PACT for Individuals With Serious Mental Illness

Background/Rationale:

People with serious mental illness (SMI) die, on average, many years prematurely, with rates
of premature mortality 2 to 3 times greater than the general population. Over 60% of
premature deaths in this population are due to "natural causes," especially poorly treated
cardiovascular, respiratory, and infectious diseases. Although the VA is a centrally
organized, comprehensive healthcare system, Veterans with SMI still have difficulty
navigating the system, and are at substantially elevated risk for premature death. Too often,
they do not attend scheduled appointments or fail to engage in primary care treatment, and
consequently do not get valuable preventive and primary care services.

Primary care in VA has undergone significant transformation under the Patent Aligned Care
Team (PACT) model, which is based on the Patient Centered Medical Home (PCMH) concept. PACT
has the goal of improving the quality, efficiency, and patient-centeredness of primary care.
But it remains unclear how PACT will impact the large populations of Veterans whose
predominant illness is treated in specialty settings, such as people with SMI. Research can
inform efforts to apply the PACT model. For example, while people with SMI do poorly with
usual primary care arrangements, there is substantial evidence that integrated care and
medical care management approaches can improve medical treatment and outcomes, and reduce
treatment costs, in people with SMI.

Objective:

Using available evidence, the investigators propose to implement and evaluate a specialized
PACT model that meets the needs of individuals with SMI ("SMI-PACT").

Methods:

This project will partner with leadership to implement SMI-PACT, with the goal of improving
healthcare and outcomes among people with SMI, while reducing unnecessary use of emergency
and hospital services. Evidence-based quality improvement strategies will be used to
reorganize processes of care. In a site-level controlled trial, this project will evaluate
the effect, relative to usual care, of SMI-PACT implementation on (a) provision of
appropriate preventive and medical treatments; (b) patient health-related quality of life and
satisfaction with care; and (c) medical and mental health treatment utilization and costs.
The project includes a mixed methods formative evaluation of usual care and SMI-PACT
implementation to strengthen the intervention, and assess barriers and facilitators to its
implementation. Mixed methods will also be used to investigate the relationships between
organizational context, intervention factors, and patient and provider outcomes; and identify
patient factors related to successful patient outcomes.

Significance:

This project's approach to SMI-PACT is consistent with the VA PACT model, and with efforts in
VA to improve care for Veterans with psychiatric disorders. This will be one of the first
projects to systematically implement and evaluate the PCMH and PACT concepts for patients
with serious mental illness. Should SMI-PACT be demonstrated to be feasible and effective,
the model could be used more broadly to improve the quality and efficiency of care for
Veterans.

Inclusion Criteria:

- All patient subjects and all staff subjects are currently enrolled in care at one of
the 3 sites for this study.

- All patient subjects will be Veterans.

Patient subjects:

- The investigators will enroll a random sample of 340 patients who have diagnoses of
schizophrenia

- schizoaffective disorder

- bipolar disorder

- chronic PTSD

- or recurrent major depression with psychosis

Staff subjects:

- The investigators will enroll approximately 15 staff per site.

- At each site this will include:

- 3 members of PACT

- 4 members of SMI-PACT (intervention site) or mental health integration (control
site)

- 4 providers from the mental health clinic

- 2 administrators who oversee the mental health clinic (e.g., psychiatry,
psychology, nursing, social work, clerks)

- and 2 administrators who oversee primary care.

Exclusion Criteria:

- Patients will not be excluded based on comorbid mental or medical diagnoses.

- However, there is a subset of individuals at mental health clinics who are
psychiatrically stable and advanced enough in their recovery that they do not require
high intensity mental health supports to make effective use of PACT.

- This will be assessed at baseline by each patient's clinician, using the Milestones of
Recovery Scale (MORS)scale.

- This scale rates an individual's ability to self-manage their care.

- Patients who rate at "early recovery" or "advanced recovery" on this scale will remain
with standard PACT, and are not eligible for SMI-PACT.