Project Bridge: Peer Health Navigator Intervention
Condition: Schizophrenia; Depression; Medical Disorders; Serious Mental Illness
MeSH terms: Schizophrenia; Mental Disorders
Study type: Interventional

Summary: 
      The mortality rate among people with Serious Mental Illness (SMI) is 2 to 3 times that of the
      general population, meaning that those with a serious mental illness die, on average, 25
      years earlier than those without an SMI. These deaths are largely attributed to preventable
      medical conditions, many of which are more common in the SMI population.

      The "Bridge" intervention is a peer navigator model that was developed to target factors that
      negatively impact healthcare access, utilization, and outcomes among individuals with serious
      mental illness (e.g., severe mood disorders and psychotic disorders). This intervention
      targets male and female, adult consumers across races/ethnicities and has been utilized by
      Pacific Clinics (Southern California's largest behavioral healthcare agency) and the
      Department of Mental Health of Los Angeles County to improve the health and quality of life
      for their consumers.

      Investigators will test the comparative effectiveness of a peer navigator intervention (the
      Bridge) to treatment as usual. The Bridge navigator intervention is designed to teach SMI
      consumers the skills to engage health care providers and to overcome motivational deficits in
      order to improve their health and healthcare use. The specific aims of this application are:

        1. To use randomized methods to examine the effectiveness of the Bridge intervention on the
           health care utilization, satisfaction with care, health status, and health care
           self-management for a sample of individuals with severe mental illness receiving public
           mental health services in the community;

        2. To use randomized methods to examine the effectiveness of the Bridge intervention on
           psychological and social well-being for a sample of individuals with severe mental
           illness receiving public mental health services in the community.

      151 participants in an Full Service Partnership (FSP) clinic operated by Pacific Clinics were
      recruited to participate in an approximately 24-month long study of Bridge navigation.
      Participants will be randomly assigned to either treatment as usual (waitlist) or immediate
      intervention with the Bridge.

      Participants in both groups will complete three assessments (baseline, 6 months, 12 months)
      and statistically compared over time. Staff stakeholders (n = 20) will also be interviewed at
      baseline and every three months of the study in order to ensure that the intervention is
      being implemented appropriately.
    

Detailed description: 
      The mortality rate among people with Serious Mental Illness (SMI) is 2 to 3 times that of the
      general population (DeHert et al., 2011), meaning that those with a serious mental illness
      die, on average, 25 years earlier than those without a SMI (Parks et al., 2006). There is
      evidence that these deaths are largely attributed to preventable medical conditions, many of
      which are more common in the SMI population. System bifurcation, or the separation of mental
      and physical health services, has been identified as a critical factor that leads to
      significant health disparities for those with SMI (Bazelon Center for Mental Health Law,
      2004).

      Grounded in patients' experiences, needs, and voices, investigators seek to generate
      knowledge about effective interventions, use outcomes that are central to patients and
      caregivers, attend to issues of implementation and dissemination, and may seek to optimize
      outcomes in the context of factors such as burden, technology, and stakeholder perspectives.
      Based on pilot work funded by the UniHealth Foundation, the goal of this Patient Centered
      Outcomes Research Institute (PCORI) proposal is to test the effectiveness of a peer health
      navigation intervention (The Bridge) in comparison to usual treatment. The Bridge is a
      peer-staffed comprehensive healthcare engagement and self management model, situated in an
      outpatient mental health clinic, where clients are taught the skills to access and manage
      their healthcare for any condition. The investigators' goal is train clients to successfully
      engage and navigate the primary health care system as well as other needed health care
      services (specialty care, lab, and pharmacy). Guided by a version of Gelberg, Andersen, and
      Leake's (2000) Behavioral Model of Health Service Use for Vulnerable Populations that
      investigators adapted for the seriously mentally ill (Brekke et al., in press), the Bridge
      combines three approaches: integrated care, patient education, and cognitive-behavioral skill
      building with an in vivo (real world) focus.

      Investigators conducted a randomized controlled trial comparing 2 groups: a) a treatment as
      usual waitlist (n =75), and b) the Bridge peer navigator intervention (n=76). Investigators
      will compare these groups across 3 time points (baseline, 6 months, 1 year) to examine the
      Bridge's effectiveness at improving health care service use, satisfaction with care, health
      knowledge, health status, health related self-efficacy, and quality of life. Outcomes will be
      measured through patient self-report and according to objective measures of health (medical
      records and insurance claims data).

      In addition, investigators conducted interviews every three months with selected stakeholders
      to assess the degree to which the intervention and the study are succeeding and what
      challenges have occurred. This will allow for corrections as the study proceeds.
      Investigators will focus on the factors that will contribute to the implementation and
      sustainability of the health navigator intervention including: cost, training, supervision,
      billing issues, and how this position will fit into the organizational model of the clinic.
      To begin the interview, investigators ask each person interviewed for his or her ideas about
      what are the critical factors for implementation and sustainability. Finally, investigators
      conducted exit interviews with each patient as part of their final assessment. Exit
      interviews focused on the patients' perceptions about the study, how it affected them, what
      went well, and what challenges they encountered. Each interview should last about 20-30
      minutes and was audio-recorded using an encrypted tape recorder. Investigators will use a
      semi-structured interview guide so that all interviewees are asked the same questions and
      data are comparable. Basic demographics such as gender, ethnicity, and age will be recorded
      for all participants.

      This PCORI proposal relies on significant stakeholder involvement in the intervention
      development, project development and management, and in the plans for dissemination and
      implementation. The ultimate goal is to provide the field a peer-delivered intervention that
      significantly reduces disparities in the utilization and outcome of health services for the
      seriously mentally ill and thereby reduce morbidity and mortality in this highly vulnerable
      population.
    

Intervention name(s): Health Navigation
Intervention type(s): Behavioral
Intervention description(s): Experimental: Immediate peer health navigator intervention vs. waitlist control.
The immediate peer health navigator intervention group will receive assistance for 6 months and then followed up with after an additional 6 months. Participants will receive training in how to self-manage their physical health and healthcare. The intervention is individualized and the number of contacts by the navigator will be determined by their need level. The waitlist control group will complete a baseline assessment and then wait for 6 months before receiving the peer health navigator intervention. They will complete a follow-up assessment after 6 months of the intervention.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: Serious mental illnesses; peer navigator; integrated health care