Patients treated in community mental health settings die, on average, 25 years earlier than the general population, and the vast majority of these premature deaths are due to cardiovascular disease. There is an urgent need to develop effective interventions to decrease this excess cardiovascular morbidity and mortality. Such interventions need to address patient-level, provider-level and system-level factors. Patient-level factors include limited knowledge about nutrition, lack of access to healthy foods, sedentary lifestyle, tobacco dependence, and poor adherence to medications and medical treatment. The weight gain and other adverse metabolic effects of antipsychotic medication treatment and the poor quality of diabetes medical care received by patients with schizophrenia (specifically the lack of appropriate intensification of medications for cardiovascular risk factors) represent provider-level factors that contribute to poor diabetes outcomes among persons with schizophrenia treated in community settings. System-level factors that need to be addressed include limited access to medical care and the fragmentation of care. We propose a model of diabetes care that is a unique collaboration between community mental health centers and a university hospital-based diabetes center. The MHC Diabetes Team model will be an adaptation of the TEAMcare approach to management of primary care patients with depression and poorly controlled type 2 diabetes. TEAMcare is a care management intervention that integrates a treat-to-target program for cardiovascular disease with collaborative care for depression. Given the unique needs and vulnerabilities of patients with schizophrenia, the adaptation of TEAMcare for this population will essentially require the development of a new intervention. The purpose of this pilot study is to evaluate the feasibility and preliminary efficacy of an innovative approach o diabetes care for a complex population at very high risk of poor diabetes outcomes.
We aim to demonstrate that 1) a team approach to diabetes care is feasible to implement in urban community mental health centers;2) that it is acceptable to multiple stakeholders (patients, primary care providers, MHC and Diabetes Center providers);and 3) that treatment by MHC TEAMcare will result in significant improvement of diabetes and cardiovascular risk factor outcomes among community mental health center outpatients with schizophrenia and co-occurring type 2 diabetes, compared to usual psychiatric care and primary care of diabetes. The achievement of these aims will lead to the development of a full scale RCT (R01) to evaluate the efficacy of this innovative model of diabetes care.
The purpose of this R21 proposal is to examine the feasibility and preliminary efficacy of an innovative approach to diabetes care for persons with serious mental illness, who are a vulnerable population at very high risk of poor diabetes outcomes. Persons treated in community mental health settings die, on average, 25 years earlier than the general population, and the vast majority of these premature deaths are due to cardiovascular disease. In this study, a small pilot feasibility randomized controlled trial (RCT) will be conductd to provide a foundation (feasibility information, data management system and effect size estimate) for a larger efficacy RCT.
