Lead/Presenter: Alexander Young,
VISN-22 MIRECC, Los Angeles
All Authors: Young AS (VISN-22 MIRECC, Los Angeles), Cohen AN (VISN 22 Mental Illness Research, Education and Clinical Center, Los Angeles), Chang DT (VA Southern Nevada Healthcare System, Las Vegas) Hamilton AB (Center for the Study of Healthcare Innovation, Implementation & Policy, Los Angeles) Lindamer LA (VA San Diego Healthcare System) Oberman R (VISN 22 Mental Illness Research, Education and Clinical Center, Los Angeles) Whelan F (UCLA Department of Psychiatry and Biobehavioral Sciences) Chang ET (VISN 22 Mental Illness Research, Education and Clinical Center, Los Angeles)
People with serious mental illness (SMI) have rates of premature mortality three times the general population, mostly due to "natural causes" such as cardiovascular disease and cancer. Often, people with SMI are not well engaged in primary care and do not receive high-value medical services. There have been numerous efforts to improve this care, and few controlled trials, with inconsistent results. Prior projects suggest that integrated care and medical care management could improve treatment and reduce treatment costs.
A hybrid implementation-effectiveness study, this is a cluster controlled trial of a medical home, the SMI Patient-Aligned Care Team (SMI PACT), to improve healthcare of patients with SMI. SMI PACT includes proactive nurse care management and integrated psychiatric treatment using collaborative care. Within VISN 22, one medical center was assigned to SMI PACT and two to usual care. Intervention patients were recruited based on having SMI that was controlled and elevated medical risk (CAN score). Linear mixed effects repeated measures models compared the intervention over time to control on assessment of chronic illness care, care experience, psychiatric symptoms, and quality of life. Formative evaluation strengthened the intervention, and studied patients, providers, organizational context and treatments.
164 intervention and 167 control patients enrolled for a median of 401 days. 39 providers enrolled. At baseline, intervention and control groups were quite similar. Participants were 15% female with mean CAN = 85. However, more intervention patients had schizophrenia (35% vs. 21%). 63 intervention patients (38%) moved all psychiatric care to the PACT. Intervention patients had 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's = 10-24, p's < .0001); and significantly greater improvement in quality of life and psychotic symptoms. Patient, provider and organizational barriers and facilitators were characterized.
A specialized PACT for SMI can be feasible, safe and more effective than usual care. This model addresses healthcare challenges faced by people with SMI.
This is one of the first controlled trials of a primary care medical home with collaborative care for people with SMI. Processes and tools have been developed for implementation.