Integrating Consumer Health Care With Supportive Housing Services
In 2001 the Institute for Community Living, Inc. (ICL), a nonprofit behavioral health care network, established a primary care clinic in Brooklyn to provide adults with serious mental illness residing in supportive housing easy access to general medical services. Three years later, an evaluation indicated that, despite engagement strategies yielding an annual physical examination rate of 85%, adherence to treatment and lifestyle regimens for controllable cardiovascular risk factors remained low (dyslipidemia, >40%; heavy smokers, 69%; obesity, 60%; and poorly controlled type 2 diabetes, 69%). In response, ICL reviewed the roles of the clinic, its consumers, and its mental health coproviders in supporting service plans. Foremost, it determined that stakeholders did not prioritize equally the treatment of often asymptomatic but serious chronic medical conditions. Most consumers poorly understood or ignored their conditions; supportive housing case managers often lacked training to support regimen adherence; and clinic staff, supportive housing case managers, and mental health coproviders communicated inadequately to ensure service coordination and integration.
To address these issues, ICL is preparing a series of toolkits on metabolic syndrome. The first, pilot tested in 2006 (supported by United Hospital Fund of New York), was created to improve outcomes associated with type 2 diabetes, which affects 27% of the clinic's 2,000 enrollees. This toolkit, designed as a general medical clinic modality carried out by a psychiatric nurse with expertise in serious mental illness and diabetes education, consists of four components administered over six months: a combined protocol guiding diabetes education sessions for individual consumers, scheduled as needed, and the integration and coordination of coprovider service plans; a consumer curriculum for five group psychoeducational sessions on diabetes self-care; a supportive housing staff curriculum for three group in-service training sessions; and a cognitive-behavioral and motivational interviewing protocol for consumers with persistent negative attitudes toward diabetes self-care.
Eighty-four consumers with uncontrolled blood glucose levels participated in the pilot, and 57 (68%) completed it. Sixty-two percent of completers had reduced blood glucose levels. Consumers with elevated levels at the pilot's outset (N=25) showed a significant reduction in mean hemoglobin A1c levels—from 9.24 to 8.18 (t=2.11, df=24, p≤.045).
Although the toolkit holds promise that consumers can respond quickly to a concerted adherence-promoting effort, the pilot methodology required alteration in the midst of implementation. Toolkit services, initially conceptualized as largely office based, had to be converted into mainly outreach services because of poor attendance. Staff follow-up on missed appointments often elicited consumer comments suggesting that their mental health service activities left them with "psychosocial treatment fatigue."
Because of the pilot, ICL staff now view the realities of general medical care access differently. Health care is no longer regarded as the sole responsibility of general medical care providers. Rather, mental health programs must find a way to prioritize general health care issues in their service cultures. Perhaps two-thirds of supportive housing consumers would be far better served if selectively offered routine medical screening, basic primary care, and toolkit-type disease management services at their mental health service locations, such as day treatment programs, supportive housing, and mental health clinics.
Although the toolkit is most easily implemented by a nurse or other general medical care professional with relevant psychiatric background, its components can be distributed among mental health staff, trained for this purpose, and delivered in a mental health setting. Because many consumers with serious mental illness have high adherence rates to some form of mental health service, a "no wrong door approach" that capitalizes on preexisting resources is promising. Prominent among them are the special relationships formed between mental health clinicians and consumers, service location with proven accessibility, and the potential for adapting evidence-based approaches intended for mental health service adherence to general medical care.
To pursue these findings, ICL has gained funding for a two-year project with a coalition of New York City's major community behavioral health care agencies. This project seeks to demonstrate how mental health system resources can be leveraged to create viable chronic medical care models within settings consumers frequent, whether operated under mental health or general medical auspices. This effort has broad service system, workforce training, and funding implications and requires close collaboration with multiple government agencies and mental health advocates to bring to fruition.
