Innovations Planned for MH Care Include ‘One-Stop Shopping’

“If I can make it there, I'll make it anywhere” goes the song about New York City.

When psychiatrist Lloyd Sederer, M.D., left his post in 2007 as executive deputy commissioner for mental hygiene in the city's Department of Health and Mental Hygiene, he took with him a strategy for mental health system reform that reaped results garnering front-page coverage in the New York Times.

Now, Sederer—who was director of APA's Division of Clinical Services from 2000 to 2002—hopes to have the same success as medical director of the New York State Office of Mental Health (OMH). His strategy for success is one that consists of identifying measurable goals for incrementally closing the gap between needs and evidence-based services—or as Sederer put it in the title of his APA Administrative Psychiatry Award Lecture in October at the 2009 Institute on Psychiatric Services, between “what we know and what we do” in public mental health.

During his tenure in New York City, Sederer was part of a team that reached agreement with the city to dramatically expand the availability of supported housing for homeless individuals with mental illness, including substance abuse, and other high-needs populations by 9,000 units. The department under his leadership also initiated a project to bring depression screening to every primary care practice in the city; the latter effort reaped front-page coverage in the New York Times on April 7, 2005 (and in Psychiatric News in the May 20, 2005, issue).

Now, as medical director of a $4 billion-a-year agency that serves 700,000 people annually in 26 state psychiatric hospitals, 60 clinics, and 2,500 community-based programs licensed and regulated by the state of New York, Sederer has established equally ambitious goals: integration of mental health treatment with general medical care and integration of mental health and alcohol and substance abuse treatment. (The OMH has also undertaken an initiative to reduce psychotropic prescribing practices that are considered “clinically questionable”; see 'OMH Takes Steps to Improve Prescribing Practices' and 'Questionable Prescribing Practices Have Officials Searching for Answers').

These are goals that express a belief in the effectiveness of government to improve public health.

“My experience in New York City was one that showed that government can work,” he told Psychiatric News. “I still hold that view. Not that it can work anywhere and everywhere, but government has the levers to facilitate change. It was very fulfilling to be part of an opportunity to move the needle on large-scale public mental health interventions and to close the gap between what we know and what we do.

“When government takes a leadership role and is not afraid to act in a progressive way, then lives can be improved and money more sensibly expended.”

What Gets Measured Gets Managed

In January of last year, 60 outpatient mental health clinics operated statewide by the OMH and servicing some 15,000 individuals with serious mental illness began collecting, reporting, and monitoring body mass index (BMI), blood pressure (BP), and smoking status in all adult patients.

A parallel health-monitoring initiative has recently been extended to children and adolescents in OMH programs.

The initiatives are in response to now widely disseminated data showing that comorbid medical factors—especially cardiovascular risk factors and metabolic syndrome—are heavily implicated in the fact that patients with serious mental illness die on average 25 years earlier than healthy individuals in the general population.

“What gets measured gets managed,” said Sederer, explaining why he believes that attention to BMI, BP, and smoking in adults will inevitably lead to better quality and longer duration of life for patients. “This is a response to the fact that the quality of many of our patients' lives is more dependent on their diabetes than on their hallucinations. Many of our patients are seeing their friends die.”

Better Integration Needed

Sederer also believes that better integration of general medical care and mental health care, though it challenges conventional practice, is a step toward enhancing the status and morale of the 750 psychiatrists and approximately 100 internists who work in OMH clinics.

“My view is that in too many ways the patients in our public service system have been stigmatized, and the doctors have felt on the low end of the totem pole,” he said. “We have an opportunity to appeal to the moral sensibilities and professional pride of OMH clinicians by providing quality tertiary care to people with serious mental illness who also have other medical illnesses. It's a way of appealing to the highest goals of professional caregivers.”

Somewhat more complex is the plan under way to ensure screening, assessment, and integrated treatment for patients with co-occurring mental illness and substance use disorders. This is a collaborative effort by clinics of the OMH and the state's Office of Alcoholism and Substance Abuse Services (OASAS), some 1,200 in all.

“After too many years of knowing that people with co-occurring mental health and substance use disorders are not getting care that works, we are changing that,” Sederer said. “We want to create ‘no wrong door’ for people seeking care and to provide integrated care in one place—one-stop shopping—since anything less has been proven futile.”

It will be aided by changes to the state's Medicaid ambulatory reimbursement policies beginning April 2010 that will allow payment for separate treatment services on the same day in the same facility, as well as enhanced rates for care provided by psychiatrists. Technical assistance for clinic directors and clinical staff in both OMH and OASAS clinics on how to provide screening, assessment, and integrated treatment is being provided by the New York State Psychiatric Institute and by the NYS Health Foundation—supported Center for Excellence in Integrated Care.

“This is a matter of aligning the competencies of the two agencies to provide treatment for both conditions in the same place,” Sederer said.

He credits the state's progressive moves in part to the arrival of Michael Hogan, Ph.D., as commissioner of mental health. It was Hogan who chaired the President's New Freedom Commission on Mental Health whose 2003 report to President George Bush recommended fundamental transformation of the nation's approach to mental health care to actively facilitate recovery, rather than merely manage symptoms.

“I can think of no more transformative commissioner,” Sederer said of Hogan. “He has realized that for all the state is spending [on mental health and substance abuse], it was not really getting what it should.”

Success of public mental health efforts at both the local and state levels has depended on what Sederer calls the “three-legged stool”—the combined support of clinical, moral, and economic suasion.

“If you rest on just one or two of those legs, you wind up on the floor,” he said. “Gathering the scientific evidence to make the clinical case is clearly [psychiatrists'] job—no one else can do that.

“But it doesn't stop there,” he said. “That's a ‘head’ argument and people are not always swayed by that alone. You also have to reach the heart—that's the moral argument about what communities should do for their fellow human beings.

“The economic argument is the one that is instrumental to the tumblers falling into place,” he said. “Once you have moral and clinical suasion, someone is going to look at your proposal with a high-power microscope and ask, ‘What is this going to cost?’ The economic argument is a matter of being able to say, ‘Here's what we are spending now, and here's how we can spend it better.’”