Practical Methods for Integrating Healthcare into Community Mental Health Services

1. Practical Methods for Integrating Healthcare into Community Mental Health Services Nancy Little, MA, LCPC William Reedy, RN Dorothy Jones Thresholds June 2011

2. Goal Participants will recognize the imperative of finding ways to address physical wellness to help increase lifespan of consumers with severe mental illnesses.

3. Objectives • At the end of this session, participants will: • Know some of the reasons why people with SMI are dying before their time • Know five strategies to incorporate into community support services that address health issues • Have three internet based resources to help educate and support consumers in establishing and achieving their health goals

4. Case Example Ben is a 57 year old, single African American living in his own apartment. He works 20 hours per week and is very active. He is overweight and has insulin (injection) dependent Type II diabetes. He has few friends, and occasionally has a girlfriend. His relationships with family members are distant. Negative symptoms and cognitive difficulties make it difficult for him to manage the diabetes. It is hard for him to make sense of medical information and he tends to confabulate. For example, he equates Hawaiian Punch with juice, and believes he can determine the calorie content of food by whether it tastes “light” or “heavy”. He does not understand his symptoms, and mostly blames himself for lack of motivation and difficulty understanding information. He does not see the connection between diet and blood sugar readings. He does not fully grasp how his active lifestyle affects his blood sugar. His goal is to get off the injectable insulin. He is seen at a managed care clinic that he unknowingly signed up for through Medicare Part D. Customer service there is abysmal. The clinic provided him with a pamphlet about diabetes.

5. OK, so there’s barriers…. • BUT 25years (average) difference in life span?

6. “People with serious mental illness die • at age 51, on average, compared with • age 76 for Americans overall.” • (USA Today 2007) • Why do people with mental illnesses • die younger?

7. Why do people with mental illnesses • die younger? • Chronic Obstructive Pulmonary Disease (COPD) • 43.5% of cigarettes smoked in US • are consumed by people with mental • illnesses, about 20% of Americans(Wall Street Journal, April 2011)

8. Why do people with mental illnesses die younger? Metabolic Syndrome and Obesity associated with psychiatric medications

9. Why do people with mental illnesses • die younger? • Diabetes • 8% to 9% of Americans have diabetes. • 16% to 25% of Americans with mental • illnesses have diabetes.

10. Why do people with mental illnesses • die younger? • Coronary Artery Disease (CAD) or • Coronary Heart Disease (CHD) • Hyperlipidemia, • Arteriosclerosis, • Atherosclerosis.

11. Why do people with mental illnesses • die younger? • Hypertension • Smoking • Excessive alcohol use • High sodium intake

12. Why do people with mental illnesses • die younger? • Congestive Heart Failure • Diminished ability of the heart to pump • blood through the circulatory system • Mental health issues can be caused by • CHF or by medications used to treat CHF

13. Why do people with mental illnesses • die younger? • Liver Disease • Alcohol and drug abuse • Hepatitis

14. Why do people with mental illnesses • die younger? • Infectious illnesses • Weakened immune system • Deficits in self care • Poor access to health care • STD’s and blood borne illnesses.

15. Why do people with mental illnesses • die younger? • Poor access to quality health care. • Poverty • Stigma • Communication lapses

16. How does this relate to Certified Psychiatric Rehabilitation Practitioner CPRP domains? • Domain II: • Maintain Own Personal Wellness • Knowledge of EBP and emerging EBP • Advocacy on behalf of consumers • Promote health goals like weight loss and nutrition (smoking cessation?)

17. Emerging EBP to integrate care • Integrated Illness Management and Recovery • Based in Illness (wellness) management and recovery • Evidence shows that addressing key knowledge and skill areas improves feeling of competence in managing illness, more time spent on improved role functioning/quality of life (Gingerich, Mueser 2005)

18. IMR (WMR) • Collaborative • Strength based • Focused (CBT Format) on goal achievement • Establishing goals • Teaching information/skills • Practicing skills in session • Homework (collaborative) • Follow up • Incremental steps towards goals

19. IIMR • Dartmouth study (NH and IL) used IMR Manual • http://store.samhsa.gov/product/SMA09-4463 and inserted health information : • Practical Facts about Diet and Exercise • Talking to your Primary Care Physician • Study subjects=over 50, identified health issue • Consumer meets regularly with practitioner and nurse • Frequent communication with PCP • Frequent communication between practitioner and nurse

22. Wellness goals established early

23. Goals and Progress • How establish goals? • Strengths and Knowledge Inventory • Do not judge goals, accept them. • “I want a full head of hair and to cure my diabetes” • How is progress assessed? • Progress toward physical health goals sometimes easier to assess, more immediate feedback. • Emphasis on behavioral change followed by cognitive/emotional change

24. Wellness Checklist

26. New Plate

28. Nurse role in IIMR • Goals: • Improve client’s awareness and understanding of medical conditions and medications • Reduce barriers to self-management • Monitor signs and symptoms related to medical diagnoses. • Desired Outcomes: • Client verbalizes medical self-management strategies • Client improves level of functioning through increased ability to self monitor changes in physical symptoms • Client improves communication with medical providers with increased knowledge of specific disease process

29. Demonstrate practitioner session • Notice how the CBT structure is adhered to

30. Dorothy’s story • Trouble started when I was a teen • First and only child at age 18 • Chattanooga • Rescue • Nursing Home • Job and apartment • Loss • IIMR • Life now

31. Demonstrate Nurse IIMR Session

32. Lessons learned • While health goals may seem obvious, the real work may not start for awhile • Establishing collaborative relationships with PCPs is hard work • One of the most important skills in IIMR is self advocacy • Health crises can be very powerful motivators

33. observations • Talking about health is easier than talking about mental health • Consumers take note of your behavior • Self advocacy is powerful

34. How can you do this at home? • Advocacy • Access to PCP • Modeling • Sleep hygiene info • Smoking cessation info • Learn about physical health/meds • Get a scale