Moving to a medical home care model for people with mental illness means aligning the interests of clinicians and patients, not an easy prospect when care is fragmented and patients have complex problems, said Mark Ragins, M.D., medical director at the MHA Village Integrated Service Agency in Long Beach, Calif.
“Our job is not to treat illnesses; it’s to help people with illnesses lead better lives,” said Ragins in an interview. “The things you have to do to live well with a chronic, serious illness require a comprehensive approach to illness that looks more like a home than a clinic.”
The MHA Village has taken some early steps toward becoming a “mental health home.” The center’s street medicine program sends psychiatric staff out with medical staff from a nearby federally qualified health center to help homeless people and people with mental illness, including substance abuse. More recently, a primary care doctor has begun to serve at the MHA Village one morning a week and works with the Assertive Community Treatment (ACT) team on a second morning.
More broadly, though, a medical home model could learn much from the mental health field, said Ragins.
For instance, the “high utilizers,” who often burden therapists and health care systems alike, can benefit from a committed ACT team, one not easily dissuaded by the patient’s complex medical issues and difficult behavior.
“ACT must be a no-fail program,” he said. “You don’t throw [the patients] out, no matter what.”
The ACT team’s patients often have high levels of suffering and lead chaotic lives, which can burn out staff members unless they unite and rely on each other for support, Ragins said. “Setting up an ACT team forces you to make commitments to individuals you don’t really like and get very involved in their lives.”
Another group of difficult-to-manage patients are those addicted to drugs.
Development of a recovery model for the medical home means making an extended commitment to the patient, says Mark Ragins, M.D.
“We have to confront our own judgment about drug addiction and our lack of acceptance of it,” he stressed. “Then we have to realize our own powerlessness and build a culture of acceptance.”
Ragins pointed out that familiar social determinants of health—poverty, race, bad neighborhoods, poor social or community support—are additional impediments to treating people with chronic illness.
“We don’t treat the sickest of the sick; we treat the poorest of the sick, or vice versa,” he said. “Too often they’re asking for charity and we give them treatment, so they drop out and don’t return.”
The solution to helping them means doing whatever it takes to overcome those problems so they don’t distract the patient from treatment. Case management is critical to helping them navigate the medical, mental health, and social service systems.
Ultimately, though, the patient—with professional assistance—has to do the hard work to get better, he said.
“My job isn’t to protect them; my job is to give them a secure foundation from which they can take risks and grow and learn,” he said. “You build trust not on ‘I can fix you’ but on ‘I’ll be there to help you learn from your mistakes.’ Teaching, guiding, coaching, building skills will get them to take more responsibility for their own lives rather than our taking responsibility for their lives.”
Collaboration and shared decision making lead to shared perspectives that can open doors to better compliance with treatment, he said. “You switch from compassion to empathy—feeling, on some level, what the patient is feeling.”
Finally, as with any chronic illness, helping patients with mental illness is not always about cure but about living with it as best they can and being resilient enough to manage symptoms at times of relapse. Peers can serve as reminders and examples of that, he said. They are people who are “ill” and “well” at the same time, who accept illness as part of a full life.
“Medical practice will not be influenced by lofty visions of medical homes, but by learning that we have the solutions to their problems,” said Ragins. “We can help general medical practitioners answer questions such as noncompliance with treatment, hopelessness, passivity, and the drug abuse that messes up everything. We need to get started with the practical things, then hope they’ll buy into the vision.”
Making sure a mental health home achieves its goals means analyzing successes, building on strengths, and motivating change—for both clinicians and patients.
Underlying all is not only the substance but the emotional content of a “home,” said Ragins: a place where one is welcomed, accepted, respected and—just possibly—healthy and happy. ■