Integrated Care at Paxton House: A Residential Program in Chicago Helps People with Severe Mental Illness Manage Co-Occurring Diabetes
Wilkniss, Sandra M., Moore, Helen, Alexander, Shirley, Fujioka, Jason, McDevitt, Judith, Braun, Susan, Zipple, Anthony, Behavioral Healthcare
Type 2 diabetes is a serious, debilitating disease disproportionately affecting persons with severe mental illness (SMI). Whereas 4% of the U.S. population has type 2 diabetes, prevalence in individuals with SMI is almost twice as high (1) and reaches a staggering 16 to 25% in individuals diagnosed with schizophrenia. (2)
Because of the strong association between diabetes and cardiovascular disease, the number-one cause of early mortality in individuals with SMI, (1,3) diabetes is a healthcare issue of epidemic proportions in this population. The increased prevalence is multiply determined by family history, lifestyle, and iatrogenic causes.
A major contributor is widespread treatment with second-generation (atypical) antipsychotics, which are associated (to varying degrees) with substantial weight gain, dyslipidemia, and increased risk for type 2 diabetes. (1,4,5) However, recent evidence indicates that schizophrenia and bipolar disorder are risk factors independent of antipsychotic use, (6) and lifestyle factors associated with weight gain and diabetes, such as poor diet and physical inactivity, are also common in this group. The costs of this epidemic are high: poor health, early mortality, reduced quality of life, and related decreased opportunity for recovery.
Fortunately, early identification and treatment of diabetes may reduce diabetes-related symptoms and prevent or slow progression of metabolic, cardiovascular, and neuropathic disease. Unfortunately, poor access to and utilization of primary care services among individuals with SMI make these positive outcomes often unattainable.
Quality community-based healthcare that addresses both mental health needs and the myriad co-occurring health conditions is rarely accessible, resulting in frequent use of emergency departments, public walk-in centers, and even jail clinics, where episodic and fragmented care leads to substandard outcomes. Despite federal, state, and foundation support to incorporate mental healthcare into generalist primary care, no community-based health system has fully met the demand for the complex and coordinated care required by persons with SMI.
In response, the University of Illinois at Chicago-School of Nursing (UIC) partnered with Thresholds (Illinois' oldest and largest psychiatric rehabilitation center) in the late 1990s to offer integrated healthcare to Thresholds' members (consumers). With significant financial support from Thresholds' Board of Directors, private funding, and leveraging of existing resources, the partners created a continuum of primary and mental healthcare: the Integrated Health Care Centers at Thresholds (IHCs).
The IHCs allow for rapid identification, monitoring, and treatment of significant healthcare issues in persons with SMI. Early outcome data revealed an alarming pattern of elevated blood sugar levels and weight gain across members and a diabetes prevalence of at least 15%, with most cases undiagnosed. Recognizing the need for a comprehensive intervention strategy, Thresholds' Executive Committee, Board of Directors, and the UIC advanced practice nurses developed a formal diabetes prevention, education, and management program, including a specialized residential treatment facility for individuals with SMI and diabetes--Paxton House.
Since its inception in August 2003, Pax-ton House has offered a comprehensive service system that promotes significant lifestyle changes through increased medical attention (using the IHCs), intensive education, nutrition consultation, exercise, therapy and psychosocial rehabilitation, smoking cessation and, in general, special coordinated care between physical and mental health, as well as residential service providers. In addition, intensive case management promotes mental and physical health self-awareness through individualized recovery plans tailored to each member's goals and needs.
Located in a historic Chicago South Shore neighborhood, Paxton House serves ten residents in a roomy, inviting, vintage three-flat red-stone building with ample common space. On-site residential staff are available 24 hours a day. The staff provide assistance with basic daily living skills, in addition to specialized diabetes care instruction. Special attention is directed toward supporting cognitive or learning needs and assisting participants in learning the importance of medication and healthcare regimen compliance.
Paxton House residents participate in an array of on-site programming, including the following:
Diabetes education. Residents spend two days a week learning about diabetes self-care. They attend a weekly diabetes education class that emphasizes current disease care information from the American Diabetes Association (ADA) and the UIC nurse practitioners.
