Improving cardiovascular health and quality of life in people with severe mental illness: a randomised trial of a ‘partners in health’ intervention

A 12-month 2-group randomised controlled trial with extended follow up to 24 months for the intervention group will be conducted to compare the Flinders Program intervention in addition to usual care, with usual care alone. The Flinders Program incorporating cardiovascular risk interventions. It provides a framework and tools to engage the patient in a collaborative structured self management assessment, tailored planning, motivational enhancement, disease management, prevention, coordination and outcome measurement. It drives optimal use of current health services. It structures and provides motivational processes for: A quitting program, control of triglycerides and diabetes; one-on-one and group components of weight reduction programs; and initiation and adherence with BP-lowering and lipid medications. It can be delivered by any clinician and for the trial it will be delivered by trial mental health nurses. The overall duration of the intervention is 20 weeks. The patient first completes the Partners in Health (PIH) scale to self-assess self-management knowledge, shared decision making, symptom management, adherence to medical management, impact of condition/s, and lifestyle behaviours. The nurse then conducts the Cue and Response (C&R) interview to understand patient strengths and barriers to change. This leads to shared decisions on issues requiring action. Nurse and patient identify the patient’s main (life) problem and set a medium term goal using the Problem and Goals tool (P&G). The Flinders Care Plan is used to document action issues for patient and nurse over the following 6-12 months. At scheduled follow-ups, the nurse monitors outcomes using PIH and P&G scores, helps the patient to achieve goals using motivational and problem-solving approaches, and uses the structured framework of the Care Plan to manage activities. The Flinders Program therefore integrates relevant evidence-based patient education programs and agreed medical, psychiatric and community services. The program can be delivered face-to-face, by phone and/or electronically to suit patient needs. A web version of the program allows patient and trial nurse to develop the care plan either face-to-face or via the web and is used for communication in real time, or asynchronously via text or email, to provide monitoring and motivational enhancement. Number, duration and frequency of Flinders Program sessions conducted by the mental health nurse with the participant will be as follows: - (Week1) 1 hour for the completion of the PIH Scale and C&R interview; - (Week2) 1 hour for completion of the P&G and Care Plan - (Week 4, 6, 8, 12, 16 and 20) 30 minutes for each scheduled follow-up sessions. It is critical to engage GPs of SMI patients. For this trial, GPs will be engaged early through their collaboration with the patient and nurse regarding the issues identified in the Care Plan. GPs' role in providing usual physical health care (such as routine blood tests and prescription of lipid-lowering and BP medication will sit alongside the self-management Care Planning process. Integration of the GP role will be enabled via the Care Plan's ability to be finalised by the GP with MBS care plan eligibility (GPMP and TCA items) and trial-nurse follow-up and liaison between GP and patient where needed. The sampling population will be patients of Southern Adelaide Local Health Network (SALHN), population 360,000.