Care management increases the use of primary and medical care services by people with severe mental illness in community mental health settings
- 1UCLA Department of Psychiatry & Biobehavioral Sciences, Los Angeles, California, USA
- 2West Los Angeles Veteran's Administration Hospital, Los Angeles, California, USA
- Correspondence to Joan Rosenbaum Asarnow
UCLA Semel Institute, 760 Westwood Plaza, Los Angeles, CA 90095-1759, USA;
The primary care, access, referral and evaluation study
The primary care, access, referral and evaluation (PCARE) study is a pioneering, and to our knowledge, first-of-its-kind study. Building on the extensive literature examining collaborative care models for enhancing mental healthcare among primary care patients,1,–,4 PCARE evaluated a care management intervention for decreasing the medical morbidity and mortality of patients with severe mental illness receiving mental healthcare in a Community Mental Health Center (CMHC).
Extant data underscores the high levels of morbidity and mortality among patients with severe mental illness treated in the public sector.5 Overall, this group of patients die about 25 years earlier compared to the general population, and problems with the quality of medical care appear to be an important contributing factor to this excess morbidity and mortality,5,–,7 highlighting the critical importance of attending to general medical and mental health needs. The PCARE study is designed to address this clinical and public health problem and advance efforts to improve health and mental health outcomes in these high-risk patients.
Consistent with the Institute of Medicine's emphasis on care coordination as a top priority for transforming healthcare8 and the importance of coordinating care across specialty and general medical services in patients with severe mental illness, the PCARE intervention emphasises care coordination and linkage to care using state of the art psychological interventions, such as motivational enhancement strategies and goal setting through action plans, as well as practical supports needed to reduce barriers to care including community referrals, public transportation tokens, help in enrolling in entitlement programmes and care managers going with patients to specialty provider visits.
In this major demonstration project, adult patients (≥18 years) receiving care for severe mental illness were recruited from a CMHC using a combination of advertisements at the CMHC, waiting room recruitment and provider referrals. Patients suffered from a variety of severe disorders including schizophrenia and mood disorders with 25% presenting with co-occurring substance use disorder. Interview assessments were conducted at baseline and at 6 and 12 months to measure medical and mental health service use, sources and sites of care and quality of life. These assessments were supplemented by medical and mental health chart reviews at baseline and at 12 months to assess the quality of preventive and cardiometabolic care. Following the baseline assessments, patients were randomised to either usual care or the intervention. The care manager intervention was delivered by two registered nurses using a manualised protocol structured to reduce barriers to primary medical care at the patient, provider and systems level.
Limitations and next steps
This important project has potential for leading to major advances. Study limitations, however, help highlight directions for future work. The study was conducted in a single CMHC site, and future work is needed to determine generalisability across diverse sites with different organisational, provider and patient characteristics. Statistical power was limited for analyses of specific medical outcomes. Usual care involved referral to potential medical clinics/providers, a relatively weak comparison group relative to collocated services or other approaches to facilitate improved care. Although one report cannot include all study results, costs and cost effectiveness were not examined; this information will be critical for making implementation and policy decisions. More detailed information regarding the intervention, which components of the intervention were most frequently utilised, and how patients perceived the intervention, would also inform the field and efforts to further evaluate intervention effectiveness and feasibility for export across a wide range of practice settings.
The PCARE study highlights an important area for quality improvement and demonstrates one strategy for addressing the critical need for improved medical care for patients struggling with severe mental illness. While many practice settings do not have the resources to implement interventions similar to the PCARE model, the results highlight the need to evaluate and address the medical needs of these high-risk patients. There is evidence that existing community mental health nurses' knowledge and skills are highly mis- or underutilised,9 10 and that effective care management of very complex patients may require the knowledge and skill of advanced practice nurses.11 This is an area of practice and practice development where the nursing profession which has expertise in care management, collaborative care models and model development can make unique and valuable contributions.
Competing interests JRA has received unrestricted research funding from Philip Morris and consulted on an unrestricted research grant from Pfizer Pharmaceuticals.