A new model of care holds promise in improving the physical health of people with mental illness, new research finds, potentially increasing the life span of individuals who typically die 25 years earlier than the general population.
The USC study, published in Schizophrenia Research, suggests the magic bullet may lie in peer navigators. These trained role models use their own life experience with recovery from mental illness, such as schizophrenia, bipolar disorder or depression, to help motivate and teach their charges skills they can use to eliminate the barriers that keep them from receiving physical care and learn how to self-manage their own health needs.
“Peer navigators have proven effective at building a strong connection with clients, and this empowerment has resulted in patients having more outpatient visits with doctors, less preference for emergency room visits, more confidence in self-managing their own health care and better detection of diseases,” said principal investigator John Brekke, the Frances G. Larson Professor of Social Work at the USC Suzanne Dworak-Peck School of Social Work.
The people who want to do this work generally have been through a life-changing medical event themselves or with a loved one. They have learned the hard way how difficult it is to navigate and manage a complicated diagnosis, treatment or chronic condition. They experienced the confusion, lack of coordination, dangers and inefficiencies in the U.S. health care system, and now they want to share both what they have learned and how to avoid missteps along the way. In many cases, these are laypeople with no prior medical experience or training.
Improving coordination of care
As federal, state and local programs work to leverage the promise of the Affordable Care Act (or its replacement under the Trump administration) for better health outcomes, using approaches that facilitate greater access to quality care and treatment like peer navigators is essential, say investigators. For the afflicted, it’s a matter of life and death.
“These individuals have oftentimes given up; they can’t help themselves and they aren’t getting standard primary health care. What’s disturbing is that they are dying from preventable medical conditions,” said Brekke.
“Just to bring this home, I often tell audiences that if I had been diagnosed with a serious mental illness, the aggregate data suggest that I would have died over a decade ago,” he added.
The causes — high blood pressure, heart disease, diabetes, obesity and asthma — are treatable. The problem is that people with serious mental illness tend to be socioeconomically disadvantaged and often don’t get the best available health care. Frequently, their own mental health providers pay too little regard to their physical health.
Brekke blames a fragmented health care system — one that segregates the services for physical health and mental health — for the health disparities these individuals experience that often lead to uncoordinated, inferior care, and increased health care costs.
“These departments are not integrated, and they never have been. 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,” he said. “We need a health care system that is prepared to deal with persons who have a serious mental illness. They require a different kind of approach.”
Coaching for success
Simple tasks may seem enormously challenging to individuals with serious mental illness. They often lack trust in professionals and agencies, and they may find the responsibility of seeking medical care overwhelming or frightening.
Brekke and his team developed and tested a behavioral model of health services use focused on educating patients with serious mental illness about self-care, giving them the tools to manage on their own and ultimately helping them find the confidence to navigate a complicated health care system — with peer navigators as coaches.
He enlisted the help of Pacific Clinics, one of Southern California’s largest behavioral health care agencies. UniHealth Foundation and the Patient-Centered Outcomes Research Institute, which is the research arm of the Affordable Care Act, have funded his team’s work.
“Many of our clients are insured, but do not know how to access and use medical care. Many did not learn as young adults how to take care of their health,” said Laura Pancake, vice president of wellness, recovery, integrated care and training at Pacific Clinics. “In many cases, families did not prioritize health, often turning to the emergency room as their primary health care provider.”
Peer navigators use motivational strategies, modeling, role-playing and coaching to help clients achieve certain behavioral goals. They assist clients in making medical appointments, finding transportation, communicating with providers, following through with lab tests and filling prescriptions, and adhering to a doctor’s care plan.
“Peer navigators serve a critical role in coordinating care among mental health care providers, primary care providers, substance abuse providers and specialty care,” Pancake said.
Feedback indicates interactions with peer navigators improve the health care experience and give consumers better access to services.
“Physicians like it because it helps them develop relationships with their patients and facilitates communication and understanding,” she said.
Lou Mallory knows firsthand the benefits. The lead peer navigator at Pacific Clinics sought out the role about six years ago to share her own experiences and coping strategies, having lived with depression for 18 years.
She recalled a recent case of a 21-year-old Hispanic man, who had never been to a doctor’s office. He thought sick people went to the emergency room. That’s what his mother had always done. He had health insurance, but never used it because his assigned doctor was 30 miles away. Mallory helped him find a doctor closer to home and accompanied him on his first doctor visits.
“I showed him how to interact with medical personnel. He had a very hard time speaking as he had shut down emotionally due to fear,” she said. “So I started the conversation, and then he was able to continue the conversation and answer the doctor’s questions.”
Today, her client is still seeing the same doctor, exuding confidence and taking care of his health on his own. Mallory beams with pride, knowing he’d still be going to the emergency room for his health care if not for her assistance.
“To me, there’s nothing better than seeing a consumer grow and learn and eventually take care of their health care needs on their own. It gives me a great sense of satisfaction,” she said.
Brekke acknowledges a secondary outcome of his research has been the positive effect on the peer navigators themselves.
“It improved aspects of their self-esteem, their confidence and job satisfaction. It actually made them much more aware of their own health care needs,” he said.
Although they go by many names, peer support and patient navigation programs play an increasingly important role in multidisciplinary care teams and offer vital additions to the workforce, making this evidence-based practice a rapidly growing approach. Professionals in both the physical and behavioral health spheres affirm the benefits of peer navigators, citing encouraging outcomes such as saving money and keeping people out of the hospital.
“Public health providers and community health clinics have expressed great interest in adopting the peer health navigation model of care,” said Pancake.
The team has already worked with the Los Angeles County Department of Mental Health to train more than 400 peer navigators in California and Washington.
Brekke notes a national movement toward using peer navigators in other disciplines, too, and with different populations. He says the positive results regarding their impact are holding steady in his research during the last five years in this area and hopes this, along with Medicaid reimbursements, will lead to even wider implementation and dissemination of this model of care.