Program Meshing Mental Health, Primary Care Meets Key Goals

Integrating primary care and mental health services for psychiatric patients has improved overall patient health, reduced use of the emergency department, and facilitated compliance with psychiatric treatment at Kings County Hospital Center in Brooklyn, N.Y.

So said clinicians and administrators at the hospital who presented the symposium “Designing a Medical Home Within the Psychiatric Continuum of Care” at APA’s 2011 Institute on Psychiatric Services in San Francisco in October. The presentation was one of many in a special integrated-care track.

They described the establishment in 2010 of the Behavioral Health Primary Care Clinic (BHPCC), a mental health outpatient clinic that employs full-time primary care physicians as well as mental health clinicians, promoting collaborative relationships across disciplines and allowing primary care and mental health appointments to be scheduled the same day in a single site (see Psychiatry, Primary Care Leaving Silos).

The BHPCC has made special use of peer counselors—psychiatric patients in recovery—to provide counseling to patients. The clinic has also served as a training site for psychiatry residents to gain increased awareness of the impact of medical comorbidities on psychiatric treatment and potentially for internal medicine residents to gain experience in managing psychiatric patients who have other medical comorbidities.

Joseph Merlino, M.D., M.P.A., deputy executive director and director of psychiatry at the hospital, and others who spoke at the symposium said that the clinic has substantially reduced the use of the emergency department as well as the “no-show” rate for patients referred from inpatient care and for follow-up visits after an initial evaluation in the outpatient clinic. They presented evidence of dramatic improvements—in weight, lipid measurements, and diet and lifestyle—for individual patients.

The results presented by Merlino and colleagues represent a stunning turnaround for a hospital that had been the focus of a 2007 suit over deficiencies in psychiatric care and the object of national news when a video posted on the Internet showed a patient dying unattended on the floor of the psychiatric emergency department.

Merlino told Psychiatric News that the hospital has worked for over three years to enact reforms aimed at creating a 21st-century model of integrated psychiatric and primary care. He noted that on the inpatient side, a special focus at Kings County has been the use of behavioral health associates instead of hospital police and a behavioral support team for challenging patients, as well as the provision of preand postnatal care for pregnant women with serious psychiatric illness.

“We have very much adopted wellness and recovery as a philosophy of care, and as part of that we very much believe in patient-centered care and a true biopsy-chosocial model of treatment,” he said.

David Estes, M.D., an internist who is director of behavioral health-medical services at Kings County, said at the institute that establishment of the BHPCC was driven by the high rate of metabolic problems among psychiatric patients as well as the large number of no-shows among patients referred to primary care. A three-month analysis of follow-up prior to the creation of the BHPCC showed that of 60 referrals of psychiatric patients to the hospital’s standard primary care clinic, only seven patients were seen for a scheduled first visit, and most of those were never seen for follow-up.

“Our goal was to create a clinic where we would no longer have that fragmented care, and we would be in one site,” Estes noted. “We wanted to improve communication between primary care and behavioral health providers, and we were looking for primary care clinicians who were comfortable dealing with psychiatric patients and who had a keen eye for the metabolic problems our psychiatric patients have.”

Following establishment of the clinic, the show rate for initial visits after referral from other areas of the hospital increased from 12 percent to 45 percent, with 59 percent of patients scheduled for follow-up returning to the clinic, Estes said.

He added that a third of patient contacts in the BHPCC are walk-in visits. “Patients love coming to the clinic,” Estes said. “They are looking for their doctor, and it’s great because they are not using the emergency room. Our physicians know the patients and will give them the time of day.”

He said a typical first visit is 45 to 60 minutes or more, compared with 30 minutes in the hospital’s standard primary care clinic, and a follow-up visit is 20 to 30 minutes or more.

“Our patients have so many things wrong,” he said. “Once you start asking questions, you find out they have been totally neglected, so it’s a matter of catching up with all the things that haven’t been addressed. And that takes time.”

Estes presented data on individual patients showing remarkable improvements on important measures of physical health: through dietary and lifestyle education, one patient’s total cholesterol level dropped from 251 to 209 between October 2010 and September 2011, while triglycerides dropped from 469 to 185 and weight dropped from 124 kg to 108 kg.

One other ingredient is important: the involvement of family members in patient care. “The family is such an important asset. Family members can encourage the patient to be compliant with therapy, and if the patient is compliant with medical therapy, he or she tends to be more compliant with psychiatric treatment.”

A video about the BHPCC is posted at <www.nyc.gov/html/hhc/kchc/media/video/kchc-behavioral-health-center.asx>.

Psychiatry, Primary Care Leaving Silos

When David Estes, M.D., finished his residency at Kings County Hospital in internal medicine in 1987, he expected to enter a conventional private practice.

“There was a position in psychiatry for a consultant, and I decided to give it a try,” he recalled. “I had never been exposed to psychiatry en masse, and I found it fascinating. Primary care medicine is all about numbers and physical examinations, but in psychiatry it’s about connecting with the patient. If you don’t make that connection, you can’t have a successful treatment.”

Estes is among a growing cadre of physicians who recognize the imperative of integrating those traditionally disparate elements—the physical examination with its target numbers and the emotional connection with patients that is native to psychiatry—in the treatment of not only psychiatric patients but the general medical population. Estes and colleagues at Kings County Hospital presented the symposium “Designing a Medical Home Within the Psychiatric Continuum of Care,” which was part of the special integrated care track at APA’s 2011 Institute on Psychiatric Services in San Francisco in October.

In an interview with Psychiatric News, Estes acknowledged that for many internists, psychiatric patients can be a challenge. “When I started doing work with psychiatric patients, I realized that every patient was a puzzle,” he said. “They wouldn’t necessarily tell you what was wrong, so you couldn’t rely on the physical examination alone. You had to develop trust with patients because if they don’t believe in what you are selling, they aren’t buying it.”

He added, “If a patient has diabetes or hypertension, the treatments are the same from patient to patient. In psychiatry it’s much more complicated; the treatment is going to change depending on the patient.”

Estes said that he has seen a turning of the tide toward integrated care in recent years. “In 1987, psychiatry was so siloed. Psychiatry did its thing and didn’t want to know about anything else that was happening with the patient medically. But as new people have come into the field, there are more and more signs of people thinking about the medical aspects of care.”

For psychiatry residents who rotate through the Kings County Behavioral Health Primary Care Clinic, the experience is an eye-opener. “We want these residents to know that it’s all about taking care of the mind and the body, and it does make an impact,” he said. “They buy into the idea, and these same residents also work in our psychiatric emergency room, with an eye toward addressing patients’ medical issues as well as their psychiatric illness.”

He added, “I can tell they begin to look at patients in a new way.”