Psychiatrists Say It's Time to Build 'Mental Health Homes'

By now, the “medical home” is widely recognized as a model of care that would ensure that individuals have a stable “home” where they always have access to care and coordination of primary and specialty health care services.

But for individuals with serious mental illness, should that home be remodeled a bit to meet their special needs?

In an article in the April Psychiatric Services, psychiatrists Thomas Smith, M.D., and Lloyd Sederer, M.D., propose a “mental health home” for those with serious and persistent mental illness that would incorporate medical home characteristics including access to and coordination of services, integration of primary and preventive care, adoption of a recovery orientation and evidence-based practices, and family and community outreach.

“Building on medical home concepts, mental health care providers can create a mental health home for individuals with serious mental illness that provides key service elements shown to enhance access, care coordination, and quality of care,” they wrote. “In most states, the public mental health system remains fragmented and complex. A mental health home with clinicians and other resources highly focused on the individual and recovery offers a means of closing existing access and quality gaps.”

Smith is an associate clinical professor of psychiatry at Columbia University College of Physicians and Surgeons. Sederer is medical director of the New York State Office of Mental Health. Formerly, Sederer had been director of APA's Division of Clinical Services.

In an interview with Psychiatric News, Smith argued the case for a special health care home for mentally ill individuals. “Our feeling is that there is a population of people with serious mental illness who are treated in the public mental health system and who have very intensive service needs but who—by dint of their circumstances—have a hard time engaging with a health care provider of any sort.

“Those individuals are much more likely to engage with a mental health team because of the intensity of their service needs,” Smith said. “It is probably unreasonable to think they are going to have two homes, so we are proposing that there could be a mental health home treatment team that takes on a lot of the coordination of care.”

In the brief period since the article has appeared, Smith said he and Sederer have received e-mails and phone calls expressing an interest in the proposal. The ground has already been laid for a mental health home in demonstration projects for integration of primary care and mental health services under consideration by the Substance Abuse and Mental Health Services Administration.

But Smith said he hopes to advance the idea to include all aspects of a recovery-focused treatment approach, including access to care, coordination of medical and mental health services, involvement of the family, and attention to cultural issues, among others.

In the vision outlined by Smith and Sederer, the mental health home clinician would be responsible for monitoring all aspects of an individual's health. In the article, they noted that the CATIE trials of schizophrenia treatment showed that 30 percent of individuals who were being treated with antipsychotic medications and met criteria for diabetes were receiving no treatment with a glucose-lowering agent.

In addition, they noted that 88 percent of those in the study with elevated cholesterol were not receiving a lipid-lowering agent, and 62 percent of those meeting criteria for hypertension were not receiving antihypertensive medications.

“The role of the mental health home psychiatrist would be to actively monitor these and other primary care indicators, educate recipients regarding health and wellness, and ensure coordination with primary care providers so that medical conditions can be appropriately managed,” Smith and Sederer wrote.

In the interview, Smith argued that in the light of recent evidence suggesting that antipsychotics themselves may contribute to metabolic disorders, psychiatric responsibility for patients' medical health needs is especially crucial.

“Psychiatrists can't in good faith say we can refer these [patients with metabolic and other medical] issues to primary care doctors when they are in part a function of our treatments,” he said.

But, he added, this need not mean that psychiatrists treat such medical conditions, but rather that they interface with primary care physicians and monitor basic health indicators such as body mass index and blood pressure, as well as lifestyle issues such as smoking status, nutrition, and physical activity.

“Our purpose was to throw it out there and see what the response is,” Smith said. “We are interested in feedback and in developing the model further. We think it offers a framework for collaborative projects between the public and private sectors and we hope to see some demonstration projects around the idea.”

“A New Kind of Homelessness for Individuals With Serious Mental Illness: The Need for a 'Mental Health Home'” is posted at<http://psychservices.psychiatryonline.org/cgi/content/full/60/4/528>.▪