Registry-Managed Care Coordination and Education for Patients With Co-occurring Diabetes and Serious Mental Illness

Objective: Longitudinal changes in health outcomes of patients with serious mental illness and co-occurring diabetes were examined after introduction of an intervention involving electronic disease management, care coordination, and personalized patient education.

Methods: This observational cohort study included 179 patients with serious mental illness and diabetes mellitus type 2 at a behavioral health home in Chicago. The intervention employed a care coordinator who used a diabetes registry to integrate services; patients also received personalized diabetes self-management education. Outcomes included glucose, lipid, and blood pressure levels as assessed by glycosylated hemoglobin, low-density lipoprotein, triglycerides, and systolic/diastolic values from electronic medical records and completion of specialty visits confirmed with optometrists and podiatrists. Interrupted time-series segmented random-effects regression models tested for level changes in the eight study quarters following intervention implementation compared with eight preimplementation study quarters, controlling for clinic site and preimplementation secular trends.

Results: Significant declines were found in levels of glucose, lipids, and blood pressure postimplementation. In addition, completed optometry referrals increased by 44% and completed podiatry referrals increased by 60%.

Conclusions: Significant improvement in medical outcomes was found among patients of a behavioral health home who had comorbid diabetes and mental illness after introduction of a multicomponent care coordination intervention, regardless of which clinic they attended.