Project Bridge: Peer Health Navigator Intervention

The mortality rate among people with Serious Mental Illness (SMI) is 2 to 3 times that of the
general population (DeHert et al., 2011), meaning that those with a serious mental illness
die, on average, 25 years earlier than those without a SMI (Parks et al., 2006). There is
evidence that these deaths are largely attributed to preventable medical conditions, many of
which are more common in the SMI population. System bifurcation, or the separation of mental
and physical health services, has been identified as a critical factor that leads to
significant health disparities for those with SMI (Bazelon Center for Mental Health Law,
2004).

Grounded in patients' experiences, needs, and voices, investigators seek to generate
knowledge about effective interventions, use outcomes that are central to patients and
caregivers, attend to issues of implementation and dissemination, and may seek to optimize
outcomes in the context of factors such as burden, technology, and stakeholder perspectives.
Based on pilot work funded by the UniHealth Foundation, the goal of this Patient Centered
Outcomes Research Institute (PCORI) proposal is to test the effectiveness of a peer health
navigation intervention (The Bridge) in comparison to usual treatment. The Bridge is a
peer-staffed comprehensive healthcare engagement and self management model, situated in an
outpatient mental health clinic, where clients are taught the skills to access and manage
their healthcare for any condition. The investigators' goal is train clients to successfully
engage and navigate the primary health care system as well as other needed health care
services (specialty care, lab, and pharmacy). Guided by a version of Gelberg, Andersen, and
Leake's (2000) Behavioral Model of Health Service Use for Vulnerable Populations that
investigators adapted for the seriously mentally ill (Brekke et al., in press), the Bridge
combines three approaches: integrated care, patient education, and cognitive-behavioral skill
building with an in vivo (real world) focus.

Investigators will conduct a randomized controlled trial comparing 2 groups: a) a treatment
as usual waitlist (n =73), and b) the Bridge peer navigator intervention (n=73).
Investigators will compare these groups across 3 time points (baseline, 6 months, 1 year) to
examine the Bridge's effectiveness at improving health care service use, satisfaction with
care, health knowledge, health status, health related self-efficacy, and quality of life.
Outcomes will be measured through patient self-report and according to objective measures of
health (medical records and insurance claims data).

In addition, investigators will conduct interviews every three months with selected
stakeholders to assess the degree to which the intervention and the study are succeeding and
what challenges have occurred. This will allow for corrections as the study proceeds.
Investigators will focus on the factors that will contribute to the implementation and
sustainability of the health navigator intervention including: cost, training, supervision,
billing issues, and how this position will fit into the organizational model of the clinic.
To begin the interview, investigators will ask each person interviewed for his or her ideas
about what are the critical factors for implementation and sustainability. Finally
investigators plan on conducting exit interviews with each patient as part of their final
assessment. Exit interviews will focus on the patients' perceptions about the study, how it
affected them, what went well, and what challenges they encountered. Each interview should
last about 20-30 minutes and will be audio-recorded using an encrypted tape recorder.
Investigators will use a semi-structured interview guide so that all interviewees are asked
the same questions and data are comparable. Basic demographics such as gender, ethnicity, and
age will be recorded for all participants.

This PCORI proposal relies on significant stakeholder involvement in the intervention
development, project development and management, and in the plans for dissemination and
implementation. The ultimate goal is to provide the field a peer-delivered intervention that
significantly reduces disparities in the utilization and outcome of health services for the
seriously mentally ill and thereby reduce morbidity and mortality in this highly vulnerable
population.

Inclusion Criteria:

- Client participants will have diagnoses of serious mental illness and be between the
ages of 18-65. All participants must be able to complete assessments in English.

- Staff participants will be between the ages of 18-65 and must be currently employed at
Pacific Clinics. All participants must be able to complete assessments in English.

- Medical providers who serve clients of Pacific Clinics will also be interviewed as
stakeholders. They will be between the ages of 18-65 and must be employees of a
medical provider serving Pacific Clinics' clients.

Exclusion Criteria:

- Clients who are under the age of 18, over the age of 65, who are under
conservatorship, cannot give informed consent themselves, or are not receiving mental
health services through Pacific Clinics will not be eligible for participation.

- Staff participants must be currently employed at Pacific Clinics and have the capacity
to give informed consent themselves.

- Medical providers must be serving Pacific Clinics' clients and have the capacity to
give informed consent themselves.