Department of Psychiatry, Weill Institute for Neurosciences, UCSF at Zuckerberg San Francisco General (ZSFG), 1001 Potrero Avenue, 7M8, San Francisco, CA, 94110, USA.
UCSF Center for Vulnerable Populations at ZSFG, San Francisco, CA, USA.
Implement Sci. 2017 Nov 14;12(1):134. doi: 10.1186/s13012-017-0663-z.
Individuals with severe mental illness (e.g., schizophrenia, bipolar disorder) die 10-25 years earlier than the general population, primarily from premature cardiovascular disease (CVD). Contributing factors are complex, but include systemic-related factors of poorly integrated primary care and mental health services. Although evidence-based models exist for integrating mental health care into primary care settings, the evidence base for integrating medical care into specialty mental health settings is limited. Such models are referred to as "reverse" integration. In this paper, we describe the application of an implementation science framework in designing a model to improve CVD outcomes for individuals with severe mental illness (SMI) who receive services in a community mental health setting.
Using principles from the theory of planned behavior, focus groups were conducted to understand stakeholder perspectives of barriers to CVD risk factor screening and treatment identify potential target behaviors. We then applied results to the overarching Behavior Change Wheel framework, a systematic and theory-driven approach that incorporates the COM-B model (capability, opportunity, motivation, and behavior), to build an intervention to improve CVD risk factor screening and treatment for people with SMI.
Following a stepped approach from the Behavior Change Wheel framework, a model to deliver primary preventive care for people that use community mental health settings as their de facto health home was developed. The CRANIUM (cardiometabolic risk assessment and treatment through a novel integration model for underserved populations with mental illness) model focuses on engaging community psychiatrists to expand their scope of practice to become responsible for CVD risk, with significant clinical decision support.
The CRANIUM model was designed by integrating behavioral change theory and implementation theory. CRANIUM is feasible to implement, is highly acceptable to, and targets provider behavior change, and is replicable and efficient for helping to integrate primary preventive care services in community mental health settings. CRANIUM can be scaled up to increase CVD preventive care delivery and ultimately improve health outcomes among people with SMI served within a public mental health care system.
患有严重精神疾病（如精神分裂症、双相情感障碍）的个体比一般人群早逝 10-25 年，主要死于过早的心血管疾病（CVD）。促成因素较为复杂，但包括初级保健和精神卫生服务整合不佳的系统性因素。尽管存在将精神卫生保健纳入初级保健环境的循证模式，但将医疗保健纳入专业精神卫生环境的循证模式有限。这种模式被称为“反向”整合。在本文中，我们描述了在设计一种模型以改善在社区心理健康环境中接受服务的严重精神疾病（SMI）个体的 CVD 结局时，应用实施科学框架的情况。
使用计划行为理论的原则，我们进行了焦点小组讨论，以了解利益相关者对 CVD 风险因素筛查和治疗的障碍的看法，确定潜在的目标行为。然后，我们将结果应用于总体行为改变车轮框架，这是一种系统且基于理论的方法，其中包含 COM-B 模型（能力、机会、动机和行为），以构建改善 SMI 人群 CVD 风险因素筛查和治疗的干预措施。
根据行为改变车轮框架的逐步方法，开发了一种针对使用社区心理健康设置作为事实上的健康之家的人群提供初级预防保健的模型。CRANIUM（通过针对患有精神疾病的服务不足人群的新型综合模型进行心血管代谢风险评估和治疗）模型侧重于使社区精神科医生参与进来，扩大其实践范围，使其对 CVD 风险负责，并提供重要的临床决策支持。
CRANIUM 模型是通过整合行为改变理论和实施理论设计的。CRANIUM 易于实施，高度可接受，针对提供者行为改变，并且对于帮助整合社区心理健康环境中的初级预防保健服务具有可复制性和高效性。CRANIUM 可以扩大规模，以增加 CVD 预防保健的提供，最终改善公共精神卫生保健系统中服务的 SMI 人群的健康结局。
