Center on Psychiatric Disability and Co-Occurring Medical Conditions

State-of-the-Science Summit on Integrated Health Care

Center on Psychiatric Disability & Co-Occurring Medical Conditions

Improving Health and Well-Being for Adults in Public Mental Health Systems - Sally Rogers

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Hi, I am Sally Rogers, Director of Research at the Center for Psychiatric Rehabilitation at Boston University.

I am happy to be talking to you today about a project we conducted at our Center that was aimed at improving the health and well being of individuals being treated in the public mental health system here in Massachusetts.

This project was conducted a part of a larger, federally funded research and training center focused on the recovery of individuals with severe mental illnesses. We believe that physical health and well being are essential for overall recovery, and that physical health challenges can limit a person’s ability to recover, and to achieve a full and satisfying life, including employment.

To conduct this study, we collaborated with a large mental health agency north of Boston that provided an array of services including outpatient, residential services, and day services. Importantly, this agency was part of a larger healthcare system and they were particularly interested in promoting health among the clients they served since they knew that a very high number had co morbid physical conditions and that many individuals used emergency and crisis services for problems and issues that could be resolved with less intensive services. We were interested in this project because of the research suggesting that individuals with severe mental illness often do not have access to primary care. Reasons for this paucity of access can include lack of insurance coverage, because primary care providers are reluctant to serve individuals with psychiatric problems, or because individuals themselves do not often take an active role in initiating their own health care.

So, we planned the study and the intervention to occur through the services of a nurse practitioner who would be hired and stationed at the agency’s outpatient mental health clinics. External funds were obtained by the agency to establish a licensed medical clinic within the mental health settings and with all of the needed equipment for exams and testing.. Challenges abounded for the startup of this service. Finding NPs in Massachusetts who understand the special challenges of the individuals served was a huge barrier, but one that was mostly overcome. Insurance and billing issues, and getting the clinics furnished and licensed were also significant undertakings. In fact, one of these medical clinics was housed on the first floor in a beautifully restored mill building set on a river in an old industrial town north of Boston. The NP’s clinic was built on the ground floor of the building and shortly after our grand opening with great fanfare, was flooded by an unusual series of spring rains. But not once, the clinic was actually flooded twice within a few week period. Funds had to be found to refurbish the clinic …and all of this occurred as we were starting to get this research project off the ground.

We conceptualized the role of the NP in this project to be multi-dimensional and not one that could be easily standardized. We knew that each individual coming into the study could have a different combination of health challenges. But we were also fairly certain we knew the primary concerns the that the NP needed to address: These included issues around obesity, respiratory problems, the need for greater physical activity, side effects of psychiatric medications, and poor nutrition. In addition to that, we knew that many of the clients felt overwhelmed by their psychiatric problems and avoided dealing with needed physical problems. In fact, in an early interview I conducted as we were planning the intervention, a young woman told me that she was not addressing a long overdue gynecological problem that she knew was critical and life threatening because she had enough to cope with in just dealing with her psychiatric condition. These stories told us that the NP could play a pivotal role in motivating individuals for and engaging them in needed care.

The other major issue we were aware of was the lack of available specialty care for conditions routine issues such as dental and eye care, which are not covered by Medicaid, but also for individuals with more serious conditions needing complex care such as cancer. Often too, finding a specialty care provider who was willing to treat an individual with a significant psychiatric history was a challenge in and of itself.

So, we conceptualized the NP role in this way: if healthcare is one big puzzle made up of 100 pieces, it would the NP’s role to fill in whatever portion of that puzzle that was not completed whether that be one critical piece, or 10. The NP could focus on engaging a person in needed health care, connecting them with specialty care, educating them about healthy eating, encouraging physical activity, or, very critically, closely monitoring their chronic condition, such as diabetes. This was a tall order for the NP, but to make the intervention client centered, we needed to begin from where the person was and figure out what health care services he or she both wanted and needed. We had to be flexible.

The study was mounted and conducted successfully with 200 individuals. During that time we worked closely with the mental health programs within the agency to educate the staff about the NPs work and most importantly to raise their awareness of the importance of attending to the physical health needs of their clients. This was a critical undertaking and important step for the agency because naturally, mental health staff focus on what they know best, which is to provide mental health services. For these providers to take on a new responsibility and address health concerns was a big challenge.

As part of the study we also conducted qualitative interviews with agency staff as well as the clients served by the NP. We learned that case managers and other mental health providers loved having the NP as part of the agency. Having the NP as part of the staff and not simply co-located there and working for another agency eliminated problems with communication and concerns about confidentiality and sharing of information. Easy access to the NP to communicate about health care issues and to be informally educated was seen as a great benefit by the mental health programs and staff.

Agency administrators also saw the benefits of having the NP in the mental health setting, though the barriers of insurance coverage and how to pay for nurse practitioners services continued to be an issue. This may be less of a problem now that we have the affordable care act and there is a focus on integrated care.

The individuals served in the study most definitely saw benefits to the NP. Many expressed deep gratitude that the NP was accessible and had more time to spend with them than their regular primary care provider. Clients also saw a benefit in a more holistic and integrated approach to their psychiatric and medical needs. We did find that the NP in this program was in a very unique position of dealing with the intersection of physical health issues and psychiatric issues as they were knowledgeable about both. Very often the physical health needs individuals with significant psychiatric issues are dismissed—physical symptoms are re-interpreted as psychiatric symptoms. The NPs in this study were uniquely able to be attuned to these issues and to how psychiatric medications affect physical status and vice versa. That is not something that most primary care providers are able to do.

Overall though, we had difficulty quantifying the benefits for the experimental study participants, perhaps because the intervention wasn’t intensive enough to see measurable changes on the health outcomes we measured. Participants may have needed more meetings and follow-up by the NP than was possible in this project. Also surprising in this study was the high level of engagement participants had with primary care providers at the beginning of the study. the vast majority of individuals had a primary care provider that they could name and that they were satisfied with. We chalked this up to MA being on the forefront of healthcare reform. This may give other states and locales hope that progress in providing primary care to folks with severe mental illnesses is possible.

For us and for the agency, I believe that the take home message from this study was about the value of having a nurse practitioner employed by and stationed in the mental health agency. The NPs who worked with us on this project were highly valued and filled a critical and unique role. Their presence within the clinic made for seamless communication and exchange of information rather than bureaucratic wrangling and barriers around medical records and confidentiality. This ultimately greatly benefited the clients they served.

I hope you found this description of our healthcare project of interest. Thank you for sharing your time with me.