APNA 27th Annual Conference Session 3043: October 11, 2013

Transcription

1 Development of a Behavioral Health Medical Home: Nurses Filling the Gap Paula Bolton, MS, ANP-BC Margaret Knight, PhD, PMHCNS-BC Catherine Coakley, MS, RN-BC Lynne Kopeski, MSN, PMHCNS-BC Karen Slifka, MSN, PMHCNS-BC McLean Hospital, Belmont, MA University of Massachusetts Lowell, School of Nursing DISCLOSURES Paula Bolton and Margaret Knight have no personal disclosures Grant from Pollinator Trust Fund Objectives Upon completion of this presentation, participants will be able to identify the medical risks of persons with serious mental illness and discuss difficulties in navigating health care system encountered by persons with serious mental illness. Upon completion of this presentation, participants will be able to discuss nursing role in the integration of psychiatric and medical care for persons with serious mental illness. Upon completion of this presentation, participants will be able to identify strategies to incorporate risk factor reduction strategies in their care of patients at all levels of the psychiatric healthcare continuum. Bolton 1

2 Introduction Cardiovascular disease and obesity are major public health problems. People with SMI live 25 years less than the general population. Mortality rates for persons with SMI have shown a steady increase. Metabolic syndrome increases risk for developing serious medical outcomes. Complications from cardiovascular disease are among the leading causes of death for patients diagnosed with chronic schizophrenia. De Hert, Schreurs, Vancampfort, & Van Winkel, 2009 Factors Increasing Risk Genetic predisposition to weight gain Sedentary lifestyles Poor nutrition Smoking Medications side effects Second generation antipsychotics especially are associated with weight gain, glucose dysregulation, and diabetes Carpenter & Buchanan, 2008 Associated Weight Gain with Antipsychotics When compared to placebo: Ziprasidone: lbs/month Haloperidol: lbs/month Risperidone: lbs/month Olanzapine: +1.5 lbs/month (results similar to those in the CATIE Study) Parsons et al., 2009 Bolton 2

3 METABOLIC SYNDROME: A group of multiple and interrelated conditions resulting from obesity, specifically abdominal obesity and insulin resistance. ATP Definition for MS Waist circumference > 40 male/35 female Triglyceride > 150 mg/dl Fasting Blood Glucose > 100 mg/dl HDL < 40 male/50 female Blood pressure > 130/85 US Department of Health & Human Services: National Heart Blood & Lung Institute, McLean Hospital Inpatient Review consecutive patient records from the Psychotic Disorders Program reviewed. 23.7% prevalence of metabolic syndrome. Risk increases continuously (to 40%) after a decade or more of treatment and was correlated to weight gain. Risk is greater for those patients taking 2 or more antipsychotics or a mood stabilizer. Centorrino et al Bolton 3

4 Nursing MS Study 2011 Sample of 73 men and 52 women, ages admitted to an inpatient psychotic disorder unit. 21 subjects (16.8%) had three or more risk factors. 26 subjects (20.8%) had at least two risk factors. Only 5 of the 47(10.6%) patients in the study with two or more risk factors for metabolic syndrome were referred for primary care follow up after discharge. Coakley, et. al Evidence: The Need for Integration of Mental Health and Primary Care Persons with serious mental illness are at higher risk for obesity, metabolic syndrome (including diabetes) and cardiovascular problems than the general population. Medications used to treat serious mental illness often effect these medical conditions. Yet, coordinated care is lacking. ADA, APA, AACE& AANO 2004 Guidelines for Monitoring Metabolic Risk Baseline screening prior to medication prescription: BMI Waist circumference FBS Fasting Lipids Ongoing Monitoring: BMI every 3 months Waist circumference annually FBS annually Fasting lipids every 5 years (or more frequently if clinically indicated). ADA et al., 2004 Bolton 4

5 Individuals with Mental Illness Have Lack of Access to Medical Care Persons with serious mental illness have difficulty navigating all aspects of medical care. Access Issues Insufficient diagnostic and preventative care Insufficient routine testing Insufficient cardiovascular procedures Bradford et al., 2006; Gill et al Factors Affecting Access to Care Compliance issues. Psychiatric symptoms that interfere with their ability to be involved in health activities. Money issues that prevent healthy food choices, memberships to gym, preventative care (co-pays, etc.). Competing health needs A fragmented system of care. Difficulty for medical provider to arrange psychiatric follow-up Difficulty for psychiatric provider to arrange medical follow up Reimbursement for services (especially mental health) spotty. Mangurian, et. al., 2013; Agency for Healthcare Research and Quality, ND Lack of Consensus Who should monitor & treat Psychiatrist should screen and refer (Hert et al. 2009). PCP s should monitor and treat (ADA, AAPA, AACE, 2004). Psychiatrist should monitor and assure treatment of medical conditions (Daumit, Crum, Gualler et al. 2002). What about APRN s? Poor physical health is a barrier to maximizing functional health. Bolton 5

6 Factors Influencing where/who Delivers Medical Care Practice setting: Solo practice Integrated health system Access to high quality medical care Access to transportation Characteristics of the practitioner Perceived expertise Medical networking options Patient characteristics Health literacy Support systems Payer systems Dixon et al Strategies for Providing Optimal Health Care RN Case Management- Care Coordination Individual assigned to oversee all services. Managed care contacts. Co-location Services Primary care imbedded in mental health clinics (APRN s). Unified setting: one location offers all services, billing etc. Behavioral health specialist in a primary care practice Strategies Formal Agreements Collaboration between a PCP and mental health center. ACT with APRN s APRN s can work within CMHC or Psychiatric clinics. APRN s can be part of a team which includes multiple disciplines. Greater emphasis on health promotion. Out-reach via phone or in person. Can be a primary or coprovider. Bolton 6