An assortment of teaching methods and materials are used to motivate and stimulate learning. Pre- and post-group testing is provided to evaluate knowledge, to evaluate information retention, and to identify what needs to be reemphasized to prompt learning about healthy lifestyle changes. These services are provided by UIC nurse practitioners and supported by Paxton House staff.
Nutrition consultation. Residents learn healthier meal selection and preparation techniques. Paxton House improved the quality of the "usual" residential program menu, decreasing meat, sugar, and fat while increasing fruits, vegetables, and fiber. A consultant develops the menus and teaches cooking and nutrition.
Exercise. Residents are taught to use exercise to control body weight and stimulate important physiologic functions. New exercise equipment, including a treadmill, stationary bikes, weights, and elliptical training devices commonly seen in health clubs, is available. Members are expected to participate in daily exercise on the equipment or by walking, doing yoga, or engaging in another exercise method. Staff observe, coach, instruct, and encourage residents as they complete their daily exercise routines.
Members also are encouraged to be more active in their daily lives and increase the number of steps taken each day, monitored by pedometers. Pedometer charts are reviewed during the weekly Diabetes Education Group meeting, and each participant receives support and encouragement.
Cognitive behavior therapy (CBT) group. Residents attend weekly CBT group meetings to address mental health concerns, including cognitive biases and behaviors related to self-care.
Special coaching. Each resident is assigned a student nurse for coaching and support related to individual goals.
Smoking cessation groups. Given smoking's complicating factors in diabetes and the high prevalence of smokers with SMI, a "Quit Smoking" group is led by UIC staff. Nicotine replacement patches and bupropion are used as needed.
Adjunct therapies. Hypnosis, acupuncture, and yoga to decrease resistance and encourage participation are used on an as-needed basis.
Paxton House staff are specially trained to address the dual problems of diabetes and mental illness. UIC nurse practitioners, registered nurses, and nursing students under their direction provide specialized training to Thresholds staff and monitor daily illness management practices in Paxton House. UIC specialists also guest lead on-site groups. Additionally, the IHCs provide healthcare backup and specialty referrals for members as needed.
Paxton House residents receive intensive case management and service coordination by on-site staff, as well as psychosocial rehabilitation services from the nearby Thresholds South Center for Recovery to address individual life goals, such as educational advancement, employment, and socialization. Center for Recovery program schedules are created to ensure that residents are offered a variety of fulfilling, skill-building experiences and activities.
Once a resident has mastered the understanding of his/her dual healthcare concerns and is actively engaged in the proper care of diabetes and mental illness, he/she graduates to a more independent living situation. The level of continued care is individualized to each member's personal situation and continues to be monitored as long as the member is associated with Thresholds.
Baseline measurements for all members include:
* ADA-recommended indicators, including height and weight (to determine BMI ratios);
* fasting glucose and lipid profiles, including hemoglobin A1c levels;
* scores on clinical measures such as the Multnomah Community Ability Scale (measures social, physical, and interpersonal functioning in community settings) and the Global Assessment Scale; and
* medical and psychiatric hospitalization rates.
Ongoing data collection includes daily glucose levels, weekly body weight measurements, daily number of steps, and daily exercise time (according to the individual's plan). Members also log their daily food intake.
Since the residence was established more than three years ago, 25 persons have been served, and 11 have moved to more independent living situations. Four other former residents presented severe therapeutic and behavior problems that required discharge back to their original, more intensive programs. However, even these residents improved their level of understanding of how to manage their diabetes, according to the service delivery team.
To date, some members have experienced significant weight loss, while others are either losing weight and/or maintaining appropriate weight levels. All program participants have increased their exercise levels in accordance with medical providers' instructions. Pedometer charts show a marked increase in the daily movement of all participants, which is a significant change from their typically sedentary lifestyles. Moreover, all residents are learning about diabetes and psychiatric-related issues in the Diabetes Education Group. Control of blood sugar levels has improved significantly, and reliance on pharmacotherapeutic supports to control levels has reduced.
