Psychiatrist Focuses on Populations in Health Delivery Services

Benjamin Druss, M.D.

As a public-health expert and a health-services researcher, Benjamin Druss, M.D., is something of a rarity for a psychiatrist.

Trained initially in both primary care and psychiatry, he began his clinical work as a consultation-liaison psychiatrist and soon realized that in many cases—and especially for patients in the public mental health system—the problems that patients were confronting went beyond the traditional clinical skills for which he was trained.

“As a clinician, what brought me to thinking about system-level issues was the fact that it seemed as though what I was trained for was not matching up with what I needed to be doing for patients,” he said. “Deciding what dose of risperidone a patient should be on was the easy part. But getting them a follow-up appointment if I saw them in the emergency room was a problem. I just didn’t feel like I could do it alone, and I realized that many of these problems required fixes at the system level.”

It’s a phenomenon he says he sees in young psychiatrists today. “I was talking recently to residents working in a community mental health center,” he told Psychiatric News. “I think a lot of them were feeling overwhelmed by what they were doing. What they were trained to do and competent to do at this point was to write prescriptions for psychiatric medications and do psychotherapy. But that didn’t really match up with what their patients needed, many of whom were coming with enormous stresses in their lives—abuse, homelessness, and other psychosocial issues.”

So following his residency, Druss received a public-health degree at Yale and spent 10 years there as a health-services researcher. In 2003, Druss came to Emory University in Atlanta, where he has become a leading researcher in integrated care. But while many of the thought leaders of this movement have focused on bringing mental health services to the primary care setting for patients with chronic medical conditions, Druss has specialized in bringing primary care services to individuals with serious and persistent mental illness in the public sector.

His perspective has caused him to look beyond simply merging mental health and primary care to a broader vision that can include a range of social and rehabilitative services—and for that reason, Druss said that he prefers the term “population-based care.”

“We call it integration,” he said, “but what we really mean to do is to make sure that patients get all the kinds of services they need and that those services extend across whole populations of people, even those who aren’t presenting for services.”

Program Provides Greater Access

At Emory, Druss’s research has been a mix of mining large datasets for information about health-service utilization patterns and intervention studies focused around the issue of improving physical health and health status in people with serious mental illness.

An example of the latter is the PCARE (Primary Care Access, Referral, and Evaluation) model, which employs a medical nurse/care manager to provide education and care coordination to help patients with serious and persistent mental illness engage in primary care.

In a study published in the American Journal of Psychiatry, care managers provided communication and advocacy with medical providers, health education, and support services in overcoming system-level fragmentation and barriers to primary medical care. At a 12-month follow-up evaluation, the intervention group received an average of 58.7 percent of recommended preventive services compared with a rate of 21.8 percent in the usual-care group. They also received a significantly higher proportion of evidence-based services for cardiometabolic conditions and were more likely to have a primary care provider.

“Several features of the PCARE study management model make it an appealing approach for community mental health clinics seeking to improve their patients’ medical care,” Druss and colleagues wrote. “Compared with co-located approaches, care management is relatively inexpensive to implement and practical for even relatively small sites that do not have the financial or staffing resources to establish fully functioning medical clinics on site. Existing mental health care managers can be retrained to add medical services to their scope of activities. Finally, a rationale for CMHCs to address primary care services among their clients may be provided by the fact that improving medical care might be associated with better mental health outcomes.”

Future Is Population-Based Care

Another ongoing project is the HOME (Health Outcome Management Evaluation) Study, which involves a partnership between a federally qualified health center in Atlanta and a local community mental health center (CMHC). The health center has set up a satellite clinic in the CMHC and employs team-based care for patients with serious mental illness and one or more active cardiometabolic problems (such as diabetes, hypertension, and hyperlipidemia). The study uses standardized, validated instruments to assess the impact of integrated community care on quality and outcomes of cardiometabolic and general medical care.

Such projects may seem visionary, but Druss echoes other leaders in the integrated/collaborative care movement in urging individual psychiatrists to reach out to their own hospitals and health systems to offer their unique expertise in the care of patients across the medical spectrum.

“One of the clear lessons that came out of work in this area is that policymakers and administrators trust their own data,” Druss said. “They are not particularly interested in whether something works in some abstract sense or in a randomized, controlled trial done someplace else. What they are most interested in is looking at their own data and understanding which ones are the high-cost patients—and those are invariably patients with comorbid mental conditions.”

And what does the future look like? “One broad theme of what is going on now and is likely to continue is the move to population-based care delivery,” Druss told Psychiatric News. “That’s the common thread through medical homes, accountable care organizations, and other movements today. They are all about improving care across populations.” ■