If you have ever tried to quit smoking or lose weight, you might recall the difficulty you had sticking to your goal. Add the challenge of managing a serious mental illness (SMI) and these health goals can become daunting. However, the pursuit of these goals has become central to addressing the staggering reality that people with serious mental illness die 25 years younger than the general population of treatable and preventable medical conditions, including heart disease, stroke and diabetes. This health crisis has moved many organizations towards making the delivery of physical health care an integral part of behavioral health services—treating patients holistically rather than only “from the neck up.”
A Best Practice Approach
At the Institute for Community Living, Inc. (ICL), a New York City not-for-profit serving over 10,000 people with mental illness and substance abuse, a multi-faceted approach to integrating physical and behavioral health services has been informed by the Chronic Care Model (CCM), which identifies the elements of a best-practice health care system for disease management, as well as the Four Quadrant Clinical Integration Model, which recommends nursing-supported care coordination for people with the highest levels of both behavioral and physical health needs.
Disease self-management is one of the key best-practice elements in the CCM. For people with SMI, self-management often begins with education, addressing the low level of health literacy—the ability to understand health information and its personal implications in this population. To this end, ICL has developed an integrated health toolkit that centers on the use of motivational interviewing (MI) to engage people around health education and as a therapeutic agent of change. These self-management tools are coupled with provider-oriented medical risk management tools that help to identify consumers with high risk medical conditions so that their needs could be addressed by the multidisciplinary team.
The Healthy Living Program and Toolkit
To assist ICL’s behavioral health workforce (largely bachelor’s level case managers working in residential and outreach settings) in using MI with persons served, the Healthy Living Workbook was created. This illustrated workbook is written at a grade 5 reading level and covers a range of topics pertaining to general/ preventive health. A modular style allows topics to be covered in any order and in varying levels of detail—worksheets can be pulled out to be discussed on their own. The health areas covered are: (1) Caring for your mental health; (2) Taking charge of check-ups; (3) Being physically active; (4) Choosing healthy foods; (5) Talking about sex; (6) Taking medication; (7) Taking care of my teeth; (8) Quitting smoking; and (9) Using the ER. Additional modules are available on COPD and Hepatitis C.
The workbook asks questions, in a MI style, about a person’s health experiences and goals. Questions such as, “What changes have you thought about making?” “How would your life be different if you made that change?” and “What would you have to give up if you made that change?” woven into the psychoeducational text of the workbook, facilitate the use of MI language in group and individual conversations around health behaviors. At the end of each chapter, an “Are you ready?” page provides a self-assessment of stage of change and recommends moving forward to a commitment to action only if there is sufficient change readiness. If there is a commitment, “Action Steps” pages facilitate the development of specific, concrete, and achievable plans for change, and “Action Step Review” pages encourage self-evaluation of the change process. Small steps successfully taken accrue to generate momentum towards lasting change.
These self-management workbooks are accompanied by toolkits designed to address systems barriers to health integration. A key toolkit item is the pocket-sized Healthy Living Info Card that facilitates timely collection and tracking of primary health indicators, including weight. On the back of the card are several suggested questions to ask a primary care provider, including, “How can I improve my food choices and physical activity?” that are meant to develop the “informed, activated patient” featured in the CCM. Other tools are more staff-oriented, including “Clinical Pathways” algorithms that take staff step by step through evidence-based/best practice assessment and treatment for disorders. Medical risk screening forms designed to identify persons with higher levels of health risk and needs are used in ICL’s programs and are reviewed in monthly team discussions involving case managers, clinicians, supervisors, and nursing staff. All tools are available in the “Clinician’s Toolbox” on the desktop of every computer across ICL.
The Healthy Living Toolkit was piloted in 49 behavioral health programs across ICL, including residential, case management, shelter, clinic, ACT and outreach programs, starting in January 2009. With funding from the New York Community Trust and Brooklyn Community Foundation, training was provided to 146 behavioral health workers. Almost 1400 individuals participated in groups and/or individual counseling. Eighty-three individuals were able to participate in cooking demonstrations, and 27 participated in a 12-week cooking skills course. One hundred individuals participated in a ICL in-house physical activity program.
The Healthy Living Questionnaire, a 15-item self-report measure that includes the SF-8 Health Outcomes Questionnaire and 7 questions regarding health behaviors covered in the Healthy Living Workbook, was administered to participants on a voluntary basis at quarterly time points. This measure is used as a clinical tool to help staff to start conversations and provide feedback to people regarding their health. A significant improvement on the question, “During the past year, how often did you visit your primary care provider?” was found at every quarter. Participants in the physical activity program had significant decreases in weight, BMI and waist circumference after 6 months of participation.
ICL has recently received funding through the New York State Health Foundation and the New York Community Trust to enhance the Healthy Living program in its mental health clinics in Brooklyn. ICL’s vision is to demonstrate the mental health clinic as an important port of entry to integrated health care for people with SMI—to create a behavioral health medical home to best serve these consumers. Mental health clinicians, who often have a closer relationship with a person with SMI than does any other provider, are well-placed to serve as the pivotal contact in integrating health services.
Using grant funds, ICL has been able to introduce a registered nurse in its clinics to work with clinicians to work with people who have been poorly served by the mainstream medical system, engaging them in discussions about their health and facilitating referrals and collaboration with health providers. Clinicians receive monthly disease management trainings with the nurse, with a focus on how common medical conditions affect mental health, and vice versa. Healthy living groups have started in two clinics, and cooking demonstrations have enhanced and changed the clinic experience and culture. Thus far, these services have been well-received, and ICL anticipates that they will continue to fill an important gap in community services.
Rosemarie Sultana-Cordero, MA, LMHC, is Clinical Coordinator, Integrated Health, Marcia Titus-Prescott, RN-BC, is Associate Director of Nursing and Associate Director of Integrated Health, Sonia Barolette, RN, is Nurse Project Manager, Integrated Health, Jennifer Meister, LCSW, is Specialist, Program Design, Evaluation and Systems Implementation, Elisa Chow, PhD, is Director of Outcomes Evaluation, Ruth Chiles, RD, is Director of Nutrition Services, Jeanie Tse, MD, is Associate Chief Medical Officer and Director of Integrated Health, and Peter Campanelli, PsyD, is Chief Executive Officer, at the Institute for Community Living.