The Living Well, Living Longer program: an integrated care strategy to improve the health of people living with severe mental illness
Andrew Simpson
A * , Lisa Parcsi A and Andrew McDonald B
A
B
Abstract
Living Well, Living Longer (The Program) is an integrated care strategy to improve the physical health of people living with severe mental illness within a public mental health service. The significant life expectancy gap experienced by this cohort is largely attributed to higher rates of cardiovascular disease and modifiable risk factors. The Program addresses this by guiding people through the four stages of screening, detection, treatment initiation, and ongoing management of coexisting chronic health conditions. The Program adopted an integrated care approach to ensure the provision of appropriate and coordinated care across hospital and primary care services. Key care pathways include a cardiometabolic health assessment clinic, shared care with general practitioners, oral health services partnership and employment of peer support workers, dietitians, exercise physiologists, and smoking cessation to provide targeted community support and interventions. There has been strong engagement with the care pathways introduced since The Program’s inception in 2013 and evaluation is currently underway to consider the impact on cardiometabolic health outcomes for participants. Critical to The Program’s effectiveness has been engagement with lived experience expertise, multidisciplinary collaboration, and strong executive support. However, significant challenges persist amid an Australian public health crisis characterised by reducing rates of free primary healthcare access for people living with severe mental illness and enduring communication challenges between primary and secondary health services. With the implementation of MyMedicare and the imminent Single Digital Patient Record across NSW Health, we stand at a critical juncture. It is imperative to establish robust systems to enhance care for this vulnerable population.
Keywords: cardiometabolic health, chronic disease management, comorbidity, health screening, integrated care, lifestyle activities, lived experience, mental health, mental health services, peer support workers, premature mortality, severe mental illness, shared care.
Case study article
Living Well, Living Longer (The Program) is an integrated care strategy within the public mental health service of a Local Health District. It was established in 2013 to improve the physical health of people living with severe mental illness (SMI). The Local Health District oversees the health and welfare of over 740,000 individuals living in an urbanised environment spanning 126 km2. The district’s Mental Health Services employ more than 1000 staff who provide direct support and therapy to people living with SMI across two hospital campuses and five community health facilities.
Context
Evidence shows that people living with SMI are six times more likely to die from cardiovascular disease and four times more likely to die from respiratory disease, contributing to a 14–23 year loss of life compared to the population average.1 This is largely attributed to high rates of modifiable cardiometabolic risk factors such as smoking, obesity, diet, and sedentary lifestyle.2 Additionally, there is high prevalence but poor screening and treatment of chronic health conditions such as dyslipidaemia, hypertension, and diabetes mellitus.3 Within Australia, national roadmaps and guidelines have been established to address this challenge.4–6 The Keeping Body in Mind program is considered a forerunner.7 However, many Local Health Districts are in the early stages of introducing a strategy and a lack of structured support for frontline staff to tackle this problem has been identified.5
Overview
The Program improves the physical health of people living with SMI through an integrated approach to health linkages, health screening, targeted interventions, and lifestyle activities. It provides a seamless, comprehensive care pathway through the four stages of screening, detection, treatment initiation, and ongoing management of people’s coexisting physical health conditions.
An Integrated Care approach was used to transform how care is delivered and improve health outcomes for patients, while reducing costs deriving from inappropriate and fragmented care across hospital and primary care services. Initial funding for The Program came from an NSW Health Planning and Innovation Fund for Integrated Care with additional Shared Care clinician enhancements jointly commissioned with the local Primary Health Network (PHN).
Program components
The Program employs peer support workers, shared care liaison clinical nurse consultants, smoking cessation support, dietitians, and exercise physiologists. A dedicated program manager sits across the clinical streams of integrated care and mental health. Since The Program’s inception, people living with SMI have been consulted on the design and implementation, including peer support worker representation at all levels of governance. The Program provides several targeted interventions to progress mental health consumers towards optimal management of their coexisting physical health conditions.
