2016 meta-analysis of 47 studies evaluated the cardiovascular risk factors. They reported a higher prevalence of smoking in UHR (odds ratio 2,3) and a lower level of physical activity associated with a normal BMI (Body Mass Index) compared to the control population. A meta-analysis about patients with a first episode of psychosis (FEP) found reduced total and LDL cholesterol levels and an increased triglyceride level compared to the control population. One study found alteration of the fasting plasmatic levels of glucose and insulin, as well as insulin resistance in FEP patients, compared to controls albeit the HbA1c level was not significantly different. A meta-analysis reported a prevalence of metabolic syndrome of 10 % in FEP or drug naïve patients versus 35 % and 20 % in treated and untreated patients with chronic schizophrenia respectively. Somatic comorbidities usually appear during the first two years of the disease. Some interventions have proven their efficacy in reducing the occurrence of metabolic syndrome and other cardiovascular risk factors. For instance, metformin, a treatment for type 2 diabetes that is allowed from the age of 10, has shown benefits in children and adolescents receiving second-generation antipsychotics in a recent meta-analysis, with a mean weight loss of 3.23kg (IC95 % -5.59 -0.86) after 16 weeks. Dietary-hygienic interventions are also effective in reducing cardiovascular risk. Other interventions such as omega-3 supplementation, vitamin D, N-acetylcysteine, and fasting have not proven to be effective. Comprehensive care programs have been developed to promote somatic care in psychiatric patients, such as the Canadian HeAL (Healthy Active Lives) program. These programs are more effective when proposed from the beginning of the disease and the introduction of antipsychotics. In this review, because there is no French recommendation, we translate a tool for the prescription of metformin and the Canadian recommendations from the HeAL program. Generalization of these programs to all young psychotic patients could improve their life expectancy and reduce the overall mortality. Prevention of cardiovascular risk factors and cardio-metabolic monitoring of treatments must be part of the standard of care in early psychosis. These programs aim at providing patients with the quality of somatic and mental care they are entitled to. This requires the involvement of all stakeholders, including patients and their families but also psychiatrists and other caregivers.

Are There Performance Advantages Favoring Federally Qualified Health Centers in Medical Home Care for Persons with Severe Mental Illness?

To identify whether medical homes in FQHCs have advantages over other group and individual medical practices in caring for people with severe mental illness. Models estimated the effect of the type of medical home on monthly service utilization, medication adherence, and total Medicaid spending over a 4-year period for adults aged 18 or older with a major depressive disorder (N = 65,755), bipolar disorder (N = 19,925), or schizophrenia (N = 8501) enrolled in North Carolina's Medicaid program. Inverse probability of treatment weights (IPTW) were used to adjust for nonrandom assignment of patients to practices. Generalized estimating equations for repeated measures were used with gamma distributions and log links for the continuous measures of medication adherence and spending, and binomial distributions with logit links for binary measures of any outpatient or any emergency department visits. Adults with major depression or bipolar disorders in FQHC medical homes had a lower probability of outpatient service use than their counterparts in individual and group practices. The probability of emergency department use, medication adherence, and total Medicaid spending were relatively similar across the three settings. This study suggests that no one type of medical practice setting-whether FQHC, other group, or individual-consistently outperforms the others in providing medical home services to people with severe mental illness.

"We're All in this Together": Peer-specialist Contributions to a Healthy Lifestyle Intervention for People with Serious Mental Illness

This qualitative study explored peer specialists' contributions to a healthy lifestyle intervention for obese/overweight individuals with serious mental illness (SMI) living in supportive housing. Intervention participants, peer specialists, and supervisors were interviewed and a grounded model emerged from the data identifying essential interpersonal attributes of the peer specialist-participant relationship. Peer specialists' disclosure of their own experiences making health behaviors changes was critical for building participants' motivation and ability to try lifestyle changes. Findings can inform peer specialist training and practice standards and facilitate the expansion of peer-delivered interventions to improve the physical health of people with SMI.

