New primary care model improves clinical outcomes for patients with severe mental illness

Over the past few years, the Department of Family Medicine and the Department of Psychiatry in UNC's School of Medicine have been working together to spearhead the development of a new "enhanced primary care" model to provide better primary care for patients who have severe mental illnesses.

A new analysis led by Alex K. Gertner, MD, PhD, psychiatry resident at UNC Hospitals, has added further evidence that the new model is effective. Gertner found that the enhanced primary care model resulted in lower hemoglobin A_1c and blood pressure for patients with severe mental illness when compared to other primary care clinics throughout the state of North Carolina, who do not use the model.

What distinguishes enhanced primary care from many prior studies is that this model is specifically adapted to meet the needs of people with severe mental illness. Many previous studies that have tested the effect of primary care on people with severe mental illness have not achieved improvements in clinical outcomes, which makes these findings exciting."

Alex K. Gertner, MD, PhD, psychiatry resident at UNC Hospitals, lead author of the study

The propensity-weighted cohort study was conducted at UNC WakeBrook, a behavioral health facility in Raleigh, and published in the Journal of Clinical Psychiatry.

Cardiometabolic health conditions - such as high blood pressure, diabetes, and heart attacks - are more common in American adults with serious mental illness than the general population. With 14.2 million adults living with a serious mental illness, this represents a major challenge that the United States healthcare system must face head-on.

Serious mental illness (SMI) is defined as a mental, behavioral, or emotional disorder resulting in serious functional impairment. Patients with SMI have been shown to have lower quality treatment for these conditions and poor cardiometabolic outcomes, both of which contribute to high-cost medical care down the line.

The clinic at WakeBrook is especially unique in that it is adapted to care for the physical health needs of people with SMIs. The clinic's enhanced primary care model involves training primary care providers to work with patients with severe mental illness, delivering integrated care with behavioral health providers, and providing longer visits to address patients' needs.

So far, use of the new primary care model has produced astounding results. A previous analysis by Gertner, Beat Steiner, MD, MPH, professor in the Department of Family Medicine, and others found that enhanced primary care reduced hospitalizations for physical health needs among people with SMI compared to usual primary care.

As for this new study, researchers started by comparing 234 patients with SMI receiving enhanced primary care at WakeBrook to 4,934 patients with SMI receiving usual primary care using electronic health data. Overall, patients who received care at WakeBrook had reductions in blood pressure and hemoglobin A_1c compared to those at other primary care clinics.

The reductions in hemoglobin A_1c and blood pressure were clinically significant. The size of the decrease in hemoglobin A_1c was comparable to what can be accomplished by starting a patient on insulin, and the size of the decrease in blood pressure was comparable to what can be accomplished by a moderate reduction in weight or an increase in physical activity.

Researchers were also able to establish that enhanced primary care increased screening patients for hemoglobin A_1c, low-density lipoprotein aka "bad cholesterol", and blood pressure compared to usual primary care.

"On average, people with SMI die 25 years earlier than the general population, with most of these deaths caused by chronic physical conditions," said Steiner, who was also involved in the new study. "Therefore, developing and implementing models for the physical health needs of our patients is a critical healthcare and public health priority."