The Health Outcomes Management and Evaluation (HOME) Study
| Status: | Completed |
|---|---|
| Conditions: | High Blood Pressure (Hypertension), High Cholesterol, Peripheral Vascular Disease, Cardiology, Diabetes |
| Therapuetic Areas: | Cardiology / Vascular Diseases, Endocrinology |
| Healthy: | No |
| Age Range: | 18 - Any |
| Updated: | 4/21/2016 |
| Start Date: | April 2010 |
| End Date: | December 2015 |
Improving Primary Care of Patients With Mental Disorders
There is an urgent need to develop practical, sustainable approaches to improving medical
care for persons treated in community mental health settings. This study will test a novel
approach for improving mental health consumers based on a partnership model between a
Community Mental Health Center and a Community Health Center. When this study is completed,
it will provide a model for a medical home for persons with severe mental illness that is
clinically robust, and organizationally and financially sustainable
care for persons treated in community mental health settings. This study will test a novel
approach for improving mental health consumers based on a partnership model between a
Community Mental Health Center and a Community Health Center. When this study is completed,
it will provide a model for a medical home for persons with severe mental illness that is
clinically robust, and organizationally and financially sustainable
Findings of excess cardiometabolic morbidity and mortality in persons with severe mental
illness (SMI) have led to a growing interest by Community Mental Health Centers (CMHCs) in
improving the medical care of the populations they treat. However, these organizations face
a number of financial and organizational barriers to implementing and sustaining such
programs. In previous and ongoing work, the study team has documented the promise of
team-based models in improving health and health care in this population. This study will
test a novel approach for improving mental health consumers based on a partnership model
between a CMHC and a Community Health Center (CHC). This partnership will capitalize on
collocation of services, the primary care expertise of the CHC, and favorable reimbursement
conditions, to develop a program that is both clinically robust and financially and
organizationally sustainable A total of 300 CMHC clients with a severe mental illness and
one or more active cardiometabolic problem (diabetes, hypertension, hyperlipidemia) will be
randomized to either onsite Integrated Community Care (ICC) (n=150) or to a referral to the
partner community health center (CHC) (n=150) for their medical problems. For those in the
ICC, the CHC will establish a satellite clinic at the CMHC staffed by a physician assistant
and care manager. The ICC will provide care for both the index cardiometabolic conditions
and common acute and chronic comorbidities.
The study will use standardized, validated instruments to assess the impact of integrated
community care on quality and outcomes of cardiometabolic and general medical care. A budget
impact analysis will be used to assess the program's financial and organizational
sustainability. When this study is completed, it will provide a model for CMHCs to provide a
medical home for the populations they serve.
illness (SMI) have led to a growing interest by Community Mental Health Centers (CMHCs) in
improving the medical care of the populations they treat. However, these organizations face
a number of financial and organizational barriers to implementing and sustaining such
programs. In previous and ongoing work, the study team has documented the promise of
team-based models in improving health and health care in this population. This study will
test a novel approach for improving mental health consumers based on a partnership model
between a CMHC and a Community Health Center (CHC). This partnership will capitalize on
collocation of services, the primary care expertise of the CHC, and favorable reimbursement
conditions, to develop a program that is both clinically robust and financially and
organizationally sustainable A total of 300 CMHC clients with a severe mental illness and
one or more active cardiometabolic problem (diabetes, hypertension, hyperlipidemia) will be
randomized to either onsite Integrated Community Care (ICC) (n=150) or to a referral to the
partner community health center (CHC) (n=150) for their medical problems. For those in the
ICC, the CHC will establish a satellite clinic at the CMHC staffed by a physician assistant
and care manager. The ICC will provide care for both the index cardiometabolic conditions
and common acute and chronic comorbidities.
The study will use standardized, validated instruments to assess the impact of integrated
community care on quality and outcomes of cardiometabolic and general medical care. A budget
impact analysis will be used to assess the program's financial and organizational
sustainability. When this study is completed, it will provide a model for CMHCs to provide a
medical home for the populations they serve.
Inclusion Criteria:
- Patient at Cobb County CSB
- one or more of the following conditions: hyperlipidemia, high blood pressure, heart
failure, diabetes
- able to give consent
Exclusion Criteria:
- unable to give consent
- does not have a cardiometabolic condition
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