A Case Study of Implementing Grant-Funded Integrated Care in a Community Mental Health Center

The US government funds integrated care demonstration projects to decrease health disparities for individuals with serious mental illness. Drawing on the Exploration Preparation Implementation Sustainability (EPIS) implementation framework, this case study of a community mental health clinic describes implementation barriers and sustainability challenges with grant-funded integrated care. Findings demonstrate that integrated care practices evolve during implementation and the following factors influenced sustainability: workforce rigidity, intervention clarity, policy and funding congruence between the agency and state/federal regulations, on-going support and training in practice application, and professional institutions. Implementation strategies for primary care integration within CMHCs include creating a flexible workforce, shared definition of integrated care, policy and funding congruence, and on-going support and training.

Meeting the Needs of Justice-Involved People With Serious Mental Illness Within Community Behavioral Health Systems

The overrepresentation of people with serious mental illness in the criminal justice system is a complex problem. A long-standing explanation for this phenomenon, the criminalization hypothesis, posits that policy changes that shifted the care of people with serious mental illness from psychiatric hospitals to an underfunded community treatment setting resulted in their overrepresentation within the criminal justice system. This framework has driven the development of interventions to connect people with serious mental illness to needed mental health and substance use treatment, a critical component for people in need. However, the criminalization hypothesis is a limited explanation of the overrepresentation of people with serious mental illness in the criminal justice system because it downplays the social and economic forces that have contributed to justice system involvement in general and minimizes the complex clinical, criminogenic, substance use, and social services needs of people with serious mental illness. A new approach is needed that focuses on addressing the multiple factors that contribute to justice involvement for this population. Although the authors' proposed approach may be viewed as aspirational, they suggest that an integrated community-based behavioral health system-i.e., intercept 0-serve as the focal point for coordinating and integrating services for justice-involved people with serious mental illness.

Integrated Care for Older Adults with Serious Mental Illness and Medical Comorbidity: Evidence-Based Models and Future Research Directions

The excess risk of early mortality, medical comorbidity, early institutionalization, and high costs among older adults with serious mental illness necessitates development and dissemination of effective and sustainable integrated care models that simultaneously address mental and physical health needs. This overview highlights current, evidence-based integrated care models, which predominantly adopt the following approaches: (1) psychosocial skills training, (2) integrated illness self-management, and (3) collaborative care and behavioral health homes. Finally, innovative models that build on these approaches by incorporating novel uses of telehealth, mobile health technology and peer support, and strategies from developing economies are discussed.

A Qualitative Study on the Barriers to Learning in a Primary Care-Behavioral Health Integration Program in an Academic Hospital: the Family Medicine Perspective

OBJECTIVE

Integrating behavioral health services into the primary care setting is a recognized approach to improving timely access and building capacity for primary care providers. The aim of this study was to examine barriers to family medicine resident learning in a co-located primary care-behavioral health integration program with psychiatrists in an academic hospital.

METHODS

The authors used a descriptive qualitative study design to collect data on participants' learning experiences from focus groups and semi-structured interviews with 5 family medicine residents, 3 psychiatry residents, 5 family physicians, 3 psychiatrists, 2 office coordinators, and 2 educational coordinators. Thematic analysis of transcripts was performed.

RESULTS

Three themes were identified with respect to barriers to learning in the program from the family medicine perspective. Organizational barriers encompassed lack of clear vision, goals, roles, and responsibilities. Administrative barriers involved complex appointment bookings and scheduling. Communication and engagement barriers included insufficient communication between team members and lack of patient engagement in the program.

CONCLUSIONS

The study findings highlight the importance of several factors for the successful implementation of a co-located academic primary care-behavioral health integrated model. This includes the formalization of program structure that encompasses shared vision, goals, roles, and responsibilities; coordinated processes for appointment bookings; team communication and patient engagement; and diverse educational and longitudinal care opportunities. With the growing number of integrated care programs, these results provide guidance for health care leaders involved in the design and management of primary care-behavioral health integration programs.

Systematic Review of the Impact of Behavioral Health Homes on Cardiometabolic Risk Factors for Adults With Serious Mental Illness

OBJECTIVE

This systematic review examined the impact of health homes on cardiometabolic risk among adults with serious mental illness.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses procedures were used to conduct the systematic review. Databases were searched for peer-reviewed articles published between 1946 and August 2018 that compared health homes with a control condition (e.g., usual care and secondary data analyses using matched samples). Participants, interventions, comparisons, outcomes, and study design criteria were used to assess study eligibility. Studies were assessed for methodological quality by using the Quality Assessment of Before and After Studies With No Control Group and the Quality Assessment of Controlled Intervention Studies.

