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Collaborative centre for cardiometabolic health in psychosis - integrating traditional healthcare to meet the needs of the mental health population


Nicholas Brisbane ,

Sydney Local Health District, AU
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Kathleen Smith

Sydney Local Health District, AU
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Introduction/Practice Change/Aim:  Rates of cardiovascular disease and its related co-morbidities in those with severe mental illness are disproportionately high. Those suffering from a severe mental illness are six times more likely to die from cardiovascular disease, four times more likely to die from respiratory disease, and overall likely to die 14-23 years earlier than the general population (Holt and Mitchell, 2015; Australian National Mental Health Commission, 2017). The Collaborative Centre for Cardiometabolic Health in Psychosis (ccCHiP) delivers an innovative service that provides a model of integrated care for the assessment and management of cardiometabolic health in those with a severe and enduring mental illness to reduce the disparity in life expectancy between the mental health and general population.

Targeted Population: As demonstrated between the Duty to Care report in 2001 and the Australian National Report on Mental Health and Suicide Prevention in 2017, the prevalence of those with a mental illness developing cardiometabolic risk factors leading to premature mortality is increasing which would indicate the limitations of traditional services delivery. Using a ‘one-stop-shop’ model, ccCHiP integrates multiple services and clinicians to provide a clinic in one afternoon to improve accessibility to a population who would otherwise have engagement and adherence challenges whilst bridging ‘traditional service delivery models’. This includes the collaborative efforts between a psychiatrist, cardiologist, endocrinologist, exercise physiologist etc. Further interactive information can be viewed via (Further discussed in Kritharides et al, 2017).

Timeline: Since implementation in 2014, ccCHiP has reviewed 26.5% of the community care coordinated mental health consumers. This comprises over 1,000 individuals, and over 40% returning for a follow-up appointment. Additionally, referrals from General Practitioners have increased by 278% and 450% from the Primary Health Network and Non-Government Organisations. Average attendance at the clinic has been 80% in a population that typically may have challenges with engagement and adherence challenges.

Sustainability: ccCHiP has proven sustainability through inclusion within standard practice of the local health network and being a catalyst for a local Mental Health/General Practitioner Shared Care Agreement. Under this agreement, consumers are linked in with a General Practitioner and ccCHiP provides the annual physical health check, providing a detailed report to the primary care providers with recommendations for improvements.

Transferability: The clinic has successfully scaled internally from one weekly outpatient, to support a second at an alternate location with a current outlook for a third weekly clinic rotating amongst the Community Health Centres. A component of success is the robust IT integration whereby patient information, pathology, and medications are automatically shared between both state-wide and private organisations. The transferrable framework has also resulted in the establishment of a parallel ccCHiP unit in Santiago, Chile.

Lessons Learned: Lessons learned throughout development comprise; an integrated care approach is required to bridge traditional service delivery in order to meet a complex cohort with growing needs; appropriate training and education can alleviate resistance to change; and allocation of a dedicated position can influence change management and drive culture change to support integrated care models and strengthen partnerships.

How to Cite: Brisbane N, Smith K. Collaborative centre for cardiometabolic health in psychosis - integrating traditional healthcare to meet the needs of the mental health population. International Journal of Integrated Care. 2019;19(4):375. DOI:
Published on 08 Aug 2019.


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