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Integrated care at Paxton House

March 1, 2007
by SANDRA M. WILKNISS, PHD, HELEN MOORE, MS, SHIRLEY ALEXANDER, MS, JASON FUJIOKA, JUDITH MCDEVITT, PHD, APN, CNP, SUSAN BRAUN, MS, APN, CNP, and ANTHONY ZIPPLE, SCD, MBA
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A residential program in Chicago helps people with severe mental illness manage co-occurring diabetes

Type 2 diabetes is a serious, debilitating disease disproportionately affecting persons with severe mental illness (SMI). Whereas 4% of the U.S. population has type 2 diabetes, prevalence in individuals with SMI is almost twice as high1 and reaches a staggering 16 to 25% in individuals diagnosed with schizophrenia.2

Because of the strong association between diabetes and cardiovascular disease, the number-one cause of early mortality in individuals with SMI,1,3 diabetes is a healthcare issue of epidemic proportions in this population. The increased prevalence is multiply determined by family history, lifestyle, and iatrogenic causes.

A major contributor is widespread treatment with second-generation (atypical) antipsychotics, which are associated (to varying degrees) with substantial weight gain, dyslipidemia, and increased risk for type 2 diabetes.1,4,5 However, recent evidence indicates that schizophrenia and bipolar disorder are risk factors independent of antipsychotic use,6 and lifestyle factors associated with weight gain and diabetes, such as poor diet and physical inactivity, are also common in this group. The costs of this epidemic are high: poor health, early mortality, reduced quality of life, and related decreased opportunity for recovery.

Fortunately, early identification and treatment of diabetes may reduce diabetes-related symptoms and prevent or slow progression of metabolic, cardiovascular, and neuropathic disease. Unfortunately, poor access to and utilization of primary care services among individuals with SMI make these positive outcomes often unattainable.

Integrated Care

Quality community-based healthcare that addresses both mental health needs and the myriad co-occurring health conditions is rarely accessible, resulting in frequent use of emergency departments, public walk-in centers, and even jail clinics, where episodic and fragmented care leads to substandard outcomes. Despite federal, state, and foundation support to incorporate mental healthcare into generalist primary care, no community-based health system has fully met the demand for the complex and coordinated care required by persons with SMI.

In response, the University of Illinois at Chicago–School of Nursing (UIC) partnered with Thresholds (Illinois' oldest and largest psychiatric rehabilitation center) in the late 1990s to offer integrated healthcare to Thresholds' members (consumers). With significant financial support from Thresholds' Board of Directors, private funding, and leveraging of existing resources, the partners created a continuum of primary and mental healthcare: the Integrated Health Care Centers at Thresholds (IHCs).

The IHCs allow for rapid identification, monitoring, and treatment of significant healthcare issues in persons with SMI. Early outcome data revealed an alarming pattern of elevated blood sugar levels and weight gain across members and a diabetes prevalence of at least 15%, with most cases undiagnosed. Recognizing the need for a comprehensive intervention strategy, Thresholds' Executive Committee, Board of Directors, and the UIC advanced practice nurses developed a formal diabetes prevention, education, and management program, including a specialized residential treatment facility for individuals with SMI and diabetes—Paxton House.

Paxton House

Since its inception in August 2003, Paxton House has offered a comprehensive service system that promotes significant lifestyle changes through increased medical attention (using the IHCs), intensive education, nutrition consultation, exercise, therapy and psychosocial rehabilitation, smoking cessation and, in general, special coordinated care between physical and mental health, as well as residential service providers. In addition, intensive case management promotes mental and physical health self-awareness through individualized recovery plans tailored to each member's goals and needs.

Located in a historic Chicago South Shore neighborhood, Paxton House serves ten residents in a roomy, inviting, vintage three-flat red-stone building with ample common space. On-site residential staff are available 24 hours a day. The staff provide assistance with basic daily living skills, in addition to specialized diabetes care instruction. Special attention is directed toward supporting cognitive or learning needs and assisting participants in learning the importance of medication and healthcare regimen compliance.

Paxton House residents participate in an array of on-site programming, including the following:

Diabetes education. Residents spend two days a week learning about diabetes self-care. They attend a weekly diabetes education class that emphasizes current disease care information from the American Diabetes Association (ADA) and the UIC nurse practitioners.

An assortment of teaching methods and materials are used to motivate and stimulate learning. Pre- and post-group testing is provided to evaluate knowledge, to evaluate information retention, and to identify what needs to be reemphasized to prompt learning about healthy lifestyle changes. These services are provided by UIC nurse practitioners and supported by Paxton House staff.

Nutrition consultation. Residents learn healthier meal selection and preparation techniques. Paxton House improved the quality of the “usual” residential program menu, decreasing meat, sugar, and fat while increasing fruits, vegetables, and fiber. A consultant develops the menus and teaches cooking and nutrition.

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