Abstract
Introduction: Despite high prevalence rates of excess mortality and morbidity among adults with type 2 diabetes (T2DM) and severe mental illness (SMI), little is known about non-pharmacological integrated interventions that target T2DM and SMI comorbidity in specialist mental health services.
This study used qualitative methods (semi-structured individual interviews, non-participatory observations, and focus groups) to:
1) explore mental health service users' and clinicians' experiences of care for adults living with T2DM and SMI comorbidity and its integration at clozapine clinics;
2) identify key areas for quality improvement within the services
Methods: Service users with a diagnosis of T2DM and SMI and clinicians across two NHS clozapine clinics in London were invited to participate. Three Public and Patient Involvement groups that included members living with T2DM and SMI were consulted during the development of the research proposal and data analysis. One researcher conducted observations of daily practice in the clinics to gain insights into service user and staff perspectives of healthcare integration. Field notes of observations in during consultations, team meetings and in clinic waiting areas were taken. Individual interviews and a separate service user and clinician feedback focus group were conducted to explore participants’ experiences of healthcare integration and identify their health priorities. Observational and focus group data were analysed using reflexive thematic analysis. The Theoretical Domains Framework was also used as a coding framework to analyse interview data to identify barriers and enablers to implementing integrated care.
Results: Barriers to accessing holistic care at the clozapine clinics included lack of continuity of care between community primary and secondary providers, limited confidence in providing diabetes support and limited awareness of service users’ diabetes needs. Factors reported to contribute to service users' positive experiences of integrated mental and physical healthcare included clinicians’ competency in assessing health risks, the quality of therapeutic relationships, and enhanced communication systems across providers. Priority areas for improvement across the services focused on enhancing clinicians’ diabetes competency, and increasing practical support for service users to remain engaged with their primary care providers.
Conclusion:
Findings from this study point to several implications for improving healthcare integration for service users with T2DM and SMI comorbidity within specialist mental health services. Embedding holistic and recovery-oriented care practices to streamline the integration of mental and physical healthcare, reduce health inequalities and promote personal recovery requires attention from policy makers, commissioners, senior management, service designers, researchers, and healthcare professionals.