Recently published studies have startled mental health professionals with the assertion that persons with serious mental illnesses in the United States can now expect to live, on average, 25 years less than everybody else. The CATIE and the State Mental Health Program Directors studies detail a hierarchy of causative factors. First, they point to the “second generation” or “atypical” neuroleptic medications, which are linked to excessive weight gain and insulin resistance in many of the persons prescribed them. The weight gain and insulin resistance appear to account for the emergence in many persons with serious mental illnesses of a medical condition termed “Metabolic Syndrome” which if left untreated, can lead to the development of Diabetes II and cardio-vascular and other systemic medical conditions.
Finally, other presumably remediable causes include consumers’ lifestyle choices, i.e., smoking, lack of exercise, poor nutrition, abuse of intoxicants; their exposure, in shelters and mental health residences, to communicable diseases; and, ultimately, their lack of access to appropriate and effective medical care.
I direct the New York City-based case management programs for FEGS, a large mental health and social welfare agency active throughout the City and in Nassau and Suffolk counties. At present, 50 case managers serve 720 clients with serious mental illnesses located in all five boroughs. After discussions with program staff, consumers and the senior vice president of the agency’s Behavioral Health division, we decided to develop a pilot training program and case management protocol whose primary objective is to prepare consumers and case managers to work closely together to improve our consumers’ access to necessary medical treatment.
We called our initiative the Integrated Collaborative Case Management Demonstration Project (ICCM) to reflect our newly balanced emphasis on behavioral and physical health care and the collaboration between consumer, case manager and health care providers that it requires. We anticipate that improved treatment access and coordination will bring with them reduced use by our consumers of emergency room medical care and in-patient hospitalization, and, ultimately, longer and healthier lives.
We launched the Project in September 2007, when a small group of self-selected case managers, consumers and team supervisors of the FEGS City-wide and Brooklyn Blended Case Management Programs began a fourteen hour-long training course designed to prepare them to improve these consumers’ access to necessary health care. It was decided to train consumers and case managers together because we assumed that a true collaborative effort between the two will be required to overcome the barriers to health care personified by overtaxed and often intolerant health care providers.
As soon as the training was completed, each of the case managers who participated selected a second consumer who, like those in the first group, was being prescribed one of the atypical anti-psychotic medications or had a chronic physical ailment. The case managers then proceeded to share with this second group the information that they had acquired in the formal training.
The case managers and both sets of consumers then set out to operationalize our ICCM Protocol, which, in summary, involves the following:
- initiation by each consumer’s primary care physician (PCP) or psychiatrist of the Metabolic Syndrome Monitoring Protocol;
- review by the PCP or psychiatrist of the Protocol’s test results with consumer and case manager, as well as communication of the results to the consumer’s other physician;
- referral (s) for recommended treatment.
Our ICCM Demonstration Project concluded in April 2008, when the last of our outcome data from the Project’s participants was fully collected. At its conclusion, the final participant cohort was comprised of nine case managers, nine consumers who had completed the formal training and thirteen who had been recruited at the formal training’s conclusion.
Training evaluation data was collected from case manager and consumer participants at the outset of the training program, at its conclusion and after each training session; from the second group of consumer participants when they joined the Project; and from all participants at the three- and six-months marks of the Demonstration Project. The intent was to determine the effectiveness of each of the seven training sessions – which the data did substantiate – and, more importantly, the impact of the training on the learning of the participants over the course of the next six months. Indeed, the case managers who completed the training pronounced themselves “empowered” and “well-informed;” and one of our consumers characterized the training’s objective as teaching consumers and case managers to “ask questions and get answers.”
Our conclusions: that our training model proved effective; more specifically, that our consumers could learn both in the classroom and as they put what they had learned into practice; and that our case managers could teach the consumers in traditional case management fashion, viz., “side by side” as they carried out the traditional case management functions of linking to and monitoring of requisite services.
Access to Medical Care: Project outcome data at the Project’s conclusion indicated improved consumer access to health care. Specifically:
- nineteen of the twenty-two consumers who completed the Project had primary care physicians at the Project’s conclusion, and all twenty-two consumers were seeing psychiatrists regularly;
- Metabolic Syndrome risk factors had been identified in sixteen consumer participants, and remedies to address the risk factors had been ordered by their physicians;
- fifteen reported being diagnosed with chronic physical ailments, with all fifteen also reporting ongoing treatment coordinated by a primary care physician;
- eighteen consumer participants expressed satisfaction with the quality of their medical care, and nineteen reported improved access to medical care.
However, several key treatment and systems issues surfaced as our Demonstration phase came to a close that we had not anticipated.
(1) We find ourselves more aware of the acute vulnerability of those of our clients who have been diagnosed with chronic medical ailments. Further, we believe we have identified key variables which heighten their risk of premature death, viz., a diagnosed chronic medical illness, a clear indication of biological vulnerability; age – particularly as they approach or enter their 50’s; active or history of substance abuse, particularly alcohol and crack cocaine. We suspect that gender might represent another risk factor, particularly for males, although the 2006 study conducted by the National Association of State Mental Health Program Directors found no correlation between increased risk and gender.
We are convinced of these individuals’ need to be connected to primary care physicians and were quite successful in achieving this with our Demonstration Project consumer cohort. Yet, we are troubled that the principal treatment venue for our consumers is hospital clinics with their rotating medical residents and the potential for disruption of care continuity which that represents.
(2) While our decision to pursue initiation of the Metabolic Syndrome Monitoring Protocol for our consumers was on target, we did not conceptualize it as a crucial preventative measure, which it should prove to be, and more apt in application for those of our clients who have yet to be diagnosed with chronic medical illnesses. Accordingly, when we expand ICCM and proceed to train our thirty-five remaining case managers and combined cohorts of seventy consumers, half of the consumers selected will have diagnosed chronic physical ailments and half will not. Efforts will be made to connect all seventy to PCPs, and to monitor their medical progress over the course of twelve months. However, the initiation of the Metabolic Syndrome Monitoring Protocol will be pursued primarily for those consumers without diagnosed chronic ailments. Our objectives will be two-fold: to forestall in the members of this consumer cohort the development of chronic ailments and to mitigate their risk of premature death.
(3) We plan to expand our ICCM model program-wide and, while doing so, to conduct a comparison study with case managers and consumers from the agency’s Nassau-Suffolk case management programs. (FEGS employs approximately 150 case managers who work with close to 2000 clients residing in all five boroughs of New York City and Nassau and Suffolk counties.)
Training will commence in September, 2008, and will continue in three two-month training cycles, each consisting of eight two-hour training sessions, until all thirty-five case managers and their accompanying consumers are trained. We estimate that this process will take seven months and should be completed by no later than March, 2009. As each training cycle is completed, an additional consumer cohort will be recruited for in vivo training by their case managers. In sum, we will replicate, with only minor adjustments, what we believe to be a proven and effective training model.
Since our ultimate objective is to develop a “best practices” paradigm that can eventually be adopted agency-wide and possibly state-wide by other case management programs and adapted to meet the needs of their consumers, we will continue collecting outcome data to determine the effectiveness of our training approach in preparing case managers and consumers to work collaboratively to improve consumers’ access to health care and prolong their lives. Outcome data from both the New York City and Nassau-Suffolk study participants will be collected over a twelve month long period to determine how effective we have been in achieving these goals and, whether, in the process, we have achieved any cost savings by reducing consumers’ medical emergency room visits and hospitalizations.