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Service Delivery Innovation Profile

Advanced Practice Nurse-Mental Health Provider Partnership Enhances Access and Improves Health Outcomes for Those With Severe Mental Illness


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Snapshot

Summary

Integrated Health Care clinics are academic, nurse-managed primary care centers operated by the University of Illinois at Chicago College of Nursing and embedded in and coordinated with Thresholds Psychiatric Rehabilitation Centers. The program provides ongoing primary and preventive care delivered by advanced practice nurses1 to individuals with serious mental illness. The purpose of the program is to increase access to quality health care and improve health outcomes for this underserved population. The program has resulted in improvements in health care indicators and high levels of satisfaction among participants. The program's provider practice patterns show consistently high rates of compliance with best practice standards.

See Description of the Innovative Activity for information about a formal quality improvement and patient safety program instituted in 2012 and Results for information about benchmarks that were exceeded in health care and patient satisfaction for quarter 1 of fiscal year 2014.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of key outcomes indicators, along with post-implementation data on program volumes, the percentage of patients meeting preestablished goals, provider adherence to evidence-based practices, and patient satisfaction levels.
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Developing Organizations

The University of Illinois at Chicago, College of Nursing; Thresholds Psychiatric Rehabilitation Centers
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Use By Other Organizations

Trilogy, a private, not-for-profit community behavioral health agency serving individuals with serious mental illness in Rogers Park and Evanston, IL, recently implemented a similar integrated model of care.

Date First Implemented

1998
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Patient Population

Vulnerable Populations > Mentally ill; Urban populationsend pp

Problem Addressed

As a vulnerable population, individuals with severe mental illness are at higher risk than the general population for serious health conditions but are less likely to access health care services for the diagnosis and treatment of comorbid disorders.2 As a consequence, these individuals have higher mortality rates for treatable and preventable health conditions2,3 and life spans that on average are 25 years less than the general public.3
  • Increased vulnerability: Individuals with mental illness are more likely to experience unemployment, poverty, homelessness, incarceration, victimization, and social isolation, which puts them at greater risk for serious comorbid medical conditions and limits their access to regular and timely primary health care services.3
  • Underserved: Symptoms of mental illness (e.g., paranoia, disorganized thinking) may prevent individuals from seeking medical care, accurately communicating their symptoms, and following prescribed treatment for comorbid medical conditions. Symptoms may also mask indicators of other serious medical conditions and impede the accurate diagnoses of comorbid conditions.3
  • High morbidity and mortality: Individuals with mental illness are more likely to have and die from serious health conditions, such as diabetes, HIV/AIDS, respiratory illness including influenza and pneumonia, and cardiovascular disease.2,3 For example, individuals with mental illness have a higher risk of developing type 2 diabetes4 and cardiovascular disorders and are at greater risk of dying from complications related to these conditions than are members of the general population.3,5,6

What They Did

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Description of the Innovative Activity

The Integrated Health Care program at Thresholds is a nurse-managed program in which advanced practice nurses rotate through existing recovery centers, providing integrated, ongoing primary and preventive care; patient education; behavioral and mental health care; and other services to individuals with severe mental illness. The program is designed to increase physical well-being and reduce negative health outcomes for these individuals. Key components of the program are described below:
  • Clinic operations: The Integrated Health Care program includes two clinics that are based in existing Thresholds psychiatric recovery centers; the clinics are open 5 days a week. Family nurse practitioners and mental health clinical nurse specialists from the University of Illinois at Chicago College of Nursing serve as advanced practice nurses who rotate between the two locations, coordinating care with Thresholds case managers and psychiatrists, University of Illinois at Chicago family practice physicians, and outside providers. Medical assistants provide support in the clinics, while undergraduate and graduate nursing students also rotate through the clinics. Psychiatric mental health advance practice nurses serve both Thresholds clients and community residents at a third clinic site. 
  • Primary and preventive care: Primary and preventive services include wellness examinations, immunizations, diagnosis and treatment of common minor health conditions, continuing care for chronic conditions, and referrals for services not available through the program. Advanced practice nurses also assess risk factors for illness by periodically conducting a detailed individual and family medical history and screening for comorbid health conditions such as cancer, tuberculosis, hypertension, diabetes, and asthma.
  • Patient education and health promotion: Based on health assessments, advanced practice nurses educate patients regarding their health status, the disease process of any comorbid health conditions, treatment options, and available services to promote recovery, disease management, or general wellness. In addition, these nurses make recommendations for treatment and general wellness activities and encourage patients to take an active role in their health care, which may include making healthy lifestyle changes (e.g., dietary changes, exercise).
  • Behavioral and mental health services: Nurses provide recommended behavioral modification programs that focus on diabetes, smoking cessation, and medication management, in addition to participating in comprehensive, coordinated psychological rehabilitation plans as outlined by Thresholds professional and clinical staff.
  • Expanded services for special subpopulations: In addition to the services described above, advanced practice nurses also provide expanded primary, preventive, and mental health services for Thresholds clients enrolled in special programs, including young adults (ages 16 to 21 years) who are newly diagnosed with mental illness at Thresholds' Lauren Juhl Young Adult Center and mothers and children enrolled in Thresholds' Mother's Project. These expanded services include screening and referrals for eating disorders and guidance on childcare, family planning, sexual health, and lifestyle issues.
  • Outreach services: In 2008, the University of Illinois at Chicago College of Nursing received funding to launch a new program called Integrated Health Care Without Walls. This program, active as of May 2009, brings integrated primary and mental health services to hard-to-reach Thresholds members through house calls, group medical visits, and telemonitoring. In particular, the program uses a multiuser telemonitoring unit to provide remote monitoring of blood pressure, blood glucose, weight, and oxygen levels on six participants (per unit) living in Thresholds group homes.
  • Web-based learning modules for nursing students and faculty: In 2009, the College of Nursing also launched a series of Web-based learning modules, called "Integrating Primary and Mental Health Care Services" (see References/Related Articles below). Developed by College of Nursing faculty and advanced practice nurses working in integrated primary and mental health care settings, these modules are designed to enhance cultural competency in integrated care for prelicensure and graduate nursing students and faculty.
  • Quality improvement/patient safety plan: Information provided in November 2013 indicates that in 2012, the leadership of Integrated Health Care initiated a formal quality improvement and patient safety plan. A quality council, comprising representatives from the clinics and the University of Illinois College of Nursing, approved the plan and endorsed the implementation of a balanced-performance computer dashboard. The dashboard provides leaders and staff of Integrated Health Care with a snapshot, based on Healthy People 2010 benchmarks, of performance in six key areas: clinical care, patient satisfaction, operations, volume, productivity, and finance.

