Adults with serious mental illness have higher rates of chronic disease and die significantly sooner than the general population. In the District of Columbia, Department of Mental Health clients die at average at age 54 - 18 years younger than the average DC resident. NORC is working with the District of Columbia Department of Health and the District of Columbia Department of Mental Health to design, implement, and evaluate an integrated behavioral health/primary care (BH/PC) project at three outpatient ambulatory clinics in the District of Columbia.
The Chronic Care Initiative in Mental Health (CCIMH) applies an integrated care model which provides evidence-driven medical management, self-management education and health system navigation support. The main components of the CCIMH program are:
- Medical management services: Nurse practitioners deliver diabetes and cardiovascular disease medical management services with integrated self-care management education on site at the mental health clinics.
- Preventive care services. Routine health screenings for diabetes and cardiovascular risk factors, health status and health self-management beliefs.
- Self-management education: Participants receive face-to-face risk factor-self-management education.
Data is collected from participants at subsequent six month intervals. Ongoing analyses examine the effects of CCIMH participation on clinical health outcomes (BMI, HbA1c, Cholesterol, Blood Pressure), self-reported health, emergency room use and hospitalization rates, and medication adherence.