Achieving Cardiovascular Health Equity in Community Mental Health: Optimizing Implementation Strategies

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People with serious mental illness (SMI) comprise 5% of the US population and experience one of the largest CVD-related mortality disparities of any group with rates 2 times higher, and dying 10-20 years earlier, than the overall US population. Underpinning this wide disparity is marked elevation in prevalence of all CVD risk factors in persons with SMI, with low rates of risk factor control. Interventions addressing CVD risk factors require tailoring for persons with SMI who often have substantial barriers related to psychiatric symptoms and cognitive impairment. There is an urgent need for scale-up of efficacious interventions shown to address the high burden of multiple CVD risk factors in SMI, however, organizational and provider-level barriers impede implementation. To improve care of persons with SMI and overcome fragmentation of the US general medical and specialty mental health systems, behavioral health homes, programs where specialty mental health organizations are responsible for coordinating primary care services, have proliferated. While they have shown improved access to primary care and screening for CVD risk factors, to-date behavioral health homes have not resulted in improvement in CVD risk factors, likely because they are not implementing evidence-based interventions. Two effective interventions, the NHLBI-funded IDEAL and NIMH-funded Life Goals interventions, have been shown to reduce CVD risk in persons with SMI. The overarching goal of this UG3/UH3 is to partner with communities in Michigan and Maryland serving persons with SMI to refine, tailor and test provision of different implementation strategies to improve uptake of these evidenced-based practices for reducing CVD risk in SMI in behavioral health homes. Replicating Effective Programs (REP) Framework components (e.g., community working group, packaging, training, technical support) will lay the groundwork for uptake and sustainment, alongside two additional implementation strategies, Coaching and Facilitation, which address provider and organizational barriers, respectively. The Specific Aims are to (1) Establish a highly collaborative and productive partnership with 24 Michigan and Maryland community mental health program sites to tailor IDEAL/Life Goals evidence-based practices and implementation strategies to fit site needs; (2) Determine effectiveness of two implementation strategy augmentations to REP, Coaching and Facilitation, on a) uptake and delivery of IDEAL/Life Goals at 18-months (primary outcome), and b) quality of care for CVD risk factors and CVD risk factors among persons with SMI, (secondary outcomes) and (3) To assess mechanisms (e.g., provider self-efficacy), moderators (e.g., implementation climate), and other relevant measures (e.g., fidelity, costs) to inform an adaptive implementation intervention to further scale up IDEAL/Life Goals in the behavioral health home setting. This innovative work will inform which combination of implementation strategies will lead to optimal uptake of effective interventions to reduce CVD risk among persons with SMI in community-based settings, a critical step in reducing their CVD disparities and achieving health equity.