Context of the Innovation

Thresholds Psychiatric Rehabilitation Centers is a large nonprofit mental health organization that provides comprehensive services to individuals with mental illness, including psychiatric and other mental health services, case management, housing assistance, education, and job training and placement. Approximately 6,000 individuals with mental illness are served each year across 30 locations throughout the Chicago metropolitan area. In 1996, Thresholds leaders set a goal to increase client access to regular primary health care, including an annual physical. During this same timeframe, family nurse practitioner students from the University of Illinois at Chicago College of Nursing were providing health education lectures and other services via onsite health fairs to Thresholds members. Recognizing the need for this population to have better access to primary care, one of the nursing faculty members approached Thresholds with the idea of using family nurse practitioners to provide annual physicals to Thresholds members. Representatives from the two organizations collaborated to develop a plan, and the first Integrated Health Care clinic was established within one of Thresholds' psychosocial recovery centers in March 1998. Today, there are three such locations.

Did It Work?

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Results

The Integrated Health Care program has enhanced access to much needed, evidence-based primary and mental health care services for individuals with severe mental illness, leading to meaningful improvements in health outcomes for this population.
  • Enhanced access: Integrated Health Care has grown significantly since its origins in 1998. The program served 900 adults and children during its first 4 years in operation, providing approximately 10,000 patient encounters during this time period. By fiscal year 2011, the program was serving 950 individuals in a single year. The annual number of patient–provider encounters grew from 200 in 1998 to more than 4,000 in fiscal year 2011. In fiscal year 2009, the program's new Integrated Health Care Without Walls component added 419 outreach visits to Thresholds clients. The program currently serves 27 percent of Thresholds members with mental illness. 
  • Improved health outcomes: A pre- and post-implementation review (12 months after enrollment in the program) of 119 individuals in 2005 found meaningful improvements in key indicators, including the following:
    • Lower blood pressure: Participants experienced an average 2.8-percent decline in systolic blood pressure and a 2.4-percent decline in diastolic blood pressure.
    • Lower cholesterol: Participants experienced an 11.6-percent decline in total cholesterol and a 13-percent decline in low-density lipoprotein (LDL) or "bad" cholesterol.
    • Lower blood sugar: Participants experienced a 22.9-percent decline in hemoglobin A1c or blood glucose levels.
  • Diabetes goals: A 2009 review of clinic encounters for 178 diabetic clients demonstrated that 76 percent achieved A1c levels equal to or less than 7, and 69 percent had LDL levels equal to or less than 100. A similar review in 2011 of clinic encounters for 250 diabetic clients demonstrated that 75 percent achieved A1c levels less than 7, and 59 percent had LDL levels less than 100. In 2011, Integrated Health Care received an "Excellence in Diabetes" award from Your Healthcare Plus, Illinois Medicaid's disease management division. Performance dashboard results (initiated in 2012) from the first quarter (Q1) of fiscal year 2014 showed Integrated Health Care exceeded the benchmark for patients with A1c levels below 7 (65 percent versus the benchmark of 58.9 percent), patients with A1c levels greater than 9 (12 percent versus the benchmark of 76.9 percent), and patients with LDL less than 100 (81 percent versus the benchmark of 61 percent). (Updated November 2013.)
  • Adherence to evidence-based best practices: A review of advanced practice nurse patterns found a high rate of compliance with evidence-based best practices for the management of chronic conditions such as hypertension and diabetes.
  • High levels of patient satisfaction: In 2006, 97.9 percent of program participants who completed a patient satisfaction survey agreed or strongly agreed that they were satisfied with their overall care. Performance dashboard results in 2013 showed that Integrated Health Care exceeded benchmark levels on three key measures of patient satisfaction for Q1 of fiscal year 2014.
  • Smoking cessation interventions: According to information provided in November 2013, Integrated Health Care exceeded the performance dashboard benchmark in providing smoking cessation advice or medication for Q1 of fiscal year 2014 by 74 percentage points (95 versus 21 percent).

