Diabetes Screening, Risk Management and Disease Management in a High-Risk Mental Health Population
Condition: Diabetes Mellitus; Schizophrenia; Psychotic Disorders
MeSH terms: Diabetes Mellitus; Schizophrenia; Psychotic Disorders
Study type: Observational

Summary: 
      Family physicians are the primary health care providers for complex patients such as persons
      with serious mental illness. The psychiatric needs of these patients could take attention
      away from management of health problems and from usual health promotion services. For
      example, Schizophrenia is associated with a higher than normal incidence of diabetes, and
      first line treatments of Schizophrenia have also been found to increase risk for diabetes. As
      such, this high-risk group requires targeted diabetes strategies. In London Ontario, services
      are provided to this high risk mental health population primarily by two community agencies:
      The Western Ontario Therapeutic Community Hostel (WOTCH) and the Canadian Mental Health
      Association (CMHA). Accordingly, the goal of this project is to assess how these patients are
      currently being managed by their family physicians and to pilot a community-based,
      multidisciplinary diabetes clinic model within this population. If this delivery model proves
      feasible and effective, family physicians could be assisted by existing community agencies in
      the management of their patients' diabetes and patients will receive improved access to this
      vital multidisciplinary team.
    

Detailed description: 
      In London Ontario, community based services are provided to the high-risk mental health
      population by primarily two community agencies: The Western Ontario Therapeutic Community
      Hostel (WOTCH) and the Canadian Mental Health Association (CMHA). WOTCH provides treatment,
      support, rehabilitation and recovery services to individuals with serious mental illness
      including case management, social recreational activities, and vocational and housing
      options. Each client is linked to a Community Support Worker who meets with the clients in
      their homes or in other community locations to develop rehabilitation plans, monitor the
      success of these plans, coordinate services and advocate on the client's behalf. Similarly,
      CMHA provides a range of education and support services in the London Middlesex area. CMHA
      provides centralized Intake and Assessment for WOTCH, London East Community Mental Health
      Services and for their own Community Support Case Management program. The qualifying criteria
      for access to the programs are based on assessment of three key elements: Disability,
      Duration and Dysfunction.

      Collectively WOTCH, CMHA and the London Mental Health Crisis Service maintain a common client
      record for clients. Individuals generate crisis plans and information is attained which
      includes primary diagnosis, co-morbid health conditions, medication, demographics and family
      physician.

      Project Population -

      Participants in the project were drawn from the active WOTCH and CMHA database. Participants
      that were identified in the database as having a diagnosis of Schizophrenia (or Psychotic
      Disorder) and/or treatment with a Novel Antipsychotic medication were approached for
      participation in the project. Any participants identified in the database with a pre-existing
      diagnosis of diabetes were not included in the initial selection of participants. A total of
      60 participants meeting the above criteria were selected for the initial screening phase of
      the project.

      Phase One

      The first phase of the proposed project aims to determine how these complex patients were
      being managed in primary care. Consent was sought from family physicians that were determined
      to be the primary care providers for the participants who met criteria for involvement in the
      project. A chart review was conducted on site at each family practice location in a space
      provided by the physician. The review includes demographic information, diagnoses, medication
      use (past and current), lab results (blood glucose and lipid profile), and a medication side
      effects profile.

      Phase Two

      The second phase of the proposed project aims to quantify the prevalence and risk profile of
      diabetes mellitus, as well as mental illness symptomology and disability, in this identified
      high-risk population. All participants identified in the chart review as not having received
      an Oral Glucose Tolerance Test (OGTT) in the past year, in accordance with current
      guidelines, were followed in phase two of the proposed project. In addition, caseworker
      feedback was used as a source of information regarding prior screening in cases where
      physicians did not consent to participate in the chart audit but the client did consent to
      participate. Participants identified as being in need of an OGTT for screening of DM were
      invited to attend a screening event held at CMHA or WOTCH facilities. Caseworkers played an
      active role in facilitating participants' attendance at the screening events. A phlebotomy
      certified staff member conducted the OGTT's. If a lipid profile had not been completed within
      the past year, the current sample will also be analyzed for lipids. Diabetes risk profile,
      the Brief Symptom Inventory (BSI) and the World Health Organization Disability Scale (WHO-DAS
      II) were also completed at this time. The OGTT was sent by the phlebotomist to a major
      central lab, contracted by the project, to ensure internal consistency of the analyses.
      Copies of the lab results were sent to the family physician, for placement in the
      participants' file, and to the data manager, for analyses related to the proposed study.

      Phase Three

      The third phase of the proposed project aims to evaluate the implementation of a
      multidisciplinary model of care, consistent with current guidelines for diabetes management,
      within this high-risk population. Participants identified in either of the previous two
      phases as having diabetes or pre-diabetes were invited to participate in a multidisciplinary
      program for diabetes management. The program runs monthly at identified usual point of WOTCH
      and CMHA service locations. Identified WOTCH and CMHA staff are encouraged to attend the
      program to serve as a consistent source of progress monitoring and to increase their
      knowledge and familiarity with the goals of diabetes management and diabetes complications.
      The program is based on the London Intercommunity Health Centre's (LIHC) diabetes risk and
      disease management program previously piloted within a Community Health Centre. During the
      clinic, participants meet individually with the Nurse Practitioner (NP) who works through a
      Diabetes Care Flow Sheet. At each monthly visit, the NP assesses glycemic control,
      hypertension, medications, weight, and foot care. Lifestyle counseling is also provided with
      respect to smoking, activity, diet and stress. At each participant's initial visit, he or she
      is provided with a pedometer and instructed on its use. This aids the NP in assessing
      physical activity and provides a motivational tool for the participant. The NP is responsible
      for highlighting any variables that fall outside the expected range. If it is decided that
      there are issues that need further clinical consultation, the NP then refers the participant
      to the appropriate team member. The DHC team includes a foot care specialist, dietician,
      Diabetes Education Nurse, and a family physician. The family physician team leader refers any
      clinical issues that fall beyond the scope of the DHC for specialist follow up. Each
      participant receives appropriate instructions regarding return to the multidisciplinary
      clinic.

      The NP also monitors each participant's need for periodic lab testing of glucose and lipids.
      Annual screening for neuropathy, nephropathy, and eye exams are indicated on the Diabetes
      Care Flow Sheet. The DHC team sends participants' family physicians' reminder notices of
      these regularly needed referrals as well as any relevant clinical data.
    

Intervention name(s): Screening; Management
Intervention type(s): Procedure; Procedure
Time perspective: Other