One member who has benefited from the program is Mr. W, a 49-year-old African-American man who moved into Paxton House on October 30, 2003. Prior to living at Paxton House, Mr. W was living at a residential hotel since April 2003, and before that he was incarcerated at the Cook County Jail for approximately ten months. Mr. W was brought to Paxton House through Thresholds' Jail Project, whose staff assisted him with housing, psychiatric care, and basic needs. Mr. W was unable to identify his diagnosis, although he did acknowledge hearing voices.
Mr. W has shown significant improvement in controlling his diabetes. He continues to experience significant weight loss, to maintain healthy blood sugar levels, to reduce his medication regime, and to conduct his daily exercise routine.
Mr. W says Paxton House is unique. Elsewhere, he didn't receive information on diabetes, and he appreciates the opportunity to learn more about his mental and physical health. "I don't know where you can go anyplace in the world to find a place like this," he says.
Type 2 diabetes and its debilitating, sometimes life-threatening, effects pose a significant obstacle to the recovery of individuals with SMI. While we cannot cure diabetes, well-established strategies are available for managing its effects. These strategies include health education, exercise, diet, frequent blood sugar readings, and so on, and are readily available in the community. However, individuals with SMI appear to have greater difficulty accessing and using these strategies. Paxton House is a novel and successful effort to make specialized healthcare available to Thresholds' members.
Paxton House has not been successful with every Thresholds member. Those who have not done well include the minority of individuals too psychiatrically ill to participate in a program that emphasizes education and self-care, as well as those who still choose not to make an effort to manage their diabetes. However, Paxton House has been helpful to a wide range of individuals who want to do a better job managing their diabetes as a part of their recovery.
Paxton House is a small and unique program, but its lessons are generalizable and have been applied to many other Thresholds programs. For example, walking groups and nutritional supports have been welcome additions to non-specialized residential services and day programs. Improved access to UIC nurse practitioners with special expertise in managing diabetes in this population also has improved the lives of members across Thresholds. While none of these interventions serves as a "magic bullet" that solves the challenges and risks posed by diabetes, they are a big step in improving the quality of life for individuals with both SMI and diabetes. Until we have a cure for diabetes, this improved management is the best that we can offer.
The authors would like to acknowledge The Robert Wood Johnson Foundation and the Health Resources and Services Administration in the U.S. Department of Health and Human Services for funding support of the Integrated Health Care Centers at Thresholds.
The Paxton House program was recognized with a 2006 Lilly Reintegration Award in Clinical Medicine.
The following authors are with Thresholds Rehabilitation Centers in Chicago: Sandra M. Wilkniss, PhD, Director, Research and Training Center; Helen Moore, MS, Residential Team Leader; Shirley Alexander, MS, is a Program Director; Jason Fujioka, Public Relations Director; and Anthony Zipple, ScD, MBA, Chief Executive Officer.
Judith McDevitt, PhD, APN, CNP, is a Clinical Associate Professor and Susan Braun, MS, APN, CNP, is the Director of Integrated Health Care at the University of Illinois at Chicago-College of Nursing.
To contact the authors, write to Sandra Wilkniss, PhD, at 4101 N. Ravenswood Ave., Chicago, IL 60613; call (773) 572-5280; or e-mail email@example.com.
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BY SANDRA M. WILKNISS, PHD; HELEN MOORE, MS; SHIRLEY ALEXANDER, MS; JASON FUJIOKA; JUDITH MCDEVITT, PHD, APN, CNP; SUSAN BRAUN, MS, APN, CNP; AND ANTHONY ZIPPLE, SCD, MBA…
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Publication information: Article title: Integrated Care at Paxton House: A Residential Program in Chicago Helps People with Severe Mental Illness Manage Co-Occurring Diabetes. Contributors: Wilkniss, Sandra M. - Author, Moore, Helen - Author, Alexander, Shirley - Author, Fujioka, Jason - Author, McDevitt, Judith - Author, Braun, Susan - Author, Zipple, Anthony - Author. Magazine title: Behavioral Healthcare. Volume: 27. Issue: 3 Publication date: March 2007. Page number: 24+. © 2009 Vendome Group LLC. COPYRIGHT 2007 Gale Group.
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