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of key outcomes indicators, along with post-implementation data on program volumes, the percentage of patients meeting preestablished goals, provider adherence to evidence-based practices, and patient satisfaction levels.

How They Did It

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Planning and Development Process

Key steps in the planning and development process include the following:
  • Establishing a planning group: A joint University of Illinois at Chicago College of Nursing and Thresholds planning group convened in 1997 to develop a business plan that outlined startup costs for each organization and potential funding sources.
  • Pursuit of funding resources: The College of Nursing and Thresholds applied for and received several grants to cover the cost of startup and development.
  • Developing a joint operating committee: A joint operating committee made up of representatives from the College of Nursing and Thresholds took responsibility for implementation and ongoing operations.
  • Formation of new partnership: In July 2007, Integrated Health Care became part of Mile Square Health Center, a Federally Qualified Health Center already affiliated with the University of Illinois at Chicago Medical Center.
  • Training: Psychiatric/mental health clinical nurse specialists and family nurse practitioners participate in monthly joint grand rounds where Integrated Health Care case studies are discussed. These sessions facilitate cross-training and creative care planning across nursing specialties. In addition, each organization provides cross-training in its areas of expertise (i.e., Thresholds provides training on mental health topics and psychiatric medications, whereas University of Illinois at Chicago provides health education training).

Resources Used and Skills Needed

  • Staffing: The program is staffed by seven family nurse practitioners, two clinical nurse specialists, one registered nurse, two medical assistants, and undergraduate and graduate nursing students at the University of Illinois at Chicago. The family nurse practitioners and clinical nurse specialists are master's-prepared College of Nursing faculty who serve as preceptors for the undergraduate and graduate students. Two master's-prepared nurse managers provide program oversight.
  • Costs: The operating budget for the first year of the program was $118,000, a figure that grew 10-fold to $1,195,100 in fiscal year 2008.
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Funding Sources

Robert Wood Johnson Foundation; Alberto Culver Foundation; Chicago Community Trust; GFF Foundation; Health Resources and Services Administration, Division of Nursing; Irvin Stern Foundation; Rebecca Susan Buffett Foundation; Sandler Foundation; Spirit Foundation; VNA Chicago Foundation; Washington Square Health Foundation
Program development has been supported through fee-for-service revenue, internal resources, grant funding from private and Federal sources, and fundraising events. The University of Illinois at Chicago provided in-kind support until grant funds were secured from the National Institutes of Health, the Robert Wood Johnson Foundation, and the Health Resources and Services Administration.

Information provided in November 2011 indicates that in 2010, Integrated Health Care was 1 of only 10 nurse-managed health centers to receive Affordable Care Act funding to expand primary and mental health care services.end fs

Tools and Other Resources

Evidence-based practice guidelines for diabetes management in patients with serious mental illness were developed by program faculty and reviewed by an expert panel. The guidelines may be found at http://uic.edu/nursing/ihc/forms/ClPrRec9_03Peer.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).

Adoption Considerations

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Getting Started with This Innovation

  • Secure buy-in and commitment from key stakeholders: It is critical to secure the commitment of dedicated primary and mental health care providers who are willing to collaborate to ensure high-quality, coordinated care for patients with serious mental illness.
  • Build mutually beneficial partnerships among community providers: Each of the three partners has made valuable contributions to and derived benefits from the Integrated Health Care program. Thresholds and Mile Square Health Center benefit from high-quality integrated primary and mental health services for their clients, whereas the University of Illinois at Chicago College of Nursing benefits from having the program's clinics as practice sites for their advanced practice nurses and undergraduate nursing students and from research that results from their practice at the clinics.
  • Maintain open communication among all partners: The complexities of merging multiple systems can be difficult, but open communication and active solicitation of input from all partners facilitates this otherwise daunting task.
  • Formalize a partnership agreement: Clearly outlining the roles and responsibilities of all partners is crucial to ensuring effective and efficient operations.

