Living Well Living Longer: truly integrated care for people with serious mental illness

Abstract

1. The life expectancy gap for people living with severe mental illness is 15-25 years less than the general population, due to physical health co-morbidities and preventable illness. 2. Living Well Living Longer is a district wide strategy delivering physical health care to this population in Sydney Local Health District (SLHD) through a new and integrated approach to physical health screening and treatment 3. The program has integrated pathways to care, new workforce models, workforce development strategies, and the use of technology to engage consumers in their health care. The program has been built on strong partnerships between clinical streams, and external partners 4. People living with severe and enduring mental illness, who are care co-ordinated bySLHD mental health service. Key stakeholders include SLHD clinical streams, Central & Eastern Sydney Primary Health Network, non government organisations, carer and consumers representatives and research partners. 5. The program was funded for 3 years through a NSW Health Innovator grant, and became permanently funded in June 2017 6. Living Well Living Longer model of care improved health outcomes through demonstrated practice change in monitoring, screening, referral and treatment of physical health in the target population improved collaboration in the establishment and facilitation of shared care between mental health services and primary health providers the integration of the health peer support workers as care navigators into mental health clinical teams technology to assist consumers set and achieve health goals workforce development embedding the principles of early intervention and prevention into clinical care provision 7. The program is dynamic and evolving, and demonstrates ongoing improvement in service integration 8. The model is transferrable across health settings, and is designed to improve physical health care co-ordination between mental health services and primary health service providers 9. The program has met its aims of establishing integrated care systems of service delivery designed to improve physical health outcomes. Practice change has been sustained over time, and new models of care developed and implemented. The program has improved the capacity of services to respond in partnership to identified population needs and work together to close health inequity gaps 10. The program has successfully implemented systems which address contributors to physical morbidity. The program places the consumer at the centre of care, and has integrated new models of care, innovative digital technology, guidelines and health pathways to support clinical outcomes, and established a new workforce of health peer support workers, exercise physiologists and dieticians to support a holistic approach to mental health service delivery 11. Investment in getting integrated care right takes time, and requires ongoing collaboration and consultation from a wide range of stakeholders. Partnerships are a priority and require sensitive management, which is helped by dedicated liaison positions to assess and manage multiple competing agendas and priorities, and maintain communication Having a system of communication and feedback from consumers, service streams and sectors allowed us to incorporate what we learnt into planning and program development and implementation Practice change takes time and ongoing clinical workforce support