Peer-Led Self-Management of General Medical Conditions for Patients With Serious Mental Illnesses: A Randomized Trial.

OBJECTIVE: Individuals with serious mental illnesses have high rates of general medical comorbidity and challenges in managing these conditions. A growing workforce of certified peer specialists is available to help these individuals more effectively manage their health and health care. However, few studies have examined the effectiveness of peer-led programs for self-management of general medical conditions for this population. METHODS: This randomized study enrolled 400 participants with a serious mental illness and one or more chronic general medical conditions across three community mental health clinics. Participants were randomly assigned to the Health and Recovery Peer (HARP) program, a self-management program for general medical conditions led by certified peer specialists (N=198), or to usual care (N=202). Assessments were conducted at baseline and three and six months. RESULTS: At six months, participants in the intervention group demonstrated a significant differential improvement in the primary study outcome, health-related quality of life. Specifically, compared with the usual care group, intervention participants had greater improvement in the Short-Form Health Survey physical component summary (an increase of 2.7 versus 1.4 points, p=.046) and mental component summary (4.6 versus 2.5 points, p=.039). Significantly greater six-month improvements in mental health recovery were seen for the intervention group (p=.02), but no other between-group differences in secondary outcome measures were significant. CONCLUSIONS: The HARP program was associated with improved physical health- and mental health-related quality of life among individuals with serious mental illness and comorbid general medical conditions, suggesting the potential benefits of more widespread dissemination of peer-led disease self-management in this population.

Randomized Trial of an Integrated Behavioral Health Home: The Health Outcomes Management and Evaluation (HOME) Study.

OBJECTIVE: Behavioral health homes provide primary care health services to patients with serious mental illness treated in community mental health settings. The objective of this study was to compare quality and outcomes of care between an integrated behavioral health home and usual care. METHOD: The study was a randomized trial of a behavioral health home developed as a partnership between a community mental health center and a Federally Qualified Health Center. A total of 447 patients with a serious mental illness and one or more cardiometabolic risk factors were randomly assigned to either the behavioral health home or usual care for 12 months. Participants in the behavioral health home received integrated medical care on-site from a nurse practitioner and a full-time nurse care manager subcontracted through the health center. RESULTS: Compared with usual care, the behavioral health home was associated with significant improvements in quality of cardiometabolic care, concordance of treatment with the chronic care model, and use of preventive services. For most cardiometabolic and general medical outcomes, both groups demonstrated improvement, although there were no statistically significant differences between the two groups over time. CONCLUSIONS: The results suggest that it is possible, even under challenging real-world conditions, to improve quality of care for patients with serious mental illness and cardiovascular risk factors. Improving quality of medical care may be necessary, but not sufficient, to improve the full range of medical outcomes in this vulnerable population.

Use of mobile technology in a community mental health setting.

INTRODUCTION: mHealth holds promise in transforming care for people with serious mental illness (SMI) and other disadvantaged populations. However, information about the rates of smartphone ownership and usage of mobile health apps among people with SMI is limited. The objective of this research is to examine the current ownership, usage patterns, and existing barriers to mobile health interventions for people with SMI treated in a public sector community mental health setting and to compare the findings with national usage patterns from the general population. METHODS: A survey was conducted to determine rates of ownership of smartphone devices among people with SMI. Surveys were administered to 100 patients with SMI at an outpatient psychiatric clinic. Results were compared with respondents to the 2012 Pew Survey of mobile phone usage. RESULTS: A total of 85% of participants reported that they owned a cell phone; of those, 37% reported that they owned a smartphone, as compared with 53% of respondents to the Pew Survey and 44% of socioeconomically disadvantaged respondents to the Pew Survey. DISCUSSION: While cell phone ownership is common among people with SMI, their adoption of smartphone technology lags behind that of the general population primarily due to cost barriers. Efforts to use mHealth in these populations need to recognize current mobile ownership patterns while planning for anticipated expansion of new technologies to poor populations as cost barriers are reduced in the coming years.

Impact of a Telepsychiatry Program at Emergency Departments Statewide on the Quality, Utilization, and Costs of Mental Health Services.

OBJECTIVE: This study estimated the impact of a statewide, centralized telepsychiatry service provided in nonpsychiatric emergency departments (EDs) on use of mental health services. METHODS: Individuals treated via telepsychiatry were compared with a matched control group of individuals with mental health diagnoses who were treated in nonparticipating hospitals. Bivariate and two-part and generalized linear regression models were used to assess differences between the two groups in outpatient follow-up, hospital admission following the ED visit, length of hospital stay if admitted, and inpatient and total costs. RESULTS: Between March 2009 and June 2013, there were 9,066 patients with at least one telepsychiatry visit. Of these, 7,261 had index telepsychiatry visits that the authors were able to successfully match. Compared with the matched control group, telepsychiatry recipients were more likely to receive 30-day outpatient follow-up (46% versus 16%, p<.001) and 90-day outpatient follow-up (54% versus 20%, p<.001). Telepsychiatry recipients were less likely than the control group to be admitted to the hospital during the index ED visit (11% versus 22%, p<.001). The combined effect of having a telepsychiatry consult during the index ED visit was a reduction of .86 days in inpatient length of stay. Thirty-day inpatient costs were $2,336 (p=.04) lower for the telepsychiatry versus the control group, but 30-day total health care costs were not statistically different. CONCLUSIONS: Telepsychiatry delivered in the ED through a centralized coordinated program has great promise for improving linkage with outpatient mental health services while reducing inpatient utilization and hospital costs.

Randomized trial of an electronic personal health record for patients with serious mental illnesses.

OBJECTIVE: The authors evaluated the effect of an electronic personal health record on the quality of medical care in a community mental health setting. METHOD: A total of 170 individuals with a serious mental disorder and a comorbid medical condition treated in a community mental health center were randomly assigned to either a personal health record or usual care. One-year outcomes assessed quality of medical care, patient activation, service use, and health-related quality of life. RESULTS: Patients used the personal health record a mean of 42.1 times during the 1-year intervention period. In the personal health record group, the total proportion of eligible preventive services received increased from 24% at baseline to 40% at the 12-month follow-up, whereas it declined in the usual care group, from 25% to 18%. In the subset of patients with one or more cardiometabolic conditions (N=118), the total proportion of eligible services received improved by 2 percentage points in the personal health record group and declined by 11 percentage points in the usual care group, resulting in a significant difference in change between the two groups. There was an increase in the number of outpatient medical visits, which appeared to explain many of the significant differences in the quality of medical care. CONCLUSIONS: Having a personal health record resulted in significantly improved quality of medical care and increased use of medical services among patients. Personal health records could provide a relatively low-cost scalable strategy for improving medical care for patients with comorbid medical and serious mental illnesses.