Evaluating Diabetes Care for Patients With Serious Mental Illness Using the Chronic Care Model

Abstract

People with serious mental illness (SMI) have a higher incidence of type 2 diabetes mellitus (T2DM) and shorter life span due to medical health problems. The chronic care model (CCM) has been used to improve care of patients with T2DM. One clinical organization that provided primary care to patients with SMI had excellent diabetes outcomes but did not have information on how they achieved those outcomes. Thus, we conducted a pilot study chart review for 30 patients with T2DM and SMI to determine how well the clinic’s system aligned with the overall CCM components and which components correlated with diabetes control. We also evaluated use of the CCM using the Assessment of Chronic Illness Care provider survey. Results showed that the clinic had an overall basic implementation level of the CCM, which allows opportunity for improvement. Two elements of the CCM were correlated with hemoglobin A1C and both were in an unexpected direction: self-management support in the variable of percentage of visits that included patient-specific goal-setting (rs = .52; P = .004) and delivery system design in the variable of number of nurse practitioner visits per study period (r s = .43; P = .02). These findings suggest that the clinic may have made more concentrated efforts to manage diabetes for patients who were not in good diabetes control. Providers noted the influence of SMI and social service organization support on these patients’ clinical outcomes. The findings will be reexamined after a fuller implementation of the CCM to further improve management in this population.

A systematic review of barriers and enablers that health professionals experience to the delivery of type 2 diabetes care for adults with severe mental illness

“…71 It was suggested that type 2 diabetes care could be improved if there was clarity in the division of labour between professional groups. 84 For example, the need to improve communication with other health professionals was identified by one study in this review, 93 suggesting a recognition of the importance of this skill but a need for improved ability. These factors were also identified within this synthesis with a variable, and at times contradictory belief, about professional responsibility identified.…”

“…For example, mental health professionals' difficulties in accessing timely information, such as scheduled type 2 diabetes care appointments, impacted their ability to motivate service users and support their clinic attendance. Both mental and physical health professionals cited that there were challenges in providing type 2 diabetes care owing to pressures resulting from reduced staff levels, 73,74,75,76,78,79,81,82,83,84 workload, 73,76,79 and a perceived lack of time; 37,73,74,75,78,80,81,82,85,86 although in one study mental health nurses and support workers felt they had sufficient time, and more so than general practitioners. 38 The identified pressures were compounded by the complex needs of individuals with both type 2 diabetes and SMI, who were deemed "undesirable" due to the "large amount of resources required to treat them such as longer medical visits to explain treatment".…”

“…38 The identified pressures were compounded by the complex needs of individuals with both type 2 diabetes and SMI, who were deemed "undesirable" due to the "large amount of resources required to treat them such as longer medical visits to explain treatment". 74 Current approaches to service provision, including transportation challenges and inappropriate appointment times, were identified as a barrier to access for service users; 37,73,74,75,78,79,80,83,84,87 with a more flexible service, such as walk-in clinics or the development of a new care pathway, identified as a type 2 diabetes care enabler. 37,73,74,78,79,83,84 A further suggestion was the development, or deployment, of a specialist role 73,74,78,79,85,88,89 with various identified responsibilities including provision of type 2 diabetes care and supporting service users to navigate the health system.…”

“…74 Current approaches to service provision, including transportation challenges and inappropriate appointment times, were identified as a barrier to access for service users; 37,73,74,75,78,79,80,83,84,87 with a more flexible service, such as walk-in clinics or the development of a new care pathway, identified as a type 2 diabetes care enabler. 37,73,74,78,79,83,84 A further suggestion was the development, or deployment, of a specialist role 73,74,78,79,85,88,89 with various identified responsibilities including provision of type 2 diabetes care and supporting service users to navigate the health system. The value of the role however was not unanimous as there were some concerns that the role would lead to service fragmentation or be unfeasible owing to cost implications.…”

Implementation of a Personalized Care Plan for Patients With Type 2 Diabetes Is Associated With Improvements in Clinical Outcomes: An Observational Real-World Study

“…1 Self-management is an important aspect of T2D treatment, and can be enhanced with the implementation of a personalized care plan. 2 Personalized care plans draw upon the "chronic care model," 3,4 which regards the patients as experts in their own disease, and actively involves them in their own health care strategy. A care plan requires motivational discussion between care providers and the patient.…”