for people ages 18 years and up (full criteria)
at San Diego, California and other locations
study started
estimated completion



People with serious mental illness have difficulty making good use of primary care, and die, on average, years earlier than others in the population. The greatest contributors to this premature mortality are medical illnesses, especially cardiovascular disease and cancer. The Patient Centered Medical Home is a model for reorganizing primary care practice so that healthcare is more effective, efficient, and user-friendly. It has been implemented across VA as the, "Patient Aligned Care Team" (PACT). It is unclear, however, how this PACT model applies to people whose predominant illness is treated by specialists. This is the case for people with serious mental illness (SMI), many of whom receive ongoing treatment at mental health clinics. To achieve optimal health outcomes in the population with SMI, it may be necessary to adapt the PACT model so that it includes approaches that have proven to improve healthcare in this population. This project implements an adapted "SMI-PACT" model, and evaluates its effect on Veterans with SMI.

Official Title

PACT to Improve Health Care in People With Serious Mental Illness (SMI-PACT)



People with serious mental illness (SMI) die, on average, many years prematurely, with rates of premature mortality 2 to 3 times greater than the general population. Over 60% of premature deaths in this population are due to "natural causes," especially poorly treated cardiovascular, respiratory, and infectious diseases. Although the VA is a centrally organized, comprehensive healthcare system, Veterans with SMI still have difficulty navigating the system, and are at substantially elevated risk for premature death. Too often, they do not attend scheduled appointments or fail to engage in primary care treatment, and consequently do not get valuable preventive and primary care services.

Primary care in VA has undergone significant transformation under the Patent Aligned Care Team (PACT) model, which is based on the Patient Centered Medical Home (PCMH) concept. PACT has the goal of improving the quality, efficiency, and patient-centeredness of primary care. But it remains unclear how PACT will impact the large populations of Veterans whose predominant illness is treated in specialty settings, such as people with SMI. Research can inform efforts to apply the PACT model. For example, while people with SMI do poorly with usual primary care arrangements, there is substantial evidence that integrated care and medical care management approaches can improve medical treatment and outcomes, and reduce treatment costs, in people with SMI.


Using available evidence, the investigators propose to implement and evaluate a specialized PACT model that meets the needs of individuals with SMI ("SMI-PACT").


This project will partner with leadership to implement SMI-PACT, with the goal of improving healthcare and outcomes among people with SMI, while reducing unnecessary use of emergency and hospital services. Evidence-based quality improvement strategies will be used to reorganize processes of care. In a site-level controlled trial, this project will evaluate the effect, relative to usual care, of SMI-PACT implementation on (a) provision of appropriate preventive and medical treatments; (b) patient health-related quality of life and satisfaction with care; and (c) medical and mental health treatment utilization and costs. The project includes a mixed methods formative evaluation of usual care and SMI-PACT implementation to strengthen the intervention, and assess barriers and facilitators to its implementation. Mixed methods will also be used to investigate the relationships between organizational context, intervention factors, and patient and provider outcomes; and identify patient factors related to successful patient outcomes.


This project's approach to SMI-PACT is consistent with the VA PACT model, and with efforts in VA to improve care for Veterans with psychiatric disorders. This will be one of the first projects to systematically implement and evaluate the PCMH and PACT concepts for patients with serious mental illness. Should SMI-PACT be demonstrated to be feasible and effective, the model could be used more broadly to improve the quality and efficiency of care for Veterans.


Schizophrenia Spectrum & Other Psychotic DisordersDelivery of HealthcareHealth Services ResearchIntegrated Healthcare SystemsHealthcare Quality, Access, and EvaluationPrimary CareQuality ImprovementPsychotic DisordersMedical HomePsychiatryPatient Care ManagementNursing Care ManagementTreatment CostsSchizophreniaMental DisordersPatient Aligned Care Team (PACT)SMI-PACT


You can join if…

Open to people ages 18 years and up

  • All patient subjects and all staff subjects are currently enrolled in care at one of the 3 sites for this study.
  • All patient subjects will be Veterans.

Patient subjects:

  • The investigators will enroll a random sample of 340 patients who have diagnoses of schizophrenia
  • schizoaffective disorder
  • bipolar disorder
  • chronic PTSD
  • or recurrent major depression with psychosis

Staff subjects:

  • The investigators will enroll approximately 15 staff per site.
  • At each site this will include:
  • 3 members of PACT
  • 4 members of SMI-PACT (intervention site) or mental health integration (control site)
  • 4 providers from the mental health clinic
  • 2 administrators who oversee the mental health clinic (e.g., psychiatry, psychology, nursing, social work, clerks)
  • and 2 administrators who oversee primary care.

You CAN'T join if...

  • Patients will not be excluded based on comorbid mental or medical diagnoses.
  • However, there is a subset of individuals at mental health clinics who are psychiatrically stable and advanced enough in their recovery that they do not require high intensity mental health supports to make effective use of PACT.
  • This will be assessed at baseline by each patient's clinician, using the Milestones of Recovery Scale (MORS)scale.
  • This scale rates an individual's ability to self-manage their care.
  • Patients who rate at "early recovery" or "advanced recovery" on this scale will remain with standard PACT, and are not eligible for SMI-PACT.


  • VA San Diego Healthcare System, San Diego, CA
    San DiegoCalifornia92161United States
  • VA Greater Los Angeles Healthcare System, West Los Angeles, CA
    West Los AngelesCalifornia90073United States


in progress, not accepting new patients
Start Date
Completion Date
VA Office of Research and Development
Study Type
Last Updated