Cordula Holzer, M.D., knew she faced a challenge when she became Horizon House's first medical director in 1999.

The agency's staff took justifiable pride in a stellar reputation for psychosocial rehabilitation. Until Holzer's arrival, however, Horizon House had primarily contracted for psychiatric services or depended on traditional community mental health centers (CMHCs) to prescribe medication.FIG1

How could she persuade the staff that on-site psychiatrists could enhance services without diminishing the importance of their psychosocial approach to treatment?

Holzer's views about community psychiatrists no doubt helped. She said," We've always looked at patients in a holistic way. We know people are more likely to get better if they have something meaningful to do. I always ask, `How can we help you get your life back together?'"

She also recognized the importance of demonstrating value. "I tell my staff that it's up to us to show that we have something to offer."

Holzer pointed out, for example, that on-site psychiatrists could take care of crises and nonpsychiatric medical problems. They would be available to prescribe medications when a patient needed them on Friday afternoon, for example.

Her common-sense approach to organizational change was not always easy to implement.

Finding psychiatrists who were willing and able to work as team members was difficult.

Typical residency programs do not foster the kinds of skills necessary to work in a team, she said. In fact, psychiatrists frequently graduate with a belief in the power of a medical hierarchy that makes it difficult for them to respect the contributions of other team members.

Those new psychiatrists often do not understand a cardinal rule for practice at CMHCs. "Don't irritate the case manager," Holzer said." Case managers have a lot of power in terms of what happens to patients and a lot of knowledge about their histories."

She realized that one new hire was not going to work out when he insisted on hospitalizing a patient despite the unanimous opposing opinion of other team members who had known the patient for a longer period.

Holzer developed her ability to integrate medicine and psychosocial rehabilitation the old-fashioned way. She watched someone else.

"I saw what Derri Shtasel, M.D., did at Friends Hospital in Philadelphia and tried to mirror her behavior," she said.

Shtasel was director of community psychiatry at that hospital and is now director of adult psychiatry at the Cambridge Health Alliance.

Holzer also recognized the value of creating a situation in which psychiatrists will want to work.

"Nobody here just does med checks," she said. "Each doctor knows that he or she will have the amount of time that is clinically necessary for each patient."

Holzer will not permit the practice of double-booking appointments, which commonly is used to address the costly problem of "no-shows."

Patients know that if they appear on time, they likely will not need to wait to see their psychiatrist. The result is a no-show rate of only 22 percent. Holzer believes that the rate for other clinical settings in Philadelphia is about twice that, based on anecdotal evidence from medical directors.

Holzer's commitment to her staff, in turn, is dependent upon a commitment from Jeff Wilush, Horizon House's chief executive officer, to whom she reports.

She has hired 10 psychiatrists since arriving in 1999 and added three psychiatric nurses.

Successful integration of good medicine and psychosocial supports occurs in a very concrete fashion at the agency's Clozaril clinic.

The antipsychotic Clozaril (clozapine) can be effective in treating schizophrenia and other serious mental illnesses. Safe use of the medication, however, requires regular blood tests that patients frequently resist. Betty Borgmann, R.N., believes that the best way to ensure that patients show up for those tests is to make them want to come to the clinic.

"We quickly learn each patient's name," she said. "They know they will see the same people each time they come. Continuity is important."

Patients are given some flexibility about when to show up for a test. If they exceed a time interval considered safe, however, case managers immediately try to reach them.

Borgmann shows a film about Clozaril to educate patients about the medication and their illness. She offers stress reduction and meditation classes.

The medication-compliance rate in the clinic is 95 percent; 87 patients are enrolled.

Not surprisingly, Holzer strongly believes in the importance of encouraging promising residents to go into community psychiatry and has spoken to various residency classes in the Philadelphia area about the field.

"Many residents have had discouraging experiences at other community mental health centers," she said. "They would see a miserable psychiatrist, inundated by repeated crises, and often relegated to med checks and would get turned off by the field."

Holzer is doing what she can to overcome that stereotype by offering four PGY-3 residents from the University of Pennsylvania Medical School a 12-month rotation. ▪