Within the Local Health District, work in this area began with the Collaborative Centre for Cardiometabolic Health in Psychosis (ccCHiP), which has provided comprehensive cardiometabolic health assessments for mental health inpatients since 2008 and evolved into a community outpatient assessment clinic in 2014.8 It now operates three times a week and accepts referrals from general practitioners (GPs) or treating psychiatrists, facilitated by mental health care coordinators and peer support workers.
The clinic brings together the consumer, carers, and care coordinators with an interdisciplinary team of cardiometabolic health experts in the fields of psychiatry, cardiology, endocrinology, dentistry, sleep medicine, and allied health. This provides a ‘one stop shop’ model to improve access to healthcare for individuals who may struggle to navigate traditional service delivery models.
The ccCHiP process is built around the successful integration of multiple cardiometabolic health specialists, who together formulate a set of treatment recommendations for each individual reviewed within the clinic. The shared care liaison clinical nurse consultants employed by The Program ensure that people are supported to attend their GP following the clinic so that recommendations can be reviewed.
Over 2000 individual consumers have received more than 3760 comprehensive cardiometabolic health assessments at ccCHiP since it commenced as an outpatient clinic in 2014.
Mental Health Shared Care improves working partnerships and health screening between the mental health service and a consumer’s nominated GP. It was jointly commissioned between the Local Health District and PHN and was developed and piloted in 2017 with the assistance of a Healthcare Redesign Project through the New South Wales Agency for Clinical Innovation.
Mental Health Shared Care improves communication and care integration between the consumer, GP, and mental health service, utilising a standardised care plan template to set clear lines of responsibility. The care plan was codesigned with consumers, peer support workers, and GPs, and includes milestones and target dates. It is built around an annual cycle of care, and physical health checks with GPs are tracked as a key performance indicator. These physical health checks double up as a post-ccCHiP review where recommendations from the clinic can be enacted by the GP, showing great integration between the two care pathways.
Within Mental Health Shared Care, there is an agreement about exchange of information between the mental health service and GP, and vital information is shared including physical and mental health reviews, prescribed medications, and metabolic monitoring.
Over 1700 individual consumers have been enrolled in a shared care agreement since 2017 with more than 350 different GPs, and the majority of these have progressed through at least one annual cycle and received a comprehensive physical health check with their GP in a shared appointment with the mental health care coordinator.
The Program employs dietitians and exercise physiologists who cover the ccCHiP clinics three times a week as well as providing comprehensive diet and exercise assessment and interventions for consumers in the community via direct referral from care coordinators. They work with consumers to develop individualised, achievable health behaviour change goals, and provide practical strategies and ongoing support to consumers to assist with goal attainment. Over 3300 unique consumers have received more than 20,000 targeted interventions from these clinicians in the community setting.
The peer support workers and exercise physiologists employed by The Program co-facilitate seven exercise programs a week across four community-based locations. Partnerships have been forged with local venues, and consumers are given subsidised entry to use the facilities. Community locations are chosen to foster the skills and confidence consumers need to access exercise independently.
A key program available to consumers is Gym & Swim, in which exercise physiologists orientate individuals to the gym equipment and provide a tailored exercise program, and a guided aqua aerobics group session is facilitated in the pool by one of the peer support workers. Participants report a sense of community and belonging as they inspire each other to attend each week and achieve renewed milestones. Evaluation (pending publication) has shown that as well as increasing exercise participation, Gym & Swim improves community connection and confidence to exercise independently or within a group setting.
The Program employs a smoking cessation officer who provides psychological interventions and nicotine replacement therapy (NRT) to consumers. Additionally, care coordinators from within the community mental health teams have been credentialed to dispense NRT, and peer support workers offer smoking cessation support groups.
The Program has partnered with the local public Oral Health Services to ensure that consumers are given priority access to free dental assessment and treatment. This collaboration is critical due to the well-established link between periodontal disease and cardiovascular disease.9 Work is currently underway to evaluate the impact of this care pathway on the oral health treatment of community mental health consumers, as well as reviewing any potential impact on cardiometabolic health.
