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Innovations : primary-care-integration


Clinical Innovations

Title: Primary Care Integration with Assertive Community Treatment


Organization: People Encouraging People  

Innovation type: Comprehensive Case Management 

What They’re Doing: Providing comprehensive care to patients with severe mental illness that fully integrates mental, behavioral and primary health care.    

Clinical Innovation: Uses Assertive Community Treatment, an evidence-based health service delivery model, to provide comprehensive, community-based mental health services and support to individuals with severe mental illness or co-occurring mental illness and substance abuse disorders.   The approach uses multi-disciplinary teams of providers (physicians, nurses, social workers, substance abuse and peer counselors, etc.) who provide mobile support around the clock in the patient’s home or neighborhood location. Services may include on-going assessment, case management, psychiatric treatment/rehabilitation, substance abuse services, health education, employment and housing assistance, and other support services. People Encouraging People includes a nurse practitioner on each team who serves as the primary care provider to the patients so that behavioral health services are fully integrated with primary health care services. Each team provides mobile care for 100 patients. 

Evaluation Type: Quasi-Experimental 

Evaluation Plan:   A retrospective chart review will be conducted to ascertain whether the addition of a primary care nurse practitioner in an ACT team results in better identification and treatment of chronic health conditions. A paired t-test will be used to compare the health outcome data that was collected prior to and during the 6 month study period. Cost data will be analyzed, in conjunction with partnering MCOs Amerigroup and United Health Care, to determine the relative cost effectiveness of the approach.  

Patient Health and Cost Outcomes:   For updated outcomes, please see "Updates" section below.  

Target Population: Adults aged 18 and over with a severe and persistent mental illness with 50% of the population having substance abuse issues. A significant percentage of the consumers also have a co-morbid somatic illness ranging from diabetes, COPD, Hepatitis to HIV, Cancer, and other significant illnesses.   These individuals come from street homelessness, jail/prison, emergency rooms, and State Hospitals and qualify for the program if they display a high level of vulnerability to morbidity and mortality factors resulting from a wide range of functional and social barriers.  

1) Results of the First Year with the Adult Nurse Practitioner (ANP) Embedded in One ACT Team: Results were analyzed as part of a quality improvement project conducted by Marcia Harton DNP, PMHCNS-BC, as part of her doctoral requirements at the University of Maryland School of Nursing. Results demonstrated that embedding an Adult Nurse Practitioner (ANP) within an Assertive Community Treatment (ACT) team is a feasible model of integrated primary and behavioral health care for clients with severe mental illness who are in treatment with an ACT team. Embedding an ANP within the ACT team increased access to health care for these clients. During the twelve months following implementation of this model of integrated care, 53 ACT clients, (51.5%) chose the ACT ANP as their primary care provider (PCP). Twenty five of those clients had not been receiving consistent health care from a PCP or any other identified health care provider prior to implementation of this model.
Screening for cardiovascular risk factors is critical for this population because cardiovascular disease is the leading cause of death (Hennekens, Hennekens, Hollar, & Casey, 2005; Wheeler, 2010). Early identification of disease can facilitate early treatment, and thus reduce the severity and/or progression of disease. Despite this finding, screening for the core measures of cardiovascular risk was not done routinely by community primary care providers prior to the ANP joining the ACT team.
Results of a paired-samples t-test, using body mass index (BMI) as a proxy for cardiovascular screening, demonstrated a statistically significant increase in the incidence of cardiovascular screening from the one-year time period before the ANP was embedded in the team (M=.2179, SD= .41552) to the one-year time period after the ANP was embedded (M= 29.8138, SD=7.13936), t (77) = -36.635, p< .001 (2-tailed).  There were also statistically significant increases in the number of screenings of waist circumference, blood pressure, fasting blood glucose, fasting triglycerides, and fasting HDL cholesterol.
The following additional selected statistics demonstrate further results of this quality improvement project. Prior to embedding an ANP within the ACT team, the number of cardiovascular risk factors that were identified among the 103 ACT clients was 66. During the 12 months following the embedding of an ANP into the Act team, the number of identified cardiovascular risk factors was 157, an increase of 138%. Prior to the embedding of the ANP, 19 clients (18.4%) had their BMI assessed, and eight (42.1%) of them had BMI measurements that put them at risk for cardiovascular disease (CVD). After the ANP was embedded, 78 clients (75.7%) had their BMI’s assessed, and 34 (43.6%) of those clients were at risk. Prior to the ANP joining the ACT team, no clients had had their waist circumferences measured (0%). After the ANP joined the ACT team, 55 clients (53.4%) had their waist circumferences measured, and 39 of those clients (70.9 %) had measurements putting them at risk for CVD. Prior to the ANP, forty-four clients (42.7%) had their fasting blood glucose checked, and twenty-two (50%) had levels considered at risk for CVD. After the ANP was embedded in the ACT team, fifty-eight clients (56.3%) had their glucose level checked, and twenty (34.5%) of those clients had at-risk levels. Twenty-eight clients (27.2%) had fasting triglyceride levels checked prior to the ANP joining the ACT team, and ten of them were at risk for CVD (35.7%). Triglyceride levels for fifty-two clients were checked after the ANP was embedded (50.5%) and nineteen of them (36.5%) were at risk for CVD. Twenty-seven clients (26.2%) had fasting HDL cholesterol checked before the ANP, and ten of them (38.5%) were at risk. After the ANP joined the ACT team, fifty-two clients (50.5%) had fasting HDL cholesterol levels checked, and nineteen of those clients (36.5%) were at risk.
Primary care integration into an Assertive Community Treatment team at People Encouraging People Inc. is a successful and feasible health care delivery model. This model focused on preventive health services, and early identification and treatment of chronic health conditions. Using cardiovascular screening as a proxy for high quality primary health care, it is evident that integrated mental, behavioral, and primary health care within the ACT team provides clients with high quality primary health care.

Date of Implementation: January 1, 2011

Contact: Dimitrios Cavathas, LCSW-C, Division Director of Community Services, ,   410-366-4299 ext. 139

Multimedia: Pending

Where to learn more: Please call 410-366-4299 for more information


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