RESULTS

Eighteen studies (i.e., 11 observational studies, four quasi-experimental studies, and three randomized controlled trials) reported on 17 health homes. Most studies reported increases in receipt of screening for cardiometabolic risk factors and service use. There was a modest reduction in selected cardiometabolic risk factors among people with serious mental illness, but clinical outcomes varied widely among studies.

CONCLUSIONS

Improvement in cardiometabolic risk factors varied across the studies, and the clinical significance of these reductions was not clear. Peer support and self-management training may represent strategies to improve cardiometabolic risk factors. Colocation of services may not be enough to significantly affect cardiometabolic risk factors. Health homes that include standardized screening, peer support and self-management training, and intervention components that target interdependent risk factors may have a greater impact on clinical outcomes.

The Policy Ecology of Behavioral Health Homes: Case Study of Maryland's Medicaid Health Home Program

Behavioral health homes, shown to improve receipt of evidence-based medical services among people with serious mental illness in randomized clinical trials, have had limited results in real-world settings; nonetheless, these programs are spreading rapidly. To date, no studies have considered what set of policies is needed to support effective implementation of these programs. As a first step toward identifying an optimal set of policies to support behavioral health home implementation, we use the policy ecology framework to map the policies surrounding Maryland's Medicaid behavioral health home program. Results suggest that existing policies fail to address important implementation barriers.

A collaboration between service users and professionals for the development and evaluation of a new program for cardiovascular risk management in persons with a diagnosis of severe mental illness: French multicenter qualitative and feasibility studies

Background

Persons with a diagnosis of severe mental illness have a life expectancy that is 20 years lower than the general population, and they are disproportionately affected by cardiovascular disorders. Improving the management of cardiovascular risk is one of the main challenges for the public health system. In the care pathway of persons with a diagnosis of severe mental illness, a better understanding of limiting and facilitating factors is required. The objective was to include persons with a diagnosis of severe mental illness, carers, and primary and mental health professionals in the creation and evaluation (feasibility) of a health promotion program designed to improve cardiovascular risk management through empowerment.

Methods

This study combines a mixed methodology with qualitative and quantitative components. A multicenter prospective qualitative study was conducted in seven mental health units in France and was coordinated by a steering committee composed of persons with a diagnosis of severe mental illness, carers, and primary and mental health professionals.

Results

This health promotion program must enable persons with a diagnosis of severe mental illness to assert their right to self-determination and to exercise greater control over their lives, beyond their diagnosis and care. Following a preliminary feasibility study, the effectiveness of this new tool will be evaluated using a randomized controlled trial in a second study.

Conclusions

The findings can be used by health organizations as a starting point for developing new and improved services for persons with a diagnosis of severe mental illness.Trial registration Clinical Trials Gov NCT03689296. Date registered September 28, 2018.

A reverse colocated integrated care model intervention among persons with severe persistent mental illness at the U.S.-Mexico border: A randomized controlled trial protocol

Persons with severe persistent mental illness (SPMI)—which includes individuals with schizophrenia, bipolar disorder, and mood disorders such as major depression—are at high risk for poor health outcomes and premature death. Persons with SPMI are largely absent from research evaluating innovative health care models due to recruitment and retention barriers. This paper presents the protocol for a randomized control trial testing a reverse colocated integrated care model in an SPMI population receiving care at a mental health clinic at the U.S.-Mexico border. The study employs a randomized control trial design to determine whether reverse colocated integrated care improves physical and mental health of persons with SPMI. Participants will be randomized to receive the integrated primary care intervention or usual care (behavioral health only). All study participants will complete baseline, 6-, and 12-month assessments. Study outcomes included blood pressure, HbA1c, cholesterol, body mass index, depression, and adult functioning. Despite challenges in recruiting and retaining SPMI patients, co-locating primary care services within a local mental health authority has the potential to improve health and reduce health disparities experienced by persons with SPMI. The study will determine the impacts of this colocated integrated care model among SPMI patients in a socio-economically disadvantaged region.

