Practical Methods for Integrating Healthcare into Community Mental Health Services

Nancy Little, MA, LCPCWilliam Reedy, RNDorothy JonesThresholdsJune 2011Practical Methods for Integrating Healthcare into Community Mental Health Services

GoalParticipants will recognize the imperative of finding ways to address physical wellness to help increase lifespan of consumers with severe mental illnesses.

ObjectivesAt the end of this session, participants will:Know some of the reasons why people with SMI are dying before their timeKnow five strategies to incorporate into community support services that address health issuesHave three internet based resources to help educate and support consumers in establishing and achieving their health goalsCase ExampleBen is a 57 year old, single African American living in his own apartment. He works 20 hours per week and is very active. He is overweight and has insulin (injection) dependent Type II diabetes. He has few friends, and occasionally has a girlfriend. His relationships with family members are distant. Negative symptoms and cognitive difficulties make it difficult for him to manage the diabetes. It is hard for him to make sense of medical information and he tends to confabulate. For example, he equates Hawaiian Punch with juice, and believes he can determine the calorie content of food by whether it tastes light or heavy. He does not understand his symptoms, and mostly blames himself for lack of motivation and difficulty understanding information. He does not see the connection between diet and blood sugar readings. He does not fully grasp how his active lifestyle affects his blood sugar. His goal is to get off the injectable insulin. He is seen at a managed care clinic that he unknowingly signed up for through Medicare Part D. Customer service there is abysmal. The clinic provided him with a pamphlet about diabetes.

Divide up into groups of 8-10 and discuss barriers to healthcare and strategies to address getting Ben good health care.4OK, so theres barriers.BUT 25 years (average) difference in life span?

People with serious mental illness die at age 51, on average, compared with age 76 for Americans overall. (USA Today 2007)

Why do people with mental illnessesdie younger?

Why do people with mental illnessesdie younger?

Chronic Obstructive Pulmonary Disease (COPD)

43.5% of cigarettes smoked in US are consumed by people with mental illnesses, about 20% of Americans (Wall Street Journal, April 2011)

Read other quotes from Wall Street Journal article:

People with SMI are more likely to smoke, but more often likely to want to quit than staff think,

It does less to reduce stress than people think it does

People who cut down and quit feel a sense of competence and then go on to achieve in other areas of life.

Quit smoking, then quit drinking, lose weight, get a job

To do this hard thing that they thought they could not do is very empowering.7Why do people with mental illnessesdie younger?

Metabolic Syndrome and Obesityassociated with psychiatric medicationsDescribe metabolic syndrome in simple terms, include a website on each disease for more information.8Why do people with mental illnessesdie younger?

Diabetes

8% to 9% of Americans have diabetes.16% to 25% of Americans with mental illnesses have diabetes.

Speak about why this is true: meds? Diet? Inactivity?9Why do people with mental illnessesdie younger?

Coronary Artery Disease (CAD) or Coronary Heart Disease (CHD)Hyperlipidemia, Arteriosclerosis, Atherosclerosis.

Why do people with mental illnessesdie younger?

Hypertension

SmokingExcessive alcohol useHigh sodium intake

How do each impact BP?11Why do people with mental illnessesdie younger?

Congestive Heart Failure

Diminished ability of the heart to pump blood through the circulatory system

Mental health issues can be caused byCHF or by medications used to treat CHFWhy do people with mental illnessesdie younger?

Liver DiseaseAlcohol and drug abuseHepatitisWhy do people with mental illnessesdie younger?

Infectious illnesses

Weakened immune systemDeficits in self care Poor access to health careSTDs and blood borne illnesses.

Why do people with mental illnessesdie younger?

Poor access to quality health care.PovertyStigmaCommunication lapsesThink about health care available to people who are poorOften doctors from other cultures, so there is, unless addressed, a potential cultural barrierHow do people in primary care serving an impoverished clientele feel about their clientele? Do they understand cognitive deficits, or might they stereotyped:For Ben, in first example, Bill and I felt strongly that he was prohibited from seeing specialists because he was poor and black, and because he is, in general, guarded and paranoid. He is reluctant to ask questions due to fear of seeming stupid. 15How does this relate to Certified Psychiatric Rehabilitation Practitioner CPRP domains?Domain II: Maintain Own Personal WellnessKnowledge of EBP and emerging EBPAdvocacy on behalf of consumersPromote health goals like weight loss and nutrition (smoking cessation?)How do we show we are taking care of wellness? What kind of role models are we?

