After 20 years of research on integrating behavioral health services into primary care, the past 10 years have seen increasing efforts to do what has been referred to as “reverse integration,” integrating good primary care into community mental health centers where patients with severe and persistent mental illnesses get the majority of their care. Marc Avery, M.D., draws on 20 years of experience as a medical leader in community mental health care when he comments on core principles that apply to both types of integration. —Jürgen Unützer, M.D., M.P.H.
One exciting benefit of the integrated care movement is the opportunity to apply its principles to our work at community mental health centers for patients with more serious psychiatric symptoms and conditions. And for me, this has been a nice opportunity to blend my two interests: consultation/liaison psychiatry and community mental health administration. Thus it was particularly exciting for me when, in 2007, my community mental health center partnered in a multisystem project with the University of Washington’s AIMS Center as a provider for the Mental Health Integration Program (MHIP)—a primary care integration program for safety-net individuals in Washington state.
This program was patterned after the IMPACT model developed by Dr. Jürgen Unützer and colleagues—but was different in two important ways. First, it included safety-net patients who presented with a wide range of psychiatric conditions and levels of severity, not just depression. Second, it included mechanisms for linking the primary care mental health program with community mental health providers. As a result, we had some excellent bidirectional sharing and learning. I was surprised at how many of the principles of primary care integration made good sense in our community mental health program. Below is a short list of some of the integrated care concepts I found useful, regardless of the setting.
Keeping an accurate list of patients under our care helps keep people in the right care. Population-based care is a core principle of integrated mental health care. This principle asserts that we keep track of all patients under our care—our “population”—even if this is just our own individual caseload. This is particularly important when working with more severely emotionally ill patients, as the symptoms and problems these patients cope with also make them much more difficult to engage and maintain in care. Our busy schedules and large caseloads make it all too easy for a difficult-to-engage patient to “fade into the background.” Fortunately, some relatively simple tools, such as care registries, can be useful in allowing us to keep track of these patients and alert us to reach out to them when needed.
Systematic use of structured rating scales can help identify patients who are not improving and may need better targeting of services. When I began using the Patient Health Questionnaire (PHQ-9), I was immediately impressed by how efficient and useful it was for tracking symptoms of depression, and I also liked how much my patients valued the ability to quantify their feelings and symptoms. I soon asked all my medical staff to use it. We noted the surprising prevalence of depressive symptoms among all of our patients. For us, the PHQ-9 quickly became a good measure of general emotional distress for many of our patients, even those without a formal diagnosis of depression. Its speed of administration was also a boon to my clinical discussions with patients, as the time saved in eliciting depression symptoms was freed up for patient education and counseling. We have supplemented the PHQ-9 with other scales and use them in much the same way.
Specialty mental health providers can, and should, prioritize physical health goals in our work with patients. Not so long ago, tracking physical health concerns with patients (such as diet, lab results, or medication adherence) seemed out of our scope of community mental health practice—especially among mental health care providers without formal medical training. However, as we began implementing integrated care into our community mental health programs, we also expanded the scope of our counseling to include broader health goals. It has been a great surprise to find just how effective we community mental health providers can be in discussing physical health concerns with patients. After all, our special expertise in communicating with those with serious mental health concerns puts us in a distinctly opportune position to have total health discussions with our patients as opposed to limiting our discussions to nonmedical subjects and concerns.
Well-coordinated care is easier, more effective and more efficient and has better outcomes, but it takes time and effort to “get there.” In many systems, the primary care and specialty mental health programs have been “carved out” from one another for so long that it seems we have forgotten how to work together. The net result has been predictable gaps and redundancies in care, missed care opportunities, and failed linkages. Application of population-based care and coordinated care offers great opportunities for improvement—however, the transformation process does not happen casually. Rather, it takes a fair amount of time, with deliberate, sustained effort. Preparing for this reality at the outset can help stave off “transformation fatigue” when initial progress made or results achieved are not exactly as expected from the outset.
These are some of the integrated care concepts that I have found to be helpful in community mental health settings. Of course, helping programs implement these processes takes time, effort, and diligence. However, the potential benefits are very much worth the effort: better and more meaningful care, more efficient use of time and resources, and better outcomes. ■