Commonwealth Research Center
“HOPES” – Helping Older People with severe mental illness Experience Success
Rationale – Research Objective and Specific Aims
Principal Investigator
Stephen Bartels, M.D.
New Hampshire-Dartmouth Psychiatric Research Center
State Office Park South
105 Pleasant Street
Concord, NH 03301
Phone: (603) 271-5747
Fax: (603) 271-5265
Email: [email protected]
Other Investigators
James Feldman, M.D. (MMHC site PI)
Massachusetts Mental Health Center and
Commonwealth Research Center
MMHC at the LSH Campus
180 Morton Street
Jamaica Plain, MA 02130
Phone: (617) 626-9483
Email: [email protected]
Joanne Wojcik, M.S., APRN, BC
Commonwealth Research Center
MMHC at the LSH Campus
180 Morton Street
Jamaica Plain, MA 02130
Phone: (617) 626-9411
Email: [email protected]
Bruce L. Bird, Ph.D. (NSMHA Site PI)
North Suffolk Mental Health Association
301 Broadway
Chelsea, MA 01950
Phone: (617) 912-7910
Email: [email protected]
MMHC HOPES Staff
Ann Fletcher, M.S.W., LICSW
Psychiatric Group Leader
Phone: (617) 626-9412
Fax: (617) 983-3035
Email: [email protected]
Meghan Driscoll, B.S.
Site Coordinator
Phone: (617) 626-9415
Fax: (617) 983-3035
Email: [email protected]
The projected growth in the population of older persons with severe mental illness (SMI) in the coming decades, coupled with a lack of services and effective treatment models, is anticipated to result in a major public health problem (Light & Lebowitz, 1991; Bartels, Levine, & Mueser, 1999; Jeste et al., 1999). Individuals with SMI who continue to require treatment in late life have substantial functional disabilities and intensive needs for services, often requiring acute psychiatric hospitalization (Mulsant et al., 1993) and long-term hospitalization (Davidson et al., 1995). Problems with community living skills account for more variance in predicting service use than any other single factor for SMI elderly (Bartels, Miles, Dain, & Smyer, under review). This is important because deficits in functioning are pervasive and debilitating for many older persons with SMI in late life, resulting in greater dependence on institution-based care and other intensive services (Semke, Goldman, & Hirad, 1996; Meeks & Murrell, 1997; Bartels, Mueser, & Miles, 1997).
Medical comorbidity is present in most older persons with SMI and is associated with worse perceived health status, more severe psychiatric symptoms, increased morbidity, and increased mortality (Dalmau, Bergman, & Brismar, 1997; Vieweg, Levenson, Pandurangi, & Silverman, 1995; Dixon, Postrado, Delahanty, Fischer, & Lehman, 1999; Goldman, 1999). Poor health practices, problem behaviors, and difficulty with treatment adherence contribute to poor health outcomes and the need for active coordination of medical and psychiatric services (Moak, 1996; Vieweg, et al., 1995; Bartels et al., 1999; Holmberg & Kane, 1999). Although problems in everyday functioning and medical comorbidity are hallmarks of SMI in older persons, rehabilitative services are lacking and primary health care is underutilized for this population. Little is known about how to provide effective rehabilitation and health management services to older persons with SMI in order to improve skills and functional outcome and to decrease the use of high-cost institution-based services.
To address this need, the proposed study will test the effectiveness of a recently developed supported rehabilitation and health management (SR/HM) intervention for older adults with severe mental illness. The intervention addresses functioning in two areas essential for preventing hospitalizations and long-term institutional care: (1) enhanced social and independent living skills and (2) improved health management. The SR component consists of manualized skills training aimed at improving competence in everyday functioning, including community living skills and social skills. A highly scripted, structured and standardized manual is being completed for each module of the skills training curriculum. The manual is revised based on feedback from the nurse specialists after they teach the material. The manual will be finalized after the first cohort of study participants randomized to the intervention group has completed the first 12 months of their participation. The health management HM component consists of training in health management skills and health management by nurses who monitor and facilitate routine preventive and acute health care. An instruction manual for the health management component of the intervention has been developed for the nurse specialist and continues to be revised based on the nurse specialists feedback. This intervention was pilot-tested in a typical community mental health center setting in NH. Results from the pilot study showed that participants who received the SR component demonstrated significantly better improvement in functioning over one year compared to a control group that did not receive SR. Individuals who received the HM component showed improvement in identification of medical conditions and receipt of medical services.
Research Objective and Specific Aims
The overall goal of this study is to demonstrate that the supported rehabilitation and health management (SR/HM) intervention is effective and can be implemented in a large scale in two different service systems. We expect that the intervention will improve outcomes in several different areas. Specifically, the effectiveness of this intervention will be tested with respect to the following specific aims and hypotheses:
Specific Aim 1 – To compare the effectiveness of SR/HM to UC in improving independent living skills and health management.
We hypothesize that compared to older individuals with severe mental illness (SMI) receiving usual care (UC), individuals receiving SR/HM will have better independent living skills and health management, evidenced by:
a) Better community living skills and better social skills based on performance-based measures and self-reports of functioning, and
b) Better medication management skills based on performance-based and self-report measures and greater use of preventive and routine primary health care (including annual check-ups with a primary care provider and participation in preventive health care).
Specific Aim 2 – To compare the effectiveness of SR/HM to UC in decreasing the use of high-cost acute and long-term institution-based services.
We hypothesize that compared to older individuals with SMI receiving usual care, individuals receiving SR/HM will use fewer high cost services, including emergency room visits, acute hospitalizations, and nursing home care. In addition, the reduced use of high cost institution-based services will be associated with better independent living skills and health management practices resulting from the SR/HM intervention.
We will also evaluate the following secondary, exploratory hypotheses:
1) The SR/HM intervention will be associated with better general health status.
2) The effectiveness of SR/HM in improving living skills and community functioning will be greatest for individuals with low levels of cognitive impairment.
Although ongoing, the study is no longer recruiting.