Diabetes Screening, Risk Management and Disease Management in a High-Risk Mental Health Population

Family physicians are the primary health care providers for complex patients such as persons with serious mental illness. The psychiatric needs of these patients could take attention away from management of health problems and from usual health promotion services. For example, Schizophrenia is associated with a higher than normal incidence of diabetes, and first line treatments of Schizophrenia have also been found to increase risk for diabetes. As such, this high-risk group requires targeted diabetes strategies. In London Ontario, services are provided to this high risk mental health population primarily by two community agencies: The Western Ontario Therapeutic Community Hostel (WOTCH) and the Canadian Mental Health Association (CMHA). Accordingly, the goal of this project is to assess how these patients are currently being managed by their family physicians and to pilot a community-based, multidisciplinary diabetes clinic model within this population. If this delivery model proves feasible and effective, family physicians could be assisted by existing community agencies in the management of their patients’ diabetes and patients will receive improved access to this vital multidisciplinary team.