Peer-Based Initiative Aims to Fill Health Care Gaps for Mentally Ill Patients

February 22, 2013
by Charli Engelhorn
John Brekke

People with severe mental illness die an average of 20 to 30 years younger than the general population, an alarming trend that caught the attention of John Brekke, a professor with the USC School of Social Work.

He was disturbed to find that this diminished life expectancy is frequently linked to complications from preventable health conditions that go untreated. With a new two-year $146,332 grant from the Unihealth Foundation, he hopes to address premature mortality among those with serious mental illness (SMI) by further developing the health model known as the Bridge Peer Health Navigator Intervention.

“There is a separation between the departments of health and mental health that leaves this population vulnerable,” Brekke said. “When the severe mentally ill try to get physical care, they face many impediments. Every place the system can break down, it does.”

The Unihealth Foundation requested this second phase of Brekke’s work after what Unihealth President Mary Odell called an “enormously successful project” that was part of a previous translational research grant provided to the University of Southern California. The first phase developed the intervention model, and the foundation recognized the potential to further Brekke’s research with application of the protocol in a pilot study.

“Patients with severe mental illness have problems accessing primary healthcare services, and with the passing of the new Affordable Healthcare Act, it is important to have mechanisms in place for that,” Odell said. “This model is already being implemented, but we hope it will be more widely implemented in community provider settings. We have high hopes for this.”

With the second phase of funding from the Unihealth Foundation, Brekke and his research team will pilot test the manual created for the Bridge model during the first phase in two mental health agencies to develop an agency-preparedness guide. The agency-specific manual will be designed to introduce the model across a wider scope of mental health clinics around the world.

Brekke and his team are working with Pacific Clinics, a Los Angeles mental health agency Brekke has partnered with on research ventures for 20 years. Pacific Clinics will help analyze the protocol and identify critical aspects that pertain to agency integration, in addition to connecting Brekke with two other agencies where the bulk of the research will be conducted.

“The two other agencies will test out the navigators, looking at agency uptake and sustainability, and they will become our case studies for what is working and what isn’t,” Brekke said. “Most often, how well providers maintain fidelity of a particular treatment and implementation is the key factor. How well they practice it and keep the intervention strong will be a main point of concern for us.”

The peer navigator model promotes access to comprehensive health care by training people who have personal experience living with mental illness to serve as navigators for fellow SMI patients, helping them break through the barriers that deter them from receiving physical care. Through this process, Brekke believes the avenues leading to comprehensive health care will become demystified and less repellent, allowing patients to learn to self-manage their care.

“The goal is to link to better health care, but it is also to give the patients the skills to do this work over time and take over their own health to the best degree possible,” Brekke said.

Deciphering the barriers to care was the premise of the first phase of the project. Brekke and his team sought to pinpoint the activities and attitudes that kept the SMI population from accessing physical health care. What they found were five main categories that either individually or collectively hindered access to medical services.

At the system level, a lack of integrated facilities that offered both mental and physical care often led to geographic complications for SMI patients needing to move from one doctor to another. Additionally, providers had little incentive to treat patients outside of their standard reimbursable care due to disparities in funding streams and insurance coverage for various services.

“These departments are not designed to integrate, and they never have been,” said Brekke. “Providers in one field are not trained in the other, and they don’t want to deal with the issues that don’t directly involve them.”

For medical providers, being distanced from SMI patients led to increased stigma, further intensifying their lack of desire to manage the complex needs and behaviors of SMI patients. Stigmas and other negative attributes can create a sense of devalued worth and character in these patients and cause a cycle of self-defeating thoughts that lead to shame, a lack of independent ability, and avoidance of services altogether.

Yet, increased need and erratic behavior are often legitimate realities for this population, and poor cognitive functioning and issues with communication can serve as personal road blocks if the patient is required to locate their own health care provider, wait in lines or in busy waiting rooms, or navigate entry systems and paperwork.

“A patient will go to the emergency room and be forced to wait for hours to get seen for eight minutes. If they do not have an aversion to public and crowded areas and don’t get up to leave, the care they are given is often slight,” said Brekke. “They don’t get many lab tests, and the providers hand out prescriptions or treatment plans that serious mentally ill people don’t understand or follow.”

Identifying these personal, professional, systemic, environmental and sociopolitical issues allowed the team to understand the challenges and set a framework for solutions. Using peers to help diminish debilitating fears and stigma is a promising approach, Brekke said, noting their ability to build a rapport and earn the trust of clients with SMI, which is vital for this population to achieve successful outcomes.

Brekke’s team currently has a contract with the Los Angeles Department of Mental Health to train 80 staff members in the health navigator model. The researchers hope to have the implementation manual ready after the two-year grant term so it may be used during training sessions for mental health professionals and tested on a larger scale, which will improve its generalizability and sustainability.

“With health care reform being what it is right now, this is becoming an issue of major national focus,” said Brekke, who has been contacted by multiple state officials and an agency in New Zealand interested in using the Bridge model. In the long term, Brekke believes this model may be also useful to other areas of public health, such as substance abuse treatment.