Chronic Condition Toolkit


Behavioral Health Provider Toolkit Overview

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In alignment with the mission and values of Gateway Health, promoting Wholecare which is a whole health model of care in which an individual’s health and well-being is supported across behavioral, physical, and environmental factors. Gateway Health is committed to promoting integrated care and to build bridges with behavioral health practitioners in an effort to improve care coordination and member health outcomes.

To support behavioral health providers in supporting care coordination for their patients, Gateway Health has developed a Behavioral Health Provider Toolkit.

Purpose:

  • Improve health outcomes for the vulnerable Seriously Mentally Ill (SMI) population
  • Decrease health inequities and disparities that are prevalent in the SMI population
  • Address the multi-factorial challenges associated with the care and treatment of chronic conditions

Mental health and physical health are fundamentally linked. People living with a serious mental illness are at higher risk of experiencing a wide range of chronic physical conditions. Conversely, people living with chronic physical health conditions experience depression and anxiety at twice the rate of the general population. Co-existing mental and physical conditions can diminish quality of life and lead to longer illness duration and worse health outcomes. This situation also generates economic costs to society due to lost work productivity and increased health service use.

Understanding the links between mind and body is the first step in developing strategies to reduce the incidence of co-existing conditions and support those already living with mental illnesses and chronic physical conditions1 .

The toolkit contains helpful information about some of the most common chronic health conditions. We encourage you to use this toolkit when discussing your patients health needs.

  • Diabetes
  • Cardiovascular Disease
  • Hypertension
  • Pregnancy and Postpartum period
  • COPD
  • Asthma

Research2 recommends the use of interventions with characteristics associated with better outcomes:
In SMI patients:

  • Longer duration (three or more months)
  • Manualized, structured approach
  • Focus on both health education and physical activity
  • Active monitoring such as weigh-ins and food diaries
  • Active monitoring of physical activity and fitness levels

In patients from the general population:

  • Use of multiple components (eg, diet, exercise, and behavioral therapy)
  • Personalization  
  • More frequent contact
  • Training for treatment providers

Recommendations for metabolic risk factor monitoring in patients with severe mental illness or on antipsychotic medication

Risk factor

Timing of assessment

First year of antipsychotic

Ongoing monitoring*

 Baseline

6 weeks

3 months

12 months

Quarterly

Annually

Personal and family history of diabetes, hypertension, or cardiovascular disease

X

X

Smoking status, physical activity, diet

X

X

X

X

Weight, body mass index

X

X

X

X

Blood pressure

X

X

X

X

Fasting glucose or HbA1c

X

X

X

X

X

Lipid profile (fasting or non-fasting)

X

X

X

X

Questions?

Contact our Provider Services.

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