For the average PfP supporter, life expectancy is nearly 80 years.

For people living with a serious mental illness, that figure drops, alarmingly, to just 55 years.

Perhaps even more disturbing is the fact that this disparity is unnecessary. According to the National Association of State Mental Health Directors, preventable medical disorders—conditions that are frequently unmanaged—are the cause of death for three of five people with a serious mental illness.

The questions, then, are who can effectively improve these outcomes and how?

For our clients, the answer is that PfP’s coordination of primary health care is the most effective method of managing the complex and complicated relationship between psychiatric and medical care.

“If a person has a serious psychiatric illness like schizophrenia, and they also have hepatitis or diabetes and hypertension, an organization like Places for People is the most appropriate place to be the ‘medical home.’ We are in the best position to help a person understand their illness and participate in treatment,“ said PfP Executive Director Francie Broderick.

PfP staff fulfill the role of a primary care coordinator partnering with our clients to give them the information, the support, and the resources necessary to address all of their health care needs.

Providing this coordination of care is nothing new. In fact, it has been part of PfP’s overall support services since the agency’s beginning, when volunteers from the State Hospital helped people discharged from institutions find and succeed in independent, community-based housing.

“We’ve always done a good job with that—maybe better than most—but we’re committed to finding a better, more efficient way to do it,“ said Broderick.

Several new initiatives at PfP seek to enhance the delivery of primary care coordination.

Health Center Partnership

PfP has recently entered into a partnership with a primary care facility, Family Care Health Center (FCHC), with a goal of improving the lines of communication between community support workers and medical providers.

This pilot project is a voluntary opportunity for clients to change doctors and provides a resource for new clients. Dr. Caroline Day at FCHC will be the provider. She came to PfP over the summer to introduce herself and answer questions about the partnership.

“The idea is that I would work in coordination with the caseworkers and with you to maximize your healthcare,” said Dr. Day, in describing her role in the partnership.

The partnership will promote integrated behavioral and physical health care by streamlining the communication process, limiting the number of medical providers that community support staff will need to work with, and offering a stable, positive environment for clients who may be fearful of seeing a doctor or who have no doctor.

Conversion to EMR

Through a generous anonymous grant, we will soon be converting to a fully electronic medical records (EMR) system. This major step reflects a nationwide trend and looks towards a future when coordination of care is greatly enhanced by the ability to access complete medical records electronically.

PfP has been planning to convert to an electronic system for several years, but the challenges have been finding the right system and the funding to make it possible. Through this grant funding, PfP will convert clinical records to an electronic format to centralize and connect several existing electronic processes, including billing.

This transition will greatly enhance the exchange of information between physical and behavioral health care providers. Internally, it will also streamline numerous documentation processes.

PfP will purchase laptops to allow community support workers to access these records while providing services in our clients’ homes in the community.

ACT: A Model of Integration

In early 2008, PfP’s HOME Team began a pilot project with a new approach to community support, through the Assertive Community Treatment (ACT) model. In the ACT model, teams are designed to be a microcosm of all the services clients would need.

Accordingly, rather than being composed wholely of “generalist” community support workers, PfP’s HOME Team also includes two, part-time treating psychiatrists, a registered nurse, a vocational specialist, and a substance abuse specialist.

As a result, coordinating psychiatric and physical health care is an active, ongoing process within the team itself.

The registered nurse for the HOME Team, Major Whittaker, joined the group after 27 years working in a mental health hospital setting. Whittaker, profiled on page 4, said he believes the greatest value of the HOME Team is in breaking the “revolving door cycle” he saw while working in the hospital.

In the hospital, he explained, the emphasis was on improving health, but that was accomplished by health care professionals doing things for clients. The HOME Team, on the other hand, works with clients to increase stability, to teach them how to manage their illness, and to be there consistently to provide support.

By doing so, the HOME Team can help break the cycle of recurring hospitalizations. “It truly does work,” said Whittaker.

Nursing and Wellness

PfP’s commitment to integration of physical health care is also demonstrated in the agency’s development of wellness programs. The Club offers health and wellness groups, and the agency is also in the process of creating a new nursing position that will serve as a Wellness Coordinator.

These programs and services provide multiple opportunities for clients to learn more about how to prevent or manage illnesses, reduce stress, and improve their health outcomes.