A cutting-edge program run through the UC San Francisco School of Nursing is helping people with mental illness better manage all of their health needs.
Sheila* is a single, homeless woman in her 40’s with a long history of bipolar affective disorder, complicated at times by substance abuse and periods of homelessness. For the past several months, she has lived in a residential treatment program offered through the Progress Foundation in San Francisco where she is receiving mental health and chemical dependency treatment.
Although Sheila has been making significant progress with her mental health issues, she has experienced some problems with her physical health, including a diagnosis of pre-diabetes.
While staff at the Progress Foundation have been helping Sheila manage her mental health, nurse practitioners in the University of California San Francisco School of Nursing’s faculty practice –Primary Care Outreach for the Mentally Ill (PCOM), which delivers primary care to Progress Foundation residents during their stay, have worked with Sheila to help her lower her blood sugar and prevent her condition from progressing to type 2 diabetes. They also want to ensure that Sheila, and other patients, continue to receive both medical and psychiatric care after they leave the residential care program.
“Many people with mental health conditions, including bipolar disorder, are more likely to have certain other physical health problems including heart disease, thyroid problems and obesity,” says Gerri Collins-Bride, a nurse practitioner who co-founded PCOM in 1995 and now serves as its clinical director, along with Linda Chafetz, PCOM’s associate director. “It’s very common for people with mental illness to have health concerns that fall through the gap between mental health and primary care.”
Chavetz, who maintains data on PCOM’s patients and services, notes that not all cities have the amount of residential care that San Francisco does, or work with such a diverse population. At PCOM, a large percentage of the patients seen are African-American and Latino, with 62 percent tenuously housed in either shelters or on the streets. More than 30 percent of their patients suffer from severe forms of depression, with diagnoses such as schizophrenia, bipolar disorder, anxiety and other stress-related disorders also represented.
To better serve their patient population, Collins-Bride, Chafetz and their colleagues are working on a new initiative funded by the Health Resources and Services Administration (HRSA) at UCSF that strives to increase inter-professional practice in these settings. Collins-Bride has put together a multidisciplinary team consisting of a project coordinator, five primary care nurses practitioners, a clinical pharmacist, two psychiatrists, three psychiatric nurse practitioners, one internal medicine physician consultant and approximately 100 direct care residential counselors spread over Progress’ 10 residential programs. Together, they hope to create a model that integrates medical records, and improve information flow, especially when mental health patients are discharged from residential programs. The team plans to measure success in part, by looking at patient outcomes in the areas of smoking cessation, metabolic monitoring, and reductions in HIV and Hepatitis C safety risk.
Their goal is not only to provide primary care during residential treatment, but to increase ongoing access to medical services. Access to primary care, in particular, is important because of high rates of medical problems among the mentally ill, some associated with their treatment, and because of well documented disparities in their care. Chafetz says, “We hope to expand PCOM to create a replicable model for integrating primary care into behavioral health.”
Nurse practitioners in the PCOM program take the care and services directly to patients, and work to empower them on how to proactively handle their health issues, and to address topics such as healthy eating and smoking cessation. They also work to build trust with patients.
“Many of the population that we see has been homeless at one time, and others are victims of assault, or trauma,” Chafetz says. “They typically have a lot of physical problems and dental needs, but their general fear and distrust of the system is another barrier that we have to work on to ensure they continue to receive care.”
As part of this project, the team is working with the San Francisco Department of Behavioral Health Services, to integrate information on primary care delivered by the program’s staff into the electronic mental health record. This will allow future clinicians in mental health programs to access this important health information.
“We hope to link the record of IPCOM primary care services in residential treatment programs to the electronic mental health record,” Collins-Bride says. “We are also looking at options that could link patients to a web-based resource where they could potentially access their own treatment plans to bring to appointments in ongoing mental health and primary care services.”
“With this type of integrated primary care/mental health record, providers could easily access a patient’s information to determine the type of treatment they have received in the past, medications they are taking, and form a plan of treatment,” Collins-Bride says.
Both Collins-Bride and Chafetz have high hopes for their grant-funded program that will continue for the next two years.
“We hope that a team-based approach to care will help our patients to not only receive quality medical care, but to also to teach them how to better care for themselves,” Collins-Bride says.
*Name changed to protect patient privacy.