Sustaining This Innovation

  • Actively pursue alternative funding sources: Because grant funding is usually time limited, active pursuit of alternative funding sources, including third-party reimbursement, is essential.
  • Partner with strong organizations with similar missions: Establishing partnerships with organizations that can help provide staff, resources, and/or funding is critical to the ongoing sustainability of this program. The formation of the Mile Square Health Center partnership represented the culmination of a deliberate process. Key staff from Thresholds and the University of Illinois at Chicago discussed the desired qualities of the ideal partner to share in the further development and expansion of the program. These individuals compiled a list of questions designed to probe for these qualities and then interviewed leaders of several Federally Qualified Health Centers before deciding to enter into negotiations with Mile Square Health Center.

Use By Other Organizations

Trilogy, a private, not-for-profit community behavioral health agency serving individuals with serious mental illness in Rogers Park and Evanston, IL, recently implemented a similar integrated model of care.

More Information

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Contact the Innovator

Emily Brigell MS, RN
Director of Integrated Healthcare
Institute for Healthcare Innovation
UIC College of Nursing
845 South Damen
Chicago, IL 60612
Phone: (312) 996-9354
Fax: (312) 996-7725
E-mail: ebrigell@uic.edu

Jay D. Forman, MA
Vice President, Strategic Development
Thresholds Psychiatric Rehabilitation Centers
4101 North Ravenswood
Chicago, IL 60613
Phone: (773) 572-5350
Fax: (773) 472-4581
E-mail: jay@thresholds.org

Innovator Disclosures

Ms. Brigell and Mr. Forman have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

Davis KE, Brigell E, Christiansen K, et al. Integrated primary and mental health care: an evolving partnership model. Psychiatr Rehabil J. 2011;34(4):317-20. [PubMed]

The Web-based learning modules "Integrating Primary and Mental Health Care Services" are available at https://blackboard.uic.edu/bbcswebdav/institution/classes/ww101-cont/Public/WOW/index.html.

The University of Illinois at Chicago College of Nursing Web site is available at: http://www.nursing.uic.edu/.

World Health Organization. Now more than ever: the contribution of nurses and midwives to primary health care. A compendium of primary care case studies. 2009. Available at: http://www.who.int/hrh/nursing_midwifery/compendium_hrh_studies.pdf.

Storfjell JL, Brigell E, Christiansen K, et al. WOW specialty home care service for individuals with serious mental illness. Home Health Care Management & Practice. 2008;21(1):23-32. Available at: http://hhc.sagepub.com/content/21/1.toc.

Wilkniss SM, Moore H, Alexander S, et al. Integrated care at Paxton House. Behav Healthc. 2007;27(3):24, 26-9. [PubMed]

McDevitt J, Braun S, Noyes M, et al. Integrated primary and mental health care: evaluating a nurse-managed center for clients with serious and persistent mental illness. Nurs Clin North Am. 2005;40(4):779-90. [PubMed]

The U.S. Department of Health and Human Services' Healthy People 2010 Web site is available at: http://www.healthypeople.gov/2010/.

Burke N, Braun S, Snyder M. Thresholds: A model for integrated nurse managed health care. chart. Jul/Aug 2004. Available at: http://findarticles.com/p/articles/mi_qa3932/is_200407/ai_n9456246.

Marion LN, Braun S, Anderson D, et al. Center for Integrated Health Care: primary and mental health care for people with severe and persistent mental illnesses. J Nurs Educ. 2004;43(2):71-4. [PubMed]

Footnotes

1 These advanced practice nurses include family nurse practitioners, psychiatric mental health nurse practitioners, and psychiatric clinical nurse specialists.
2 Muir-Cochrane E. Medical co-morbidity risk factors and barriers to care for people with schizophrenia. J Psychiatr Ment Health Nurs. 2006;13(4):447-52. [PubMed]
3 Mauer B. Morbidity and Mortality in People with Serious Mental Illness. Alexandria, VA: National Association of State Mental Health Program Directors (MASMHPD) Medical Directors Council. 2006 Oct. Technical Report No. 13.
4 Dickerson FB, Goldberg RW, Brown CH, et al. Diabetes knowledge among persons with serious mental illness and type 2 diabetes. Psychosomatics. 2005;46(5):418-24. [PubMed]
5 Newcomer JW, Hennekens CH. Severe mental illness and risk of cardiovascular disease. JAMA. 2007;298(15):1794-6. [PubMed]
6 Skala JA. Severe mental illness increases the risk of death from coronary heart disease or stroke. Evid Based Ment Health. 2007;10(4):105. [PubMed]
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: September 08, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: April 09, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: November 12, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.