Caring for the Cardio-metabolic Health of the Severely Mentally Ill

The average schizophrenia sufferer, for example, may die 30 or 40 years prematurely – their truncated lifespan the result of common and largely preventable illnesses, which are poorly treated because of their lifestyle and neglect by the community.

In an effort to relieve this dreadful toll, a ground-breaking integrated approach to caring for the physical health of SMI sufferers is being trialled in clinics at Sydney Local Health District.

It is hoped the program – the Collaborative Centre for Cardiometabolic Health in Psychosis (ccCHiP) - can be rolled-out to other local health districts in the Sydney Health Partners network.

Mental Health Stream leader and Professor of Psychiatry at Concord Clinical School, Professor Tim Lambert, says cutting-edge information technology and “common sense” in service delivery models are combining to improve health outcomes for Australians battling severe mental illness.

“The most vulnerable psychiatric populations - those with complex and enduring disorders such as schizophrenia or bipolar disorder - typically carry multiple cardio-metabolic risks such as obesity, high blood pressure, high cholesterol, gum disease, diabetes, high smoking rates, and sedentary lifestyles and so on,” said Professor Lambert.

“The best estimate we have is that these SMI people represent up to 3.5 per cent of the population. In a country of 25 million, that is a lot of people who are potentially living in poor health and dying much too young.”

Professor Lambert says the traditional approach to public health care doesn’t work for the severely mentally ill. They have a poor record of attending clinical appointments and may not be able to remember what they are there for, what treatments they have had elsewhere, or what instructions or lifestyle advice they were given by clinicians.

“Recognising the difficulty SMI patients experience in attending multiple, serial and geographically dislocated assessments, we believe there is a need for a clinical approach that spans the gap between traditional psychiatry and general medicine.

“We are taking the common sense approach of providing assessment by up to eight disciplines in a single session. These comprise dietetics, exercise physiology, oral health (dental), nursing, cardiology, endocrinology, sleep medicine, general medical psychiatry, and pharmacology.

“At the end of the session, the whole team discusses each patient in order to provide an interdisciplinary synthesis of the issues presented during the assessment - and incorporating relevant clinical materials assessed prior to the clinic.

Patients have the services of a community nurse who will take them to visit their GP within four weeks of attending a clinic.

To help clinicians and GPs work with a lot of information, the program is also innovating in the IT space. The workflow incorporates a bespoke web application that incorporates the functions of relational database, an adherence promotional tool to assist patients (using a variety of graphics-rich tools), an e-learning tool for multidisciplinary students, and a reporting tool that automates the development of reports for all relevant clinicians involved in the patient’s care.

ccCHiP is being pioneered by Sydney Local Health District and now has the support of the leadership of the other two LHDs in the Partnership - Northern and Western Sydney local health districts. Sydney Health Part is facilitating the introduction of this novel clinical model across the network.

“The message from this program is that every clinician, in any branch of medicine and health, now needs to be master of the “three Cs” – Chronicity, Complexity and Co-morbidity,” said Professor Lambert.