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

The study, published April 5 in the Journal of General Internal Medicine, is the first controlled trial to look at the benefits of a primary care medical home for patients with serious mental illnesses (SMI), such as schizophrenia or bipolar disorder, who die at rates three times higher than the general population.

Individuals with serious mental illnesses often have psychiatric symptoms, cognitive deficits, impaired social skills, social disadvantage and high rates of addiction to substances, including tobacco. These individuals use hospitals and emergency rooms more frequently than patients with chronic illnesses alone -- but use primary care less often and are less likely to receive high value preventative and chronic care services.

The patient-centered medical home is a care model that provides comprehensive, coordinated care among patients and their clinicians through the use of registries, information technology and other resources. It is intended to ensure that patients receive care on a continuous basis to better manage chronic conditions and maintain wellness -- rather than just during separate, periodic visits to the doctor's office.

"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 efforts to improve care for patients with SMI and to reduce the use of high-cost emergency visits have involved a variety of approaches, including co-locating mental health and primary care. However, most have failed to produce substantial improvement in patients' treatment or care outcomes when compared to individuals with SMI receiving usual services.

To find out how effective the patient-centered medical home was to improve care and treatment of patients with SMI, the researchers designed, implemented, and studied a specialized patient-centered medical home in the U.S. Veterans Health (VA) Administration, referred to by the VA as Patient Aligned Care Teams or PACTs.

Three VA medical centers participated in the study: VA Greater Los Angeles, VA San Diego and VA Southern Nevada Healthcare Systems, with one location assigned to implement the intervention, and the other two serving as a comparison group receiving the usual care provided to patients with SMI. Patients with seriously mental illness were those with schizophrenia, bipolar disorder, recurrent major depression with psychosis or chronic severe post-traumatic stress disorder.

Care in the "intervention group" was provided by a specialized, integrated team of healthcare professionals that provided both primary and psychiatric care, including a primary care doctor and a nurse care manager who were co-located at the same site. A psychiatrist consulted to the team, including being available by phone, instant messaging or email. All patients were given the choice to continue receiving mental health care from their established psychiatrist elsewhere or to move all their psychiatric care to the SMI PACT medical home team.

In the "usual" care group, patients continued to receive care as usual, with primary care delivered by a team of a clinicians -- either a physician or nurse practitioner -- a nurse, 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 patients with SMI,164 received the "intervention," under the new care model, while 167 received usual care at the other two VA medical centers. Participants were in the study for an average of 401 days.

To evaluate the effectiveness of the primary medical home model, the researchers examined data taken from patient surveys at the beginning 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. Additional outcomes such as psychiatric symptoms and care for chronic illness were also measured along with data on various screenings, diagnoses, prescriptions, services and medical visits to determine the appropriateness and quality of treatment.

Key findings from the study showed that 40 percent of intervention participants moved their psychiatric care to the primary care SMI PACT. The intervention patients also experienced greater improvement over time in appropriate screenings that included: body mass index (87.8% vs. 70.5% receiving usual care), lipids (53.7% vs. 24.7% receiving usual care); and glucose (72.6% vs. 51.2% receiving usual care). There was also greater improvement in all areas of chronic illness care such as 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 serious mental illness are some of the most challenging and expensive patients to treat, it is possible to help seriously mentally ill individuals be healthy and productive, while minimizing their need to use hospital and emergency departments," said Dr. Young. "We found this care model to be effective in improving treatment appropriateness and patient outcomes. And while this model certainly needs further study, it should be considered to improve care for people with serious mental illness."