Credit: Michael Bretherton/istockphoto
By now, the "medical home" is widely recognized as a model of
care that would ensure that individuals have a stable "home" where
they always have access to care and coordination of primary and specialty
health care services.
But for individuals with serious mental illness, should that home be
remodeled a bit to meet their special needs?
In an article in the April Psychiatric Services, psychiatrists
Thomas Smith, M.D., and Lloyd Sederer, M.D., propose a "mental health
home" for those with serious and persistent mental illness that would
incorporate medical home characteristics including access to and coordination
of services, integration of primary and preventive care, adoption of a
recovery orientation and evidence-based practices, and family and community
"Building on medical home concepts, mental health care providers can
create a mental health home for individuals with serious mental illness that
provides key service elements shown to enhance access, care coordination, and
quality of care," they wrote. "In most states, the public mental
health system remains fragmented and complex. A mental health home with
clinicians and other resources highly focused on the individual and recovery
offers a means of closing existing access and quality gaps."
Smith is an associate clinical professor of psychiatry at Columbia
University College of Physicians and Surgeons. Sederer is medical director of
the New York State Office of Mental Health. Formerly, Sederer had been
director of APA's Division of Clinical Services.
In an interview with Psychiatric News, Smith argued the case for a
special health care home for mentally ill individuals. "Our feeling is
that there is a population of people with serious mental illness who are
treated in the public mental health system and who have very intensive service
needs but who—by dint of their circumstances—have a hard time
engaging with a health care provider of any sort.
"Those individuals are much more likely to engage with a mental
health team because of the intensity of their service needs," Smith
said. "It is probably unreasonable to think they are going to have two
homes, so we are proposing that there could be a mental health home treatment
team that takes on a lot of the coordination of care."
In the brief period since the article has appeared, Smith said he and
Sederer have received e-mails and phone calls expressing an interest in the
proposal. The ground has already been laid for a mental health home in
demonstration projects for integration of primary care and mental health
services under consideration by the Substance Abuse and Mental Health Services
But Smith said he hopes to advance the idea to include all aspects of a
recovery-focused treatment approach, including access to care, coordination of
medical and mental health services, involvement of the family, and attention
to cultural issues, among others.
In the vision outlined by Smith and Sederer, the mental health home
clinician would be responsible for monitoring all aspects of an individual's
health. In the article, they noted that the CATIE trials of schizophrenia
treatment showed that 30 percent of individuals who were being treated with
antipsychotic medications and met criteria for diabetes were receiving no
treatment with a glucose-lowering agent.
In addition, they noted that 88 percent of those in the study with elevated
cholesterol were not receiving a lipid-lowering agent, and 62 percent of those
meeting criteria for hypertension were not receiving antihypertensive
"The role of the mental health home psychiatrist would be to actively
monitor these and other primary care indicators, educate recipients regarding
health and wellness, and ensure coordination with primary care providers so
that medical conditions can be appropriately managed," Smith and Sederer
In the interview, Smith argued that in the light of recent evidence
suggesting that antipsychotics themselves may contribute to metabolic
disorders, psychiatric responsibility for patients' medical health needs is
"Psychiatrists can't in good faith say we can refer these [patients
with metabolic and other medical] issues to primary care doctors when they are
in part a function of our treatments," he said.
But, he added, this need not mean that psychiatrists treat such medical
conditions, but rather that they interface with primary care physicians and
monitor basic health indicators such as body mass index and blood pressure, as
well as lifestyle issues such as smoking status, nutrition, and physical
"Our purpose was to throw it out there and see what the response
is," Smith said. "We are interested in feedback and in developing
the model further. We think it offers a framework for collaborative projects
between the public and private sectors and we hope to see some demonstration
projects around the idea."
"A New Kind of Homelessness for Individuals With Serious
Mental Illness: The Need for a 'Mental Health Home'" is posted at<http://psychservices.psychiatryonline.org/cgi/content/full/60/4/528>.▪