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Could ‘nurse navigators’ help the severely mentally ill?
People with serious mental illness are dying much earlier than average from entirely preventable diseases, a situation a new policy aims to improve.
So-called 'nurse navigators' could be part of a new system to improve the physical health of those with severe mental illness.
‘They just fall into a black hole.’
James Dunbar, an honorary professor at Deakin University Medical School, paints a bleak picture of the way the system is set up to care for the physical health of people with severe mental illness.
While the link between poor mental health and physical health is long established, Professor Dunbar says it is only more recent research that has shown to what extent people with serious mental illness are dying early, mostly from entirely preventable diseases.
‘It’s something which has always been there and it’s only when somebody actually cuts up all the numbers and says, “my God, look at this”, you realise that the system has just not been aware of the scale of the problem,’ he told newsGP.
Figures from the Australian Institute of Health and Welfare (AIHW) indicate that people with severe mental illness die up to 20 years prematurely on average – but, as Professor Dunbar highlights, they are largely dying from the same things as everyone else.
‘We’ve made great progress with life expectancy over the last generation or so, a lot of it through medication, reducing cholesterol and blood pressure, a huge amount from smoking cessation,’ he said.
‘But these benefits have not flowed through to people with serious mental illness.’
Speaking on a recent podcast, Professor Dunbar says smoking is five times higher among the cohort compared to the broader population, while the rate of cardiovascular disease and respiratory disease are cited as being six and four times higher respectively.
People with severe mental illness are also much more likely to take drugs, and much less likely to take part in early prevention screening programs, he says.
However, Professor Dunbar believes there is a solution.
Writing alongside two-co-authors in an editorial in the latest Medical Journal of Australia (MJA), the paper sets out system improvements that could make a fundamental difference.
‘Primary care is not organised to provide this group with screening for cardiometabolic risk factors,’ it states.
For Professor Dunbar, one of the most impactful changes would be to increase the level of proactive clinical engagement.
‘The most important step is to do for people with serious mental illness what we’ve done for subgroups, like people with diabetes, asthma and heart disease, where a practice has a register and checks how the patient is doing compared with guideline targets,’ he said.
‘That would make a huge difference to life expectancy.’
This is where the ‘nurse navigators’ would come in: under the proposal, they would help general practices guide those with severe mental illness through a fragmented and complex system.
Professor Dunbar knows the inherent challenges.
‘There’s no question that it will be much harder to get patients with serious mental illness to come for check-ups than for people who have diabetes,’ he said. ‘That’s just how it is.’
But for Dr Cathy Andronis, Chair of RACGP Specific Interests Psychological Medicine, the concept is strong.
‘One of the reasons we’re seeing such discrepancy in life expectancy is because people in this situation access health services less,’ she told newsGP.
‘They tend to deny symptoms or ignore symptoms, or they can’t afford to see somebody for their symptoms, or they’re just so preoccupied by other concerns, other stresses in their lives.
‘The more people we can involve in their care, the more gently we can nudge them in that direction, that will be beneficial for them.’
Professor Dunbar, an RACGP Fellow, is very conscious of the time pressures general practices are already under.
‘You can’t take busy people, which practice nurses and GPs are, and ask them to work harder – that’s just demoralising,’ he said.
‘That’s why we propose this workforce of nurse navigators on the grounds that their job would be to liaise with the psychiatric services, community services, on behalf of the practice, to support all the health-promoting messages.’
This would include helping patients with healthy diets, increasing physical activity and smoking cessation, he says – but there would be a trade-off.
‘One of the problems for some people with serious mental illnesses is they don’t have a regular general practice,’ he said.
‘The deal for the practice would be, you get your nurse navigator to help you do all this work but in return if your local mental health service wants to find a practice for someone who doesn’t have one, you need to take the patient.
‘That’s the deal of how it would work so that we’d eventually end up with all people with serious mental illness having a regular practice.’
Integrated shared care
To Professor Dunbar’s mind, this idea is the most important one for the systemic improvements proposed, but there are several other strands bracketed together in a policy proposal called Being Equally Well.
These are outlined in depth in an MJA supplement for which he was the editorial co-ordinator along with Rosemary Calder, a Professor of Health Policy at Victoria University’s Mitchell Institute.
They include integrating guidelines and shared care protocols between the RACGP and the Royal Australian and New Zealand College of Psychiatrists (RANZCP) – a move that the colleges are in active discussions over.
‘[The] guidelines are reasonably aligned but implementation pathways need collaboration,’ Professor Mark Morgan, Chair of RACGP Expert Committee – Quality Care (REC–QC), told newsGP.
He co-authored a perspective article in the MJA supplement about the issue, in which he outlines the requirements for implementing the guidelines and protocols.
‘Investments are needed to support people with serious mental illness to be equally well,’ he wrote.
According to Professor Dunbar, the Being Equally Well policy evolved using this type of collaborative approach to identify the requirements of general practice and psychiatrists.
‘We need to build it up from the frontline and say to the frontline, “what are the tools you need for the job?”, and go from there,’ he said.
‘So that’s how we did it.’
The health implications of medications are also among the issues considered by the
MJA article, with a focus on metabolic syndrome and the possibility of antidiabetic medicines being used among the severely mentally ill to reduce cardiometabolic risk.
Another critical part of the policy, Professor Dunbar says, would involve practice registers feeding data into a National Mental Health Clinical Quality Register.
‘It would allow the [Federal] Government to see what the performance was, and if that the performance is getting better year on year. And if not, why not?’, he said.
‘For me the quality improvement at practice, PHN and national level is crucial because if you don’t measure it, you don’t manage it.’
He also believes the policy proposals are timely with the Strengthening Medicare Taskforce currently convening and its focus on improving access to GP-led multidisciplinary team care, including nursing.
‘We’re advocating not only good use of practice nurses, but this new nurse navigator group,’ he said.
‘They want to see better teamwork. We say this has to be all about teamwork.
‘They are saying they want better management of chronic diseases. Here we have a group where we can make a huge difference with everything we know how to do already.
‘And the economic payoff? You hope that you reduce the hospital costs, the health costs, and have [people with serious mental illness] contribute to the workforce far more than they do at present.’
Dr Andronis also wants to see change and welcomes the discussion as the mental health burden of the pandemic continues to be felt.
‘It’s a really important conversation to talk about coordinated team care,’ she said. ‘We really need to be more coordinated and efficient to get better outcomes.’
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