Mechanisms and therapeutic implications of hypermutation in gliomas.
Academic Article
Overview
abstract
BACKGROUND: Americans with serious mental illness (SMI) die an average of 25 years earlier than those without SMI owing to modifiable risk factors; medical conditions; and lack of access to high-quality coordinated care. Researchers have amassed evidence on strategies to address this disparity. OBJECTIVES: This research studied the outcomes of patients with SMI enrolled at the Wellness Center (WC; N = 786), a co-located primary care clinic in a community mental health center that offered 4 evidenced-based practices: (1) routine screening and monitoring of health indicators; (2) onsite provision of primary care; (3) care coordination; and (4) access to peer health navigators. Patient-centered outcome measures were administered to 203 WC patients. We had 3 specific aims. The first was to use mixed methods to collect a range of information about who chooses to use WC services and in what combinations, with what short- and longer-term effects, and with what outcomes. The second aim was to use participant interviews to identify barriers to and facilitators of access, service use, and improvements in person-centered outcomes and to elicit suggestions for changes and additional interventions to improve the quality and effectiveness of the WC. The third aim was to collaborate with people in recovery (patients) in using the data collected through aims 1 and 2 to develop and pilot a peer-led, community-based intervention to enhance access and choice and to improve person-centered health outcomes among 37 patients who had shown no improvement in their health despite using services at the WC. METHODS: The sample included 786 poor urban adults with SMI who were enrolled at the WC and had or were at risk for comorbid medical conditions. Using participatory and mixed methodology, we assessed aims 1 and 2 by collecting health (N = 786) and patient-centered outcome (N = 203) data on patients when they enrolled at the WC and at 6-month follow-up intervals. For aims 1 and 2, we conducted a nonrandomized, observational cohort study examining outcomes, as well as qualitative interviews (N = 40). For aim 2 we also surveyed and conducted focus groups with staff to investigate possible facilitators for integrating care. Using the data collected through aims 1 and 2, we developed a “whole health” pilot intervention that would be led by people living with mental and physical illness. For aim 3 we conducted a pre–post comparison with 37 participants who agreed to participate out of the 40 possible participants—randomly selected from a group of individuals whose health had gotten worse since their enrollment at the WC—to participate in a 6-month pilot intervention that included wraparound personalized wellness coaching and a peer-led holistic health group curriculum addressing the 8 dimensions of wellness (ie, physical, intellectual, environmental, spiritual, emotional, financial, social, and occupational) and the social determinants of health. We compared outcomes from the intervention participants with outcomes from a nontreatment control group. We used linear mixed models to investigate changes in outcomes over time and qualitative interviews with phenomenological analysis to examine the experience of health care and wellness. RESULTS: We found the following results: Aim 1: Health indicators did not improve over time across all study participants. Improvement in participants' health indicator risk (a variable calculated for this study that summarized risk for multiple chronic conditions, including diabetes, high blood pressure, and obesity) was related to service use, treatment satisfaction, and person-centered variables. Aim 2: Analysis of barriers to and facilitators of physical health care showed that the top barriers to receiving health care were transportation, remembering appointments, and housing instability. Top facilitators were defined as “receiving mental health services,” “liking your health care provider,” and “feeling as though you can talk to your provider.” Barriers and facilitators were also affected by demographic factors. Mixed methods investigation of the staff experience of care integration showed that both mental health center and primary care staff wanted a shared electronic health record and increased communication across sites. Aim 3: We invited patients whose health indicators got worse despite receiving care from the WC to participate in the peer-developed and -led Harambee intervention. (The intervention participants selected the name Harambee, which is Swahili for “pulling together” or “let's come together.”) Postintervention results suggested that participants in Harambee had fewer psychiatric/substance abuse visits to emergency departments, decreased alcohol use, improved wellness, increased treatment plan input, and increased treatment satisfaction compared with controls. CONCLUSIONS: The involvement of patients as co-researchers benefited all aspects of the research process, from design to dissemination. Co-location and evidence-based practices did not result in significant improvement in health indicators, although the possibility exists that changes might occur over time. However, the community-based peer-led holistic health intervention based on social determinants, structural competency, and the 8 dimensions of wellness holds promise as an augmented service for people with mental illness, although additional research is needed to test the target mechanisms of this intervention and its effectiveness over time. LIMITATIONS: The research had several limitations. First, data were missing regarding health indicators and variations in service use at the Wellness Center. To address these variations, we conducted subgroup analyses of engagement and the experience of health and wellness. Second, we used a randomly sorted sampling procedure in which individuals were invited to participate in the Harambee intervention in the sequence in which they appeared on a randomly sorted list. If people on this list were unreachable at the time of recruitment, we skipped them. If we contacted them before the study began but after all the intervention slots were filled, we invited them to participate in the nonintervention control group. This increased the possibility of introducing more unmeasured confounding variables than what might be observed in a randomized clinical trial. Finally, a naturalistic study has innate limitations for examining the comparative effectiveness of the Wellness Center. However, these results are promising and important for research in this area.
