Integrated Care for Veterans with Diabetes & Serious Mental Illness Judith A. Long, MD Steven C. Marcus, PhD

Patients with SMI  DM is 2-3 times more common  2-3 times higher mortality from DM and CAD  Medication adherence and glucose control is poor  Integrated care where patients receive primary and mental health care within the same site advocated  No studies looking at how integrated care affects disease specific outcomes

Objectives Determine if integrated care is associated with improved »DM medication adherence »Glucose control In a population of veterans with both DM and SMI served by one VA medical center

Integrated Medical Care at the Philadelphia VAMC  Located in the mental health clinic  1 MD, 3 NP, 1MA  Part of the mental health team, attend mental health clinic conferences and meetings  1/3 of appointment slots unscheduled to accommodate walk-ins and walk-overs

Population Identification Philadelphia VAMC Data ( ) DM 250 ICD-9CM HbA1c Hypoglycemic Rx HS500,HS501, HS502

Outcome Measures MPR for hypoglycemic meds during 12 months preceding the last recorded HbA1c »good adherence (MPR ≥ 80%) »marginal adherence (MPR ≥ 50%) HbA1c (lower better)

Main Independent Predictor SMI in Integrated Care »Schizophrenia (any 295 ICD-9CM code) or bipolar disorder (code ) »At least one primary care appointment in behavior health clinic (code 531) SMI not in Integrated care No SMI

Population Characteristics SMI Not Integrated SMI Integrated No SMI n Age, y ± SD59 ± ± ± 11.3 Sex, % White,% Black,% Unknown,% Other,%231 Insulin, %19%7%15%

Outcomes by Site of Care MPR≥80%MPR≥50%HbA1c SMI Not Integrated43%66%7.8±2.1 SMI Integrated51% 75%*7.5±1.9 No SMI 50%* 75%* 7.4±1.6* * Compare to Not Integrated p < 0.05

Adjusted Outcomes by Site of Care MPR≥80% OR (95% CI) MPR≥50% OR (95% CI) HbA1c β (p value) SMI Not Integrated SMI Integrated Care 1.33 ( ) 1.52 ( ) (0.01) No SMI 1.02 ( ) 1.29 ( ) 0.11 (0.20) *Adjusting for age, sex, race

Limitations/Future Work Limitations  One institution  No adjustment for SMI severity  Reasons in integrated care non-random  Definition of being in integrated care generous  Cross sectional Future Work  Multiple Institutions  Primary data collection  Multiple Institutions/Qualitative work  Confirm site of primary care with PCP

Integrated Care  Better DM medication adherence  Better glucose control  May be an important means of improving chronic disease management and disease specific outcomes for patients with SMI