Persons with severe mental illness (SMI) in the public system die 25 years earlier than their counterparts in the general population.1,2 This is due in large part to treatable medical conditions and modifiable lifestyle factors. Those with SMI living into their later years have a rate of serious illness (including cardiovascular disease, diabetes, and respiratory disease) several times that of the general population.1 Further highlighting the seriousness of the problem, the National Association of State Mental Health Program Directors recommends classifying any adult with a SMI over age 50 as “geriatric” because his/her needs are the same as a 65-year-old person in the general population.
The “10 by 10” campaign, an effort to increase mental healthcare consumers' life expectancy by 10 years in 10 years, has been highly effective in publicizing the issues facing this population. As part of these initial efforts to raise awareness, it is important to publicize integrated primary care and mental/behavioral healthcare models and share lessons learned, especially since more attention has been devoted to how to integrate behavioral healthcare into physical healthcare settings. Thresholds, a large psychosocial rehabilitation center in Chicago, has for the past 10 years offered physical healthcare to its members (i.e., consumers) through three federally qualified healthcare clinics (FQHCs), referred to within Thresholds as integrated healthcare clinics (IHCs).
Each IHC serves a different region/part of the Chicago metropolitan area. The north clinic is newly housed in a refurbished flower store next door to Thresholds' young adult program. The clinic has 4 exam rooms and is adorned with beautiful artwork and furnished with new equipment and comfortable, stylish furniture in the waiting room. The South Side clinic has 2 exam rooms and is on-site at Thresholds' South Center for Recovery. The third and smallest clinic serves one of Thresholds' most important subpopulations: women suffering from mental illness and their children. The clinic provides preventive care for mothers and their children, ensuring that the kids are up to date with immunizations and that they receive annual physicals. All three IHCs are staffed by advanced practice nurses overseen by a University of Illinois at Chicago (UIC) nurse and Thresholds' chief clinical officer.
The partnership between Thresholds and UIC nurses began 10 years ago with a small demonstration project that placed a clinic with 1 exam room in a Thresholds program on Chicago's South Side. The clinic was open 4 hours a week, but after adding another exam room now operates 40 hours a week. As one longtime staff member notes, “We started as a little storefront, mom-and-pop operation.”
During the past 10 years two clinics have been added and their scope of care expanded to meet members' changing needs. Thresholds provides a laboratory, reception areas, computers, and T1 lines, while UIC provides equipment, clinical and office supplies, medications, and clinical staff, including a family physician for consultation and referral. A Robert Wood Johnson Foundation grant helped secure the FQHC status, thus making the clinics self-sustaining.
We have learned many lessons in our 10-year partnership.
Holistic care makes sense. When asked how using the clinics and working with the nurses has changed her perspective, one Thresholds staff member said, “For many trained as mental health providers, it is easy to find ourselves focusing on what we perceive to be the ‘mental health’ issues our members present, when in fact it is far more productive to approach treatment more holistically by understanding symptoms within the context of the whole person. We need to move away from compartmentalizing symptoms and toward providing effective integrative health services.”
Addressing the physical health conditions of persons with SMI is the foundation for recovery-oriented services. Members like the idea of holistic care more than they do mental health services, as receiving wellness and holistic care is less stigmatizing than receiving mental healthcare.
Coordination takes support at upper levels and thus requires buy-in throughout both the physical and mental health systems. Also, steering committees that regularly hear frontline staff's concerns work best.
Without a shared medical record, coordination cannot be done as well as is possible. Jay Forman, Thresholds' vice-president of strategic development, notes that not having a shared medical record has been a barrier to coordinating care. In the next few years, “This will be a priority,” he says.
Facing new challenges
To meet new challenges and to contribute to the nascent research body on integrated care, three new projects are being undertaken by the Thresholds Institute, Thresholds' training and research arm.
Integrated Healthcare Without Walls. This is a service-extension project that tries to engage consumers in their own physical healthcare by bringing care to them through visits to their residences, visits to group homes, or telemedicine visits. The goal is to reach members who have not used the IHCs and do not have a primary healthcare provider.