The Program has partnered with the local Institute of Academic Surgery and pioneered research into surgical outcomes for people living with SMI, publishing the first studies in Australia demonstrating that this group experience worse surgical outcomes than the general population.10,11 The team conducted qualitative research to identify readily implementable strategies to improve the surgical experience for people living with SMI, which may be as simple as having their mental health acknowledged and proactively managed.12 Attempts have been made to introduce mental health screening tools into the surgical setting to ensure that people living with SMI are identified and appropriately supported to improve surgical outcomes.13,14
In addition to the various components described, The Program engages in many other strategies which fall under the umbrella goal of improving the health of people living with SMI. For example, a Physical Health Discussion Prompt Tool has been codesigned to encourage collaborative goal setting around physical health with consumers. A strategy has been introduced to screen and treat hepatitis C virus with a goal to eradicate the virus in this population. All mental health consumers are supported to receive vaccinations for COVID-19 and boosters as required. Additionally, a Side Effect & Preventive Health Screening Tool has been developed to encourage conversations about side effects and preventive health, and provide guidance for how to best support consumers who experience them.15
Enablers
The Program has strong executive buy in with high level of commitment demonstrated by the chief executive and senior executive team. The governance structure includes executive stakeholders from across clinical streams, lived experience and carer representatives, community managed organisations and the PHN, ensuring a range of expertise can be drawn on. The bimonthly steering committee enables all stakeholders to feel a sense of mutual investment in decision making.
The Program has implemented physical health assessment guidelines for community mental health services, ensuring that physical and mental health are given equal priority. Consequently, all mental health care coordinators, irrespective of their professional background, are trained to conduct metabolic monitoring, which includes measuring waist circumference and blood pressure. An escalation strategy within the guidelines ensures that all staff know how to appropriately respond to irregular blood pressure readings.
Finally, the continued input of lived experience expertise across all levels of governance has been a critical enabler to ensure the direction of The Program has remained consumer focused. The multidisciplinary nature of the workforce encompassing peer support workers, senior nurses, exercise physiologist, dietitians, and psychologists emboldens a holistic recovery focused approach.
Barriers
Engaging people living with SMI in changing their health behaviours and utilising health services can be challenging.2,16 Systemic obstacles pose further challenges. The current Activity Based Funding model within NSW Health fails to adequately support the needs of a highly specialised, low-volume, high-cost service. It has been found that 80% of people living with SMI are diagnosed with a chronic health comorbidity.2 Consequently, it is not feasible for a public mental health service to comprehensively manage chronic disease comorbidities for more than 3000 individuals in their care each year. The Program has mitigated this by introducing shared care with GPs, but since 2022 there has been a significant decline in practices willing to offer free ‘bulk billed’ consultations to patients.17
Additionally, for Mental Health Shared Care, communicating effectively with GPs has been challenging via traditional methods (e.g. letter, fax, or phone call). A research project is currently underway in collaboration with two local universities and the PHN to enhance shared care by utilising an online shared care planning tool. The development of shared information systems between primary and secondary health services is a key step to improve the quality of shared care available to people living with SMI.18
Conclusion
The Program has made substantial progress in supporting the physical health needs of people living with SMI and evaluation is underway to quantify the impact of these interventions on physical health outcomes. However, with the existing fee-for-service model of primary care, we are currently facing a public health crisis that makes addressing these issues exceptionally challenging.19,20 With the introduction of MyMedicare, the new voluntary patient registration model for primary healthcare in Australia, and the imminent implementation of a Single Digital Patient Record within NSW Health, we stand at a critical juncture. The success of future initiatives will depend on whether robust systems can be implemented to enable better care for people living with SMI. Only time will tell if these changes lead to more effective and integrated health services for this vulnerable population.
Ethics
No human subjects are involved in this case study article. Related research is in progress with approvals listed below: Living Well, Living Longer Evaluation: Retrospective Analysis of Community Mental Health Metabolic Monitoring Forms (Sydney Local Health District Human Research Ethics Committee – Concord Repatriation General Hospital), An Economic Evaluation, Cohort and Implementation Study of the Collaborative Centre for Cardiometabolic Health in Psychosis (Sydney Local Health District Ethics Review Committee – RPAH Zone)
Data availability
Only routinely collected process data (e.g. raw counts of contacts) are mentioned in this article.
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