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Delivering Primary Care at Mental Health Clinics Wins in Trial

WASHINGTON — Adults with serious mental and physical illness who received primary care at behavioral health clinics in South Texas saw greater reductions in systolic blood pressure and HbA1c (glycated hemoglobin) levels compared with usual care in a randomized trial, according to researchers.

This treatment model for individuals with serious mental illness, called “reverse co-location” of primary care and psychobehavioral treatment, essentially makes the community mental health clinic the patients’ “medical home” for their healthcare needs.

Karen Sautter Errichetti, DrPH, MPH, of Health Resources in Action, a Boston-based nonprofit public health institute, shared the results of the study at the AcademyHealth Annual Research Meeting here on Monday.

“This is the epicenter of heath equity work,” said Errichetti, underscoring the social determinants of health — from mental to socioeconomic and sociopolitical challenges — faced by residents of the South Texas border region where the study was implemented.

“What was amazing was that we got a positive result,” she said, in a follow-up phone interview, noting that in these types of studies it’s rare to see a difference between the intervention and control groups.

“To be able to move blood pressure within 1 year in a population with severe mental health challenges is striking and notable,” Errichetti told MedPage Today — highlighting the finding that the intervention group saw a slight improvement in systolic blood pressure that was statistically significant.

“That kind of finding is not common in the literature,” she added.

This is the first study, “to my knowledge,” that systolic blood pressure has moved in the setting of a local mental health authority in a population that is predominantly Hispanic, she said.

When controlling baseline measures and covariates, researchers found that participants in the treatment group had greater reductions in the confirmatory outcome (reduced systolic blood pressure, β=-3.86, P=0.04) and an additional finding of reduced HbA1c (β=-0.36, P=0.001) at 12 months in comparison with control participants, according to a May 2018 final evaluation report from Tropical Texas Behavioral Health (TTBH), a local mental health authority serving 1.2 million residents of Hidalgo, Cameron, and Willacy counties in Texas.

As for the overall clinical impact, one would need to assess whether the reductions in systolic blood pressure or HbA1c moved an individual from hypertensive to pre-hypertensive or from diabetes to controlled diabetes, Errichetti said, “and we did not do those kinds of analyses.”

Asked what precisely was included in the care plans that contributed to the improvements in health, Errichetti said she couldn’t say. Some patients might have seen a primary care physician and been prescribed a blood pressure medication as part of a care plan, which accounted for the reduction in blood pressure, while another patient might have been prescribed a walking program during a visit with the chronic care nurse, Errichetti speculated.

“We can’t disentangle what may have made the difference for that individual patient. All we can say is that co-locating primary care in a local mental health authority setting improves systolic blood pressure and A1c,” Errichetti said.

The report also clarified that researchers saw “no negative intervention effects” on the confirmatory or exploratory outcomes of the study.

Errichetti worked alongside two other co-lead authors, M. Marlen Ramirez of TTBH, and Michelle Brodesky of Methodist Healthcare Ministries, to complete the study.

The randomized controlled trial was part of the Sí Texas (Social Innovation for a Healthy South Texas Evaluation) initiative, a multi-site evaluation of integrated behavioral health programs enacted by eight organizations, which was funded through a 2014 grant from the Social Innovation Fund, part of the Corporation for National and Community Service.

The study involved four behavioral health clinics, two of which tested integrated care strategies.

The core research question explored by Errichetti and her colleagues was whether adult patients with serious mental illness — e.g., depression, schizophrenia, bipolar disorder — who received coordinated and co-located behavioral health and primary care services would see improvements in their health and quality of life after 12 months when compared with a similarly matched group of adults who received only behavioral health services.

Study Details

Participants in the study were adults older than age 18, with a diagnosed serious and persistent mental illness who had one or more chronic conditions — hypertension, poorly controlled diabetes, obesity, or hypercholesterolemia. Participants also needed to be residents of either Hidalgo or Cameron Counties.

The researchers excluded adults who were actively suicidal at the time of enrollment or pregnant.

Data for relevant measures was collected at baseline and at 6 and 12 months.

A total of 416 participants enrolled in the study; 249 were randomized to the treatment group, and 167 were randomized to the control group. The mean age of study participants was 41. Approximately 55% were female, and 93% were Hispanic; 31% of the participants had bipolar disorder, 46% had major depression, and 20% had schizophrenia.

The protocol for the treatment arm stipulated a minimum of two visits with a primary care clinician per patient and one visit with a dietitian or chronic care nurse. However, Errichetti explained, the study followed an intent-to-treat approach, meaning that there wasn’t a required threshold of visits that participants needed to meet in order to be included in the analysis, as long as they came in to have assessments and measures taken.

The “vast majority” of participants, however, did complete the required minimum visits, she noted.

In addition to systolic blood pressure and HbA1c levels, the researchers also measured diastolic blood pressure, body mass index, cholesterol, and PHQ-9 scores.

Depression scores did not improve in the treatment arm, and there weren’t any statistically significant differences between groups. The researchers also looked at “adult functioning” — a quality-of-life indicator — but found no statistically significant differences. (The measurement tool has not yet been validated, and so those results weren’t presented at the meeting, she said.)

The primary limitation of the study is its generalizability, said Errichetti. Because the study was conducted in a population of people with serious mental illness and in a border community, generalizability is limited to populations meeting those contexts. In addition, she said, while it may be relevant to studies of other communities of color, “it really has the most broad applicability to communities that are similar to it.”

“When we’re working in a setting where many social determinants are at play, we want to make sure that the interventions we design are going to work in those settings,” Errichetti stated. “This [study] is going to be tremendously helpful in thinking about how to work on issues like health equity — which is something that I think people at the border think about a lot — and it has the potential to reduce healthcare disparities, simply by locating primary care in a trusted setting for individuals who are among the most vulnerable in the United States,” she said referring to people with serious mental illness.

The authors reported no conflicts of interest.