Anyone in here smoke?

This is an emerging EBP

Advocacy extending t docs16Emerging EBP to integrate careIntegrated Illness Management and RecoveryBased in Illness (wellness) management and recoveryEvidence shows that addressing key knowledge and skill areas improves feeling of competence in managing illness, more time spent on improved role functioning/quality of life (Gingerich, Mueser 2005)IMR (WMR)CollaborativeStrength basedFocused (CBT Format) on goal achievementEstablishing goalsTeaching information/skillsPracticing skills in sessionHomework (collaborative)Follow upIncremental steps towards goalsIIMRDartmouth study (NH and IL) used IMR Manual http://store.samhsa.gov/product/SMA09-4463and inserted health information : Practical Facts about Diet and ExerciseTalking to your Primary Care PhysicianStudy subjects=over 50, identified health issueConsumer meets regularly with practitioner and nurseFrequent communication with PCPFrequent communication between practitioner and nurse

IL: will this intervention work in a more ethnically diverse population?19Current IMR for Psychiatric IllnessAdded Medical Illness Management and WellnessRecoveryWellnessPsycho-education on Mental IllnessEducation on Medical IllnessStress Vulnerability and Mental IllnessStress-Vulnerability and Medical IllnessBuilding Social Supports and RecoveryBuilding Social Supports and WellnessPsychiatric Medication Adherence StrategiesMedical Medication Adherence StrategiesPsychiatric Relapse PreventionMedical Relapse PreventionCoping with Stress and Solving ProblemsCoping with Health-related Stress and Solving ProblemsCoping with Psychiatric SymptomsCoping with Chronic Pain and Medical SymptomsSubstance AbuseMedication MisuseA Guide to Navigating the Mental Health SystemA Guide to Navigating the Medical Health Care SystemCurrent IMR for Psychiatric IllnessAdded Medical Illness Management and WellnessWellness goals established early

Goals and ProgressHow establish goals?Strengths and Knowledge InventoryDo not judge goals, accept them.I want a full head of hair and to cure my diabetesHow is progress assessed?Progress toward physical health goals sometimes easier to assess, more immediate feedback.Emphasis on behavioral change followed by cognitive/emotional changeThe good news is we know a lot about psych meds and the symptoms they target as well as side effects.

The bad news is that we know little about meds that treat things like diabetes and blood pressure. Day to day, the latter have a stronger effect on lifespan than that latter.

Story about mini-strokeStory about osteo-arthritis and resistance to coming in to group23Areas of my healthI am not satisfiedI am moderately satisfiedI am very satisfiedDietExerciseSleep HabitsStress Level / Coping StrategiesHealth CareWellness Checklist

New Plate

Nurse role in IIMRGoals:Improve clients awareness and understanding of medical conditions and medications Reduce barriers to self-managementMonitor signs and symptoms related to medical diagnoses.Desired Outcomes:Client verbalizes medical self-management strategiesClient improves level of functioning through increased ability to self monitor changes in physical symptomsClient improves communication with medical providers with increased knowledge of specific disease process

Demonstrate practitioner sessionNotice how the CBT structure is adhered to

Dorothys storyTrouble started when I was a teenFirst and only child at age 18ChattanoogaRescueNursing HomeJob and apartmentLoss IIMRLife nowDemonstrate Nurse IIMR Session

Lessons learnedWhile health goals may seem obvious, the real work may not start for awhileEstablishing collaborative relationships with PCPs is hard workOne of the most important skills in IIMR is self advocacyHealth crises can be very powerful motivatorsobservationsTalking about health is easier than talking about mental healthConsumers take note of your behaviorSelf advocacy is powerfulHow can you do this at home?AdvocacyAccess to PCPModelingSleep hygiene infoSmoking cessation infoLearn about physical health/medsGet a scale