"You'd think that people who deal with developmental disabilities and
those who work in mental health would be professional neighbors, but it's not
so," said Pauline Lucero-Esquivel, M.A., coordinator of a collaborative
project serving people in New Mexico with both diagnoses. She spoke at the
annual meeting of the National Association for Rural Mental Health in
Albuquerque in June.
In New Mexico, funding for the developmentally disabled programs is
separate from that for mental health programs. Staff members mainly worked in
one area or the other, leaving a gap into which patients could fall.
To overcome those divisions and provide better, more coordinated care, a
coalition of agencies and organizations developed a pilot project to try to
bridge that gap.
The project adopted an innovative strategy linking four local clinics in
the state with services from the Department of Health and the Department of
Human Services, managed care organizations, the University of New Mexico
Health Sciences Center, and the Developmental Disabilities Planning Council,
an advocacy agency.
Participants set out to decrease barriers to services, increase clinicians'
skills, and improve communication among all involved, especially in rural
settings around the state.
Rather than hand down decrees from on high, the participants began with a
long series of discussions that involved everyone connected with the project.
Meetings began in spring 2001, and the first clinical consultation took place
in Taos in November 2002. Eventually, three other rural clinics joined the
program—in Shiprock (August 2006), Roswell (June 2008), and Silver City
The primary goal was to find ways to coordinate care and solve problems for
people who were "bouncing around the system," as one participant
said. That meant sharing information, while finding ways to maintain
confidentiality in both the clinical sense and also in small-town settings
where gossip is rife, extended families are common, and a practitioner may see
more than one member of a family.
Myriad staffing, clinical, and administrative challenges required a lot of
discussion long before the first patient was seen.
In the past, representatives from the health department and the university
were seen by rural service providers and patients alike as outsiders all too
willing to show up, tell the locals what to do, and then disappear, said
neuropsychiatrist Alya Reeve, M.D., an associate professor of psychiatry and
neurology at the University of New Mexico and a co-investigator on the
Continuum of Care Project, one of the groups involved in the larger project. A
good deal of listening at the local level was needed to learn what each clinic
"We had to go out to the clinics and not expect people who work there
to come to Albuquerque," said Reeve. "Also, we knew that whatever
we did would feel, sound, and act differently in the different parts of the
The landscape, weather, economy, and ethnic mix were different at each
site, so approaches needed to be tailored accordingly.
The Taos site was a long-established community mental health center and got
an early start because a local psychiatrist wanted to know more about treating
patients with developmental disabilities. In Shiprock, the clinic site was an
Indian Health Service clinic. In Roswell, it was a combination of the student
health center at Eastern New Mexico University and a private mental health
practice that ran an inpatient unit. In Silver City, a primary care clinic
containing a behavioral health unit served as the base.
The discussions revealed ways to open the flow of information among all
participants. A case manager's knowledge of a patient's workplace or other
setting might prove to be a critical link for the team psychiatrist, while the
psychiatrist might learn to ask the case manager or social workers for a wider
range of background information.
Team members also learned when others were ready (or not) to move on to
subsequent phases of the program, said Lucero-Esquivel. "People needed
to feel comfortable talking to and working with others, so they didn't feel
out of their element."
Team members from state agencies and the university included clinicians and
administrative personnel. Someone who understands contracts and billing is
essential, said Lucero-Esquivel. Each local team included a clinic
coordinator, clinicians, financial and administrative support, and patient,
family, and community supports. The local teams identified meeting goals.
"We don't come from the big city with our money and our expertise and
tell them how to do things. We really follow their lead and see what their
needs are," said Lucero-Esquivel.
Some discussions focused on suggestions for a patient's needs, others on
learning about research or new ways of treatment, and still others on helping
people navigate the complex system.
Beyond the technicalities, though, lay the value of cultivating
relationships among all team members.
"Investing time is important," said Lucero-Esquivel."
That helps to better understand people's intentions and reduce the
chance of miscommunication."
Over time, as the local teams gained experience, the need for face-to-face
meetings, originally scheduled quarterly, lessened. The project team members
gradually became a consulting resource, doing more work through phone calls,
validating the local expertise, and making greater use of telehealth
Evaluation of the process using questionnaires and interviews found that
providers not only felt more competent as time went by, but also felt that it
allowed them to develop best-practice models of the collaboration. Everyone
involved gained a deeper understanding of what developmentally disabled people
with mental health problems needed and how team members could make those
services more accessible. ▪