Clinical Trials.gov Identifier: NCT03881657.

Predictors of Receipt of Physical Health Services in Mental Health Clinics

To inform efforts to improve physical health care for adults with serious mental illness, this study examines predictors of provision and receipt of physical health services in freestanding mental health clinics in New York state. The number of services provided over the initial 12-months of implementation varied across clinics from 0 to 1407. Receipt of services was associated with a diagnosis of schizophrenia, frequent mental and physical health visits in the prior year, and prescription of antipsychotic medications. Additional support may also be needed to enable clinics to target patients without established patterns of frequent mental health or medical visits.

Integrating Primary Care Into Community Mental Health Centres in Texas, USA: Results of a Case Study Investigation

Introduction

Despite evidence that people with serious mental illness benefit from receiving primary care within mental health care settings, there is little research on this type of integration. The objective of this study was to characterize how providers and patients experienced implementation of primary care into specialty mental health services.

Methods

During site visits, study team members interviewed staff and conducted focus groups with patients at 10 United States community mental health centres then beginning to integrate primary into their practices. One year later, follow up phone interviews with key centre staff informants validated and updated findings. Data analysis included thematic coding of results from staff interviews and patient focus groups.

Results

Findings included the importance of the scope of primary care services provided on site, given limited alternatives available to patients; rapid scale-up; overcoming challenges in provider recruitment and retention; and adaptations to engage patients as well as to improve communication between mental health and primary care providers.

Conclusion

Providers and patients perceived improvements through integrated care. However, the majority of patients were uninsured, and the funding was short term. The long-term viability of integrated care for community mental health centre patients may hinge on adequate, predictable public funding.

[A caregiver-person with schizophrenia partnership to improve oral health education]

INTRODUCTION

Poor oral health in persons with schizophrenia is a major public health issue affecting 600,000 people in France. The aim of this article was to present the different stages in the development of a specific oral health educational program for persons with schizophrenia. It takes into account experimental knowledge of these persons and presents the results of the feasibility study.

PATIENTS AND METHOD

The focus group method was applied to a group of health professionals and users to highlight an exploratory corpus in order to develop an oral health educational program. An expert group including persons with schizophrenia among others validated the fields and tools of this program. A feasibility study was then conducted in a control group of 7 persons with schizophrenia.

RESULTS

Altogether, 26 persons participated in this feasibility study. The main fields investigated by the expert group aimed to promote personal responsibility for one’s health, to improve access to the healthcare system and to promote the global management of health. The feasibility study showed the ability of this program to change persons with schizophrenia representations and knowledge of this health problem. Most educational tools were considered relevant.

CONCLUSION

An oral health educational program was built as part of a caregiver-persons with schizophrenia partnership and showed its feasibility. A multicentric randomized trial is currently ongoing to assess the efficacy of this program with a high level of proof.

Perspectives of Individuals With Serious Mental Illness on a Reverse-Colocated Care Model: A Qualitative Study

OBJECTIVE

Individuals with serious mental illness experience excess mortality related to general medical comorbidities. Reverse-integrated and reverse-colocated models of care have been proposed as a system-level solution. Such models integrate primary care services within behavioral health settings. Further understanding of consumer perspectives on these models is needed to ensure that models adequately engage consumers on the basis of their expressed needs. This qualitative study examined the perspectives of English- and Spanish-speaking individuals with serious mental illness on their current experience with the management of their medical care and on a hypothetical reverse-colocated care model.

METHODS

Semistructured interviews were conducted in a purposive sample of 30 individuals with serious mental illness recruited from two outpatient mental health clinics affiliated with a comprehensive community-based program. The interview assessed the participant's current experience with the management of their health care, followed by a vignette describing a reverse--colocated care model and questions to elicit the participant's reaction to the vignette. An inductive thematic analysis was employed.

RESULTS

Consumers expressed positive views of the potential for working with trusted staff, increased communication, and access to care through reverse colocation. Reflections on current health management experience were notable for an emphasis on self-efficacy and receipt of support for self-management strategies from mental health clinicians.

CONCLUSIONS

Study findings add to prior literature indicating support for assistance with management of general medical health in the mental health setting among individuals with serious mental illness. Key themes similar to those in previous studies generate hypotheses for further evaluation.