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The Effectiveness of a Specialized Primary Care Medical Home for Patients with Serious Mental Illness

Journal of General Internal Medicine (2022)Cite this article

Abstract

Background

There are unmet primary care needs among people with serious mental illness that might be improved with integrated care and medical care management. Many healthcare organizations have attempted to address this problem, but few interventions have been rigorously studied and found to be effective.

Objective

Study the implementation and effectiveness of a novel, specialized primary care medical home designed to improve the healthcare of patients with serious mental illness.

Design, Setting, and Participants.

Clustered controlled trial for a median of 401 days. One Veterans Health Administration medical center was assigned to intervention and two were assigned to usual care (control). Thirty-nine clinicians and managers were included in the study, as well as 331 patients who met eligibility criteria.

Intervention.

A specialized medical home with systematic patient engagement, proactive nurse panel management, a collaborative care psychiatrist, and a primary care physician providing care that included psychiatric treatment.

Main Measures.

Quality of care, chronic illness care and care experience, symptoms, and quality of life.

Key Results.

Sixty-five intervention patients (40%) moved all psychiatric care to the primary care team. No adverse events were attributable to the intervention. Compared with control, intervention patients had greater improvement over time in appropriate screening for body mass index, lipids, and glucose (χ2 = 6.9, 14.3, and 3.9; P’s < .05); greater improvement in all domains of chronic illness care (activation, decision support, goal-setting, counseling, coordination) and care experience (doctor-patient interaction, shared decision-making, care coordination, access; F for each 10–24, P’s < .05); and greater improvement in mental health-related quality of life (F = 3.9, P = .05) and psychotic symptoms (F = 3.9, P = .05).

Conclusion

A primary care medical home for serious mental illness can be feasible to implement, safe, and more effective than usual care.

Trial Registration.

ClinicalTrials.gov Identifier: NCT01668355.

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Acknowledgements

The authors thank Merlyn Vinzon for provision of patient care, Lisa Rubinstein for consultations on project design, and Karen Chu for contributions to data analysis. The contents of this publication and the views expressed therein do not necessarily represent the views of the Department of Veterans Affairs, the American Psychiatric Association, or affiliated institutions.

Funding

This research was supported by the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Serve Quality Enhancement Research Initiative (SDP 12–177) and VISN-22 Mental Illness Research, Education and Clinical Center (MIRECC).

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Authors and Affiliations

  1. Greater Los Angeles Veterans Healthcare System, Los Angeles, CA, USA

    Alexander S. Young MD, MSHS, Evelyn T. Chang MD, MSHS, Rebecca Oberman MPH, MSW & Alison B. Hamilton PhD, MPH

  2. University of California, Los Angeles, CA, USA

    Alexander S. Young MD, MSHS, Evelyn T. Chang MD, MSHS, Alison B. Hamilton PhD, MPH, Jesse Sanford & Fiona Whelan MS

  3. American Psychiatric Association, Washington, DC, USA

    Amy N. Cohen PhD

  4. Southern Nevada Veterans Healthcare System, North Las Vegas, NV, USA

    Dennis T. Chang MD

  5. San Diego Veterans Healthcare System, San Diego, CA, USA

    Laurie A. Lindamer PhD

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  1. Alexander S. Young MD, MSHS
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Contributions

Authors Young, Cohen, and Oberman had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Young, Cohen, E. Chang, Hamilton.

Acquisition of data: Young, Cohen, E. Chang, D Chang, Lindamer, Oberman.

Analysis and interpretation of data: Young, Cohen, E. Chang, D. Chang, Hamilton, Lindamer, Oberman, Sanford, Whelan.

Drafting of manuscript: Young, Sanford, E. Chang.

Critical revision of the manuscript for important intellectual content: Young, Cohen, Sanford, E. Chang, D. Chang, Hamilton, Lindamer, Oberman, Whelan.

Statistical analysis: Young, Cohen, Sanford, Whelan.

Obtained funding: Young, Cohen, Hamilton.

Administrative, technical, or material support: Oberman.

Study supervision: Young, D. Chang, Oberman, Lindamer.

Corresponding author

Correspondence to Alexander S. Young MD, MSHS.

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Conflict of Interest

The authors declare that they do not have a conflict of interest.

Disclaimer

The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

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Prior Presentations

1. Young AS, Chang ET, Cohen AN, Chang DT, Hamilton AB, Lindamer LA, Oberman R, Whelan F: The Implementation and Effectiveness of a Specialized Primary Care PACT to Improve the Health Care of Veterans with Serious Mental Illness. Research presentation at the 2019 VA HSR&D QUERI National Conference, Washington DC, October 31, 2019.

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Young, A., Chang, E., Cohen, A. et al. The Effectiveness of a Specialized Primary Care Medical Home for Patients with Serious Mental Illness. J GEN INTERN MED (2022). https://doi.org/10.1007/s11606-021-07270-x

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Keywords

  • Care coordination
  • Patient centered medial home
  • Screening
  • Behavioral health
  • Health system, hospital or practice redesign
  • Disparities
  • Veteran care