7 Challenges Not all strategies would be appropriate for all settings. Additional cost for personnel/services would increase for comprehensive services. Workforce development. Holistic approach, collaboration and competing needs. Additional challenges Lack of clinician awareness of need for health education. MD s - SW s RN s -APRN s Patients lack knowledge about own health status and health risks. Transition of care from all levels of care needs to be seamless (inpatient partial hospitalizationoutpatient) Wellness education needed throughout Nursing Intervention to Reduce MS Risks in Persons with SMI Pilot study. Persons with Schizophrenia, Bipolar Disorder b/n ages Developed, initiated and managed by nurses. 20 week post-discharge protocol. Bolton 7

8 Initial Screening Presence of 2 risk factors for MS. Baseline waist circumference, vital signs and biological measures (FBS, triglycerides, HDL). QOL measure. Health Goal development. Methods Weekly in person (while hospitalized) or telephone contact (post discharge) with psychiatric nurse to coach on progress toward health goal. NP visits for Health Assessment post discharge week 2, 6, 10, 14 and 18. Psychiatric nurse visit immediately following for measurement of perceived progress toward health goal and coaching. Evaluation of biological measures week 10 and 18. Initial Findings Recruitment difficulties. Coordination of care issues. Complexity of care. Unstable mental status following discharge. Bolton 8

9 Case Study No year old with first psychotic break Had gained 60 lbs while on risperdal before seeing APRN. Did not recognize significance of weight gain I didn t realize what this weight gain meant Developed a plan for healthier eating and some moderate exercise. Case Study No year old married man, head of computer department in University History of bipolar disorder, seen by NP/psych RN team following hospitalization for acute mania Still very disorganized post discharge 18 week follow up post discharge Psychopharm issues - medical issues Lifestyle issue - work-related issues Case Study No yo patient with schizophrenia Type 2 DM on insulin for few years Homeless at times Compliance with med/psych regimen waxes and wanes Multiple issues including: Diabetic teaching (in context of limited capacity) Management of medications Lifestyle interventions given limited resources Bolton 9

10 Need for Integration of Mental Health and Primary Care Access is limited (both directions) Care of persons with SMI is complicated Inadequate monitoring PRACTICE IMPLICATIONS Psychiatric nurse role Role of Advanced Practice Nurse Thorough assessment/risk identification Integration of care (psychiatric and medical) Lifestyle modification programs Images All clip art images available to from: publichttp://office.microsoft.com/enus/images/results.aspx?qu=overweight&ex =1&AxInstalled=copy&Download=MC &ext=WMF&c=0 at=5 Bolton 10

11 References Agency for Healthcare Research and Quality,(ND). Experts call for integrating mental health into primary care Publication #12-RA004. Retrieved from American Diabetes Association, American Psychiatric Association, American Association of Clinical Endocrinologists, North American Association for the Study of Obesity Consensus development conference on antipsychotic drugs and obesit and diabetes. Diabetes Care, 27(2), Bradford, D.W., Kim, M.M., Braxton, L,E., Marx, C.E., Butterfield, M. & Elbogen, E.B Access to medical care among persons with psychotic and major affective disorders. Psychiatric Services, 59(8), Carpenter, W.T., & Buchanan, R.W. (2008). Lessons to take home from CATIE. Psychiatric Services, 59, Centorrino, F., Masters, G.M., Talamo, A., Baldessarini, R.J. & Ongur,D Metabolic syndrome in psychiatrically hospitalized patients treated with antipsychotics and other psychotropics. Human Psychopharmacology, 27, Coakley, C, Bolton, P, Flaherty, L, Kopeski, L, Slifka, K, Sutherland, M, C. 2012, The Incidence of Metabolic Syndrome in an Inpatient Psychiatric Setting. Journal of Psychosocial Nursing, 50:3, Daumit, G.L., Crum, R.M. Gauller, E et al. (2002). Receipt of preventative medical services at psychiatric visits by patients with severe mental illness. Psychiatric Services, 53, DeHert, M., Schreurs, V., Vancampfort, D. & Van Winlel, R Metabolic syndrome in people with schizophrenia: a review. World Psychiatry, 8, Dixon, L.B., Adler, D.A., Berlant, J.L., Dulit, R.A., Goldman, B., Hackman, A.L., Oslin, D.W., Sirus, S.G., Sonis, W.A., Valenstein, M. (2007). Psychiatrists and primary caring : What are our boundaries of responsibility. Psychiatric Services, 58(5), Gill, K.J., Murphy, A.A., Zechner, M.R., Swarbrick, M. & Spagnolo, A.B. (2009). Co-morbid psychiatric and medical disorders: Challenges and strategies. Journal of Rehabilitation, 75(3), Mangurian, C, Giwa, F., Shumway, M., Fuentes-Afflick, E., Perez-Stable, E., Dilley, J., Schilinger, D, C Primary Care Providers Views on Metabolic Monitoring of Outpatients Taking Antipsychotic Medication. Psychiatric Services,64:6, Parsons, B., Allison, D.B., Loebel, A., Williams, K., Giller, E., Romano, S. & Siu, C Weight effects associated with antipsychotics: A comprehensive database analysis. Schizophrenia Research,110, US Department of Health & Human Services: National Heart Blood & Lung Institute, National Cholesterol Education Program, ATP III. Retrieved from Bolton 11