May 17, 2019 

Integrated Care for Older Adults 

with Serious Mental Illness and 

Medical Comorbidity: EvidenceBased Models and Future 

Research Directions 

Stephen J. Bartels; Peter R. DiMilia; Karen L. Fortuna; 

John A. Naslund The Psychiatric Clinics of North America, 

41(1), 153–164, 2018. 

Statement of the Problem 

Older adults with serious mental illnesses (SMI), such as 

schizophrenia, schizoaffective disorder, and bipolar 

disorder, have more hospitalizations and 4 times greater 

risk of death at any given age than those without SMI. They 

are also 3.5 times more likely to live in a nursing home. 

Despite higher acute and long-term healthcare costs, adults 

with SMI experience greater barriers to preventive and 

routine health care, and often receive care that is 

fragmented and inadequate. These disparities highlight a 

need for effective and sustainable integrated care models 

designed specifically to support the special health care 

needs among older adults with SMI. 

The Goal 

This paper provides a summary of evidence-based 

integrated models of care that address the mental and 

physical health needs of older adults with SMI. 

What the Researchers Did 

Key Findings: 

 Social skills training 

interventions are associated 

with improved social 

functioning and independent 

community living among 

older adults with serious 

mental illness. 

 Illness self-management 

programs can improve 

management of either 

psychiatric or medical 

disorder among older adults 

with serious mental illness— 

but integrated interventions 

that address both are 

scarce. 

 Integrated health homes 

have the potential to 

increase access to 

preventive care and improve 

the quality of care for 

chronic medical conditions, 

but inconsistently achieve 

clinically significant results. 

This paper provided brief overviews of the following evidence-based approaches to integrate care 

for older adults with SMI: (1) psychosocial skills training, (2) illness self-management, and (3) 

behavioral health homes. For each approach, the authors summarize the components and duration 

of the programs, and their impact as demonstrated through randomized controlled trials (RCT). 
What the Researchers Found 

Psychosocial Skills Training: Three group-based programs have research evidence of effectiveness 

in improving psychosocial skills among older adults with SMI: (1) Helping Older People Experience 

Success (HOPES) program, (2) Functional Adaptation Skills Training (FAST) program, and (3) 

Cognitive-Behavioral Social Skills Training (CBSST) program. These programs range from 12 

weeks (CBSST) to 12 months (HOPES); an integrated health management component of HOPES is 

delivered by a registered nurse. Common features of all three are that they are group-based, 

provide accommodations for people with physical or cognitive disabilities, and use age-appropriate 

cognitive behavioral principles and skills training techniques to meet the specific needs of older 

adults with SMI. 

Integrated Illness Management and Recovery: Three interventions have been shown to be effective 

in improving chronic disease self-management among adults with SMI: (1) Health and Recovery 

Peer (HARP) program, (2) Targeted Training in Illness Management (TTIM), and (3) Integrated 

Illness Management and Recovery (I-IMR). The HARP program consists of 6 peer specialist-led 

sessions and was adapted from the widely-disseminated Chronic Disease Self-Management 

Program. TTIM is also group-based and is led by a peer and a nurse educator. This 12-week 

program blends social support with diabetes and mental health psychoeducation and goal setting. IIMR combines four evidence-based psychosocial interventions: psychoeducation, which improves 

knowledge about mental illness management; behavioral tailoring which improves medication 

adherence; coping skills training, which reduces distress related to symptoms; and relapse 

prevention training. 

Behavioral Health Homes: In contrast 

to the extensive research on 

integrating mental health care in 

primary care settings, little research 

has studied co-locating primary care 

within mental health settings. Three 

RCTs that assessed the impact of 

behavioral health homes on adults 

with SMI and medical comorbidity 

were identified. A 2001 study 

evaluated the effectiveness of colocating primary care services in 

Veterans Affairs hospital’s mental health clinics. After 12 months, veterans who received care in this 

co-located clinic received, on average, more preventive services and self-reported better physical 

health functioning. The Primary Care Access, Referral and Evaluation (PCARE) intervention 

involved a nurse care manager, located at a community mental health center, who coordinated care 

with medical providers and used motivational interviewing to enhance patient activation, promote 

self-management and health advocacy skills. In an RCT, after 12 months, patients who received 

PCARE had more primary care visits and greater reduction in 10-year risk of cardiovascular 

disease, compared to those receiving usual care. The 2017 Health Outcomes Management and 

Evaluation (HOME) study compared outcomes among patients receiving primary care through a 

Behavioral Health Home to those who received usual care, and found that Behavioral Health Home 

patients had higher preventive service uptake and better quality of cardiometabolic care, but 

showed no clinically significant difference in blood pressure, cholesterol, blood glucose, or 10-year 

cardiovascular risk. 
Why the Research Matters 

There is an unprecedented growth in the number of middle-aged and older adults with serious 

mental illnesses, and these individuals have high rates of comorbid chronic medical illness. In 

contrast to a large number of evidence-based practices for older adults with depression and 

comorbid medical illnesses, there are only a limited number of interventions aimed at addressing 

the needs of adults with comorbid physical and serious mental illness. The existing interventions 

have shown promise in improving illness management, increasing access to primary care and 

preventive services, and improving the quality of care for some medical conditions—but these 

models have not improved clinically significant outcomes. 

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