In Treating Individuals with Serious Mental Illness, Primary Care Medical Homes Proved to be Effective

According to a new study led by UCLA researchers, a specialized primary care medical home enhanced the care and treatment of patients with major mental illness, resulting in improved mental health-related quality of life.

The study, published in the Journal of General Internal Medicine, is the first to look at the benefits of a primary care medical home for patients with serious mental disorders (SMI), such as schizophrenia or bipolar disorder, who die at three times the general population’s rate.

Individuals suffering from major mental diseases frequently exhibit psychiatric symptoms, cognitive deficiencies, decreased social skills, social disadvantage, and a high rate of substance addiction, especially cigarette addiction. These people visit hospitals and emergency rooms more frequently than patients with chronic illnesses alone, but they see primary care less frequently and are less likely to obtain high-value preventive and chronic care treatments.

The patient-centered medical home is a care model that uses registries, information technology, and other resources to deliver comprehensive, coordinated care between patients and their providers. Its goal is to guarantee that patients receive care on a continuous basis in order to better manage chronic illnesses and preserve wellbeing, rather than merely during discrete, periodic trips to the doctor’s office.

Our team’s study shows that a patient-centered medical home can be effective and should be considered for improving the health care of patients with serious mental illnesses.

Dr. Alex Young

“Just as few psychiatrists are trained in primary care or can provide these services, the same is true for primary care physicians and we need to be able to better coordinate care for these vulnerable patients,” said Dr. Alex Young, lead author of the study and interim chair of the department of psychiatry and director of the Semel Institute for Neuroscience & Human Behavior at the David Geffen School of Medicine at UCLA, and associate director of the Health Services Unit at the VA VISN 22 Mental Illness, Research, Education and Clinical Center. “Our team’s study shows that a patient-centered medical home can be effective and should be considered for improving the health care of patients with serious mental illnesses.”

Numerous initiatives have been made to improve care for people with SMI and reduce the usage of high-cost emergency visits, including co-locating mental health and general care. However, when compared to individuals with SMI receiving standard treatments, most have failed to create significant improvements in treatment or care outcomes.

The researchers designed, implemented, and studied a specialized patient-centered medical home in the United States Veterans Health Administration, referred to by the VA as Patient Aligned Care Teams or PACTs, to determine how effective the patient-centered medical home was in improving care and treatment of patients with SMI.

The trial included three VA medical centers: VA Greater Los Angeles, VA San Diego, and VA Southern Nevada Healthcare Systems, with one facility assigned to execute the intervention and the other two serving as a comparison group getting standard care for SMI patients. Patients with severe mental illnesses included those suffering from schizophrenia, bipolar disorder, recurrent major depression with psychosis, or chronic severe post-traumatic stress disorder.

Primary care medical home found to be more effective than usual care in treating patients with serious mental illness

The “intervention group” received care from a specialized, integrated team of healthcare professionals who offered both general and psychiatric care, including a primary care doctor and a nurse care manager who worked at the same facility. A psychiatrist provided consultation to the team, including being available via phone, instant chat, or email. All patients were offered the option of continuing to receive mental health care from their existing psychiatrist or shifting all of their psychiatric care to the SMI PACT medical home team.

Patients in the “usual” care group continued to receive care as normal, with primary care provided by a team of clinicians (either a physician or a nurse practitioner), a nurse, a medical assistant, and clerks. Services for patients were provided at specialty mental health clinics that were separate from primary care.

In the study of 331 SMI patients, 164 received the “intervention” under the new treatment model, while the remaining 167 received normal care at the other two VA medical sites. Participants spent an average of 401 days in the trial.

The researchers examined data from patient surveys taken at the start of the study and after 12 months that measured primary preventive screenings, perceived chronic illness care, patients’ care experience, and health-related quality of life to assess the effectiveness of the primary medical home model. To establish the appropriateness and quality of therapy, other outcomes such as psychiatric symptoms and chronic disease care were measured alongside data on various screens, diagnoses, prescriptions, services, and physician visits.

The study’s key findings revealed that 40% of intervention participants transferred their psychiatric care to the primary care SMI PACT. The intervention patients also improved over time in suitable tests such as BMI (87.8 percent vs. 70.5 percent receiving usual treatment), lipids (53.7 percent vs. 24.7 percent receiving usual care), and glucose (72.6 percent vs. 51.2 percent receiving usual care). There was also a greater improvement in all aspects of chronic illness care, including decision support, goal setting, and counseling, as well as care experience in doctor-patient interactions, shared decision-making, care coordination, access to care, and mental-health related quality of life.

“While people with major mental illness are some of the most difficult and expensive patients to treat,” said Dr. Young, “it is possible to enable seriously mentally ill individuals be healthy and productive while decreasing their need to use hospital and emergency departments. This care paradigm was proven to be effective in terms of enhancing treatment appropriateness and patient outcomes. While this concept requires further investigation, it should be examined in order to enhance care for persons suffering from significant mental illness.”

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