Abstract and Introduction
Abstract
Introduction Efficacy trials have shown that primary care co-located in the mental health setting improves the receipt of high-quality medical care among people with serious mental illness. We tested whether implementation of such a program affected health service use and cardiovascular risk factor control among veterans with serious mental illness who had previously demonstrated limited primary care engagement.
Methods We performed a cohort study of veterans enrolled in a co-located, integrated primary care clinic in the mental health outpatient unit through targeted chart review. Two successive 6-month periods in the year before and in the year following enrollment in the co-located primary care clinic were examined for primary care and emergency department use and for goal attainment of blood pressure, fasting blood lipids, body mass index (BMI), and, among patients with diabetes, hemoglobin A1c (HbA1c). We used repeated-measures logistic regression to analyze goal attainment and repeated measures Poisson regression to analyze service use.
Results Compared with the period before enrollment, the 97 veterans enrolled in the clinic had significantly more primary care visits during 6 months and significantly improved goal attainment for blood pressure, low-density lipoprotein cholesterol, triglycerides, and BMI. Changes with regard to goal attainment for high-density lipoprotein cholesterol and HbA1c were not significant.
Conclusion Enrollment in a co-located, integrated clinic was associated with increased primary care use and improved attainment of some cardiovascular risk goals among veterans with serious mental illness. Such a clinic can be implemented effectively in the mental health setting.
Introduction
Cardiovascular disease (CVD) risk factors are common among patients with serious mental illnesses (SMI) such as schizophrenia, schizoaffective disorder, and bipolar disorder. The quality of care for CVD is poor in patients with SMI, and their CVD risk factors are commonly missed or ignored.
Veterans with SMI have fewer medical visits than do other US Veterans Administration (VA) patients. SMI patients primarily seek care for mental health conditions rather than for physical conditions, so the mental health setting may be a more effective "home" site for primary care services. Co-location and integration of primary care services in the mental health setting is an innovation that may reduce some of the barriers to delivery and receipt of high-quality medical care among patients with SMI. Co-location refers to the placement of primary care providers in the mental health setting, and integration is coordination of care with mental health providers. Previous studies of this care model have shown an increase in primary care visits, improved attainment of performance measures, and reduced emergency department use. However, these studies were limited in their ability to demonstrate that co-located care can be implemented in a clinical setting and to assess the effect of the clinic on CVD risk management. This is because these studies were done in an experimental setting, did not examine within-patient changes, or did not study the effect on cardiovascular measures.
We explored the effect of enrollment in a primary care clinic co-located and integrated in the outpatient mental health program on service use and control of CVD risk among veterans with SMI. We hypothesized that enrollment in this clinic would improve primary care access, reduce emergency department visits and hospitalizations, and improve control of CVD risk factors.