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

描述（由申请人提供）：降低严重精神疾病（SMI）患者早期死亡率的努力主要集中在“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，医疗保健本身对降低早期道德的贡献不成比例地小。一般人群的疾病自我管理培训（SMT）已被证明可以改善健康结果并降低与慢性健康状况相关的成本，方法是教授和指导个人监测症状，自我管理治疗和改善健康行为。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，并可能通过日常提示自我管理和远程监控来防止普通人群中昂贵的急诊室和急性住院治疗，护士可以在疾病管理算法的指导下进行先发制人的干预。据我们所知，这两种方法都没有被经验性地评估为SMI患者行为健康之家的综合组成部分。我们提出了一项随机对照试验，对300名患有SMI和医疗合并症的患者进行评估，以评估仅在社区健康之家（CBHH）中的n = 100名患者的结局，与接受自我管理培训（CBHH+SMT）的n=100名患者和接受自动远程医疗（CBHH+AT）的n=100名患者进行比较。我们将检验以下3个假设：主要H1：CBHH+SMT和CBHH+AT与单独CBHH相比，将与4、8、12和24个月时更好的健康自我管理（通过健康实践量表的自测能力测量）和（探索性E1）更好的心理健康自我管理（通过疾病管理和恢复量表测量）相关。H2：与CBHH单药治疗相比，CBHH+SMT和CBHH+AT将使第4、8、12和24个月时的早期死亡（通过避免死亡风险指数测量）和精神症状（BPRS）（探索性E2）风险降低更大。H3：与CBHH单药治疗相比，CBHH+SMT和CBHH+AT在第4、8、12和24个月时的急性服务使用（急诊室访视和住院）和（探索性E3）急性服务使用成本较低。为了区分CBHH+SMT和CBHH+AT（如果发现两者均有效），我们将评价从干预终点（12个月）到最终随访（24个月）的主要结局的持续性，并计算实施和提供SMT和AT的额外增量成本。我们还将探讨主观健康状况（SF-12）和个体心血管危险因素的差异 (e.g., BMI、烟草使用、血压、葡萄糖、脂质），比较CBHH+SMT、CBHH+AT和单独CBHH。最后，我们将探讨降低早期死亡风险的目标2主要结局（即，改善健康自我管理）和目标3的主要结果，即不太紧急的服务使用（即，药物依从性和护士先发制人干预的次数）。

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).