Self-Management Training and Automated Telehealth to Improve SMI Health Outcomes

描述（由申请人提供）：减少严重精神疾病患者早期死亡率的工作主要集中在“健康之家”提供综合初级保健。然而，与改善自我管理和健康行为相比，医疗保健本身对早期道德水平下降的贡献小得不成比例。疾病自我管理培训（SMT）在普通人群中已被证明可以通过教学和指导个人监测症状、自我管理治疗和改善健康行为来改善健康结果并降低与慢性健康状况相关的成本。最近，自动远程医疗（AT）等技术的使用已被证明可以改善结果，并有可能通过每日提示自我管理和护士在疾病管理算法的指导下进行远程监测来防止普通人群中昂贵的急诊室和急性住院。据我们所知，这两种方法都没有作为重度精神分裂症患者行为健康之家的综合组成部分进行实证评估。我们提出了一项包含300名重度精神障碍患者和医疗共病患者的随机对照试验，以评估n=100人单独接受社区健康之家（CBHH）的结果，n=100人同时接受自我管理培训（CBHH+SMT）， n=100人同时接受自动远程医疗（CBHH+AT）的结果。我们将检验以下3个假设：初级H1：与单独CBHH相比，CBHH+SMT和CBHH+AT在4、8、12和24个月时与更大的健康自我管理（由健康实践自评能力量表测量）和（探索性E1）更大的心理健康自我管理（由疾病管理和康复量表测量）相关。与单独使用CBHH相比，原发性H2: CBHH+SMT和CBHH+AT将与4、8、12和24个月时早期死亡风险（通过可避免死亡风险指数衡量）和精神症状（BPRS）（探索性E2）的更大降低相关。初级H3：与单独CBHH相比，CBHH+SMT和CBHH+AT将与较少的急性服务使用（急诊室就诊和住院）和（探索性E3）在4,8,12和24个月减少急性服务使用成本相关。如果发现CBHH+SMT和CBHH+AT都有效，为了区分CBHH+SMT和CBHH+AT，我们将评估从干预终点（12个月）到最终随访（24个月）的主要结果的持续性，并将计算实施和提供SMT和AT的额外增量成本。我们还将探讨主观健康（SF-12）和个体心血管危险因素的差异

DESCRIPTION (provided by applicant): Efforts to reduce early mortality in persons with serious mental illness (SMI) have largely focused on providing integrated primary care in a "health home". Yet medical care alone accounts for a disproportionately small contribution to reductions in early morality in comparison to improving self-management and health behaviors. Illness self-management training (SMT) in the general population has been shown to improve health outcomes and lower costs associated with chronic health conditions by teaching and coaching individuals on monitoring symptoms, self-administering treatments, and improving health behaviors. More recently, the use of technologies such as Automated Telehealth (AT) has been shown to improve outcomes and potentially prevent expensive emergency room and acute hospitalizations in the general population by daily prompting of self-management and remote monitoring by a nurse who can pre-emptively intervene, guided by disease management algorithms. To our knowledge, neither of these approaches has been empirically evaluated as an integrated component in a behavioral health home for persons with SMI. We propose an RCT of 300 persons with SMI and medical comorbidity to evaluate outcomes for n=100 in a Community Based Health Home alone (CBHH), compared to n=100 also receiving Self-Management Training (CBHH+SMT), and n=100 also receiving Automated Telehealth (CBHH+AT). We will test the following 3 hypotheses: Primary H1: CBHH+SMT and CBHH+AT compared to CBHH alone, will be associated with greater health self-management (measured by the Self Rated Abilities for Health Practices Scale) and (Exploratory E1) greater mental health self-management (measured by the Illness Management and Recovery Scale) at 4, 8, 12, and 24-months. Primary H2: CBHH+SMT and CBHH+AT compared to CBHH alone, will be associated with greater reduction in risk of early mortality (as measured by the Avoidable Mortality Risk Index) and (Exploratory E2) in psychiatric symptoms (BPRS) at 4, 8, 12, and 24 months. Primary H3: CBHH+SMT and CBHH+AT compared to CBHH alone, will be associated with less acute service use (emergency room visits and hospitalizations) and (Exploratory E3) less acute service use costs at 4, 8, 12, and 24-months. In order to differentiate CBHH+SMT and CBHH+AT if both are found to be effective, we will evaluate the persistence of primary outcomes from intervention endpoint (at 12 months) to the final follow-up (at 24 months) and will calculate the additional incremental costs of implementing and providing SMT and AT. We will also explore differences in subjective health (SF-12) and in individual cardiovascular risk factors (e.g., BMI, tobacco use, blood pressure, glucose, lipids), comparing CBHH+SMT, CBHH+AT, and CBHH alone. Finally, we will explore hypothesized mechanisms of action (potential mediators) for the Aim 2 primary outcome of reduced risk of early mortality (i.e., improvement in health self-management) and for the Aim 3 primary outcome of less acute service use (i.e., medication adherence and number of nurse preemptive interventions).