No single path to integration

President and CEO Dale K. Klatzker, PhD, with new director of integrated care, Nelly Burdette, PsyD.

The community mental health organization based in Rhode Island's capital city would list more than a few ingredients in a recipe for successful integration of behavioral health and primary care services. A wellness component, commitment at the highest level of the organization, and a dedicated staff function in integrated care would qualify among the many must-haves, judging from the early experiences of The Providence Center.

Perhaps most importantly, according to the community mental health center's leaders, successful pursuit of integrated care must be guided by the thought that there isn't merely one care model that will prove beneficial. In addition, the behavioral health and primary medical cultures stand little chance of co-existing if individuals care too much about who gets the credit.

“The CEOs of our two organizations started to work together and developed this energy,” says Jackie S. Fantes, MD, associate medical director for Providence Community Health Centers, which is partnering with The Providence Center on projects on each organization's home turf. “We came to the realization of, ‘Wow, we can work together; this is great.’”

The two organizations have teamed up on a pair of initiatives designed to benefit distinct populations. Since last summer, a licensed clinical social worker from The Providence Center has been housed at one of Providence Community Health Centers' primary care clinics, available to primary care patients mainly for brief counseling for mental health issues such as depression and anxiety.

And in a groundbreaking project (which was scheduled to open for business at the start of 2011) the primary care organization is establishing an on-site primary care clinic with one physician and two other clinical staffers at The Providence Center's main adult treatment site. The clinic is expected to serve seriously mentally ill clients who despite a number of physical health concerns have never established a consistent relationship with a primary care physician.

In November, The Providence Center took another uncommon step for a CMHC: It hired a director of integrated care specifically to oversee initiatives that are expected to increase in importance as terms such as “accountable care organizations” begin to dominate the language in the healthcare marketplace.

Nelly Burdette, PsyD's experiences, which in the past have mainly involved work with primary care professionals, include a former role at Cherokee Health Systems in Tennessee, one of the first CMHCs in the country to have demonstrated success with fully integrated behavioral health and primary care services under one roof.

“There has not been as much experience around the country with medical services embedded in behavioral health,” Burdette says. “Doctors are not trained to be in a mental health facility. For many of them, seeing one or two of our patients a day would produce enough stress for them for the day. Our professionals see 10 of these patients a day.”

Services at primary care site

The first manifestation of cooperative discussions between CEOs Dale K. Klatzker, PhD, of The Providence Center and Merrill Thomas of Providence Community Health Centers came to life last summer at one of the primary care organization's clinic sites in Providence.

Through a private foundation grant, The Providence Center houses a social worker at one of Providence Community Health Centers' primary care clinics (The Providence Center has a similar arrangement under the foundation-supported effort with a second community health center in Rhode Island). The social worker is familiar with intake processes through her prior work in emergency services with the CMHC. In her role at the primary care clinic, she receives referrals from primary care physicians in situations where a medical patient might be experiencing symptoms of a mental health issue.

Providence Community Health Centers' Fantes explains that the program maintains some open access to the social worker's time for clinic patients, and pre-scheduled appointments are made for some patients as well. The LCSW operates under a general guideline that if she doesn't believe a patient's problem can be sufficiently addressed in four 45-minute sessions, she should refer that patient elsewhere for more specialized mental health treatment.

“If she starts to do a whole bunch of counseling, that limits the time available for referrals,” says Fantes.

For many of these clinic patients, the opportunity to see a mental health professional at a primary care site reduces the stigma they likely associate with receiving mental healthcare. Ironically, patients with serious mental illness who are longtime clients in the public mental health system often express the same hesitation about receiving general medical care. This dichotomy helps explain why integrated care in general is becoming focused to tailoring services to the patient, not to judging whether one location ultimately will be considered the “better” setting for integrated care.

Thomas sees the social worker's presence as playing a pivotal role for the primary care organization's patient population. “We have a lot of patients with depression at our medical clinics,” he says.

He and Klatzker agree that while integrating services should produce better physical and behavioral health outcomes for both organizations' clients, it made little sense for either organization to build from scratch the services in which they were not well-versed. “We didn't want to reinvent the wheel with behavioral health,” Thomas says.

Adds Klatzker, “I didn't want to be in competition with them; I wanted to be in collaboration. This was about building relationships, starting with the CEOs. It would have been a lot harder to do without our involvement.”

Clinic at CMHC

Both organizations are buzzing about the establishment of an on-site primary care clinic at The Providence Center. On a mid-December visit to The Providence Center's main adult treatment site not far from downtown Providence, one could observe the clinic's three exam rooms and reception area gradually taking shape. Burdette walked through the construction area and explained that her office is located right around the corner-she will be working hand-in-hand with the clinic's physician, nurse and medical assistant, especially at the outset.

Numerous details will go into ensuring that public mental health clients who have had inconsistent or no general medical care over the years will have a positive experience when referred to the clinic. Burdette says research has demonstrated that primary care and behavioral health services have to appear coordinated even to the patient's eye.

“If when the patient goes to the primary care area they notice a change in the flooring, there is stigma,” Burdette says. There should be no indication that they are entering foreign territory.

The Providence Center's patient base brings a number of medical issues that historically have not been addressed sufficiently. “A lot are overweight and smoke too much,” says chief operating officer Deborah O'Brien. “Some of their medications increase the risk for diabetes. Often they're not eating consistent meals.”

Burdette acknowledges that successfully integrating medical services into The Providence Center's daily operations will take time. “Some of the questions doctors will ask can unleash tears in our patients, and how do you deal with that? It can be a frightening experience for primary care doctors.”

The physician who has been assigned to the clinic at The Providence Center, Maria Cristina Chan, MD, recently completed her residency and admits she received little exposure to psychiatric issues in her training. She approaches her new assignment with a combination of excitement and apprehension.

“I've been told that when these patients are sick they usually end up in the emergency room,” Chan says. “This is going to be a very good opportunity for them to receive care.”

Wellness element

The Providence Center realizes that its typical client's well-being rests not only on managing any co-occurring health conditions but also on pursuing healthy lifestyle goals. It thus decided to integrate into its program the In SHAPE model of health and wellness that was initiated at Monadnock Family Services in New Hampshire, an effort that pairs clients who have serious mental illness with personal health mentors.

“We started our effort with a case manager who became certified in personal training,” says Holly Fitting, The Providence Center's associate director of community support services.

Participants receive a medical and nutritional assessment and are able to take fitness classes either at a local YMCA or on-site at the CMHC (the latter appeals to those who might find working out at a gym intimidating). Participants who show an interest in maintaining a gym schedule can receive subsidized memberships. Cooking classes also are available.

Fitting says more than 100 clients were referred to In SHAPE within the first couple of months of its availability at The Providence Center. Services are tailored to what each individual wants to work on for health and fitness goals. Celebrations of achievement are planned at various intervals.

A four-year grant of $500,000 a year from the Substance Abuse and Mental Health Services Administration (SAMHSA) is making many of the general health services at The Providence Center possible, including implementation of In SHAPE as well as the presence of medical nursing staff on two of the center's assertive community treatment teams. The Providence Center received the grant in its second attempt to win federal funding support for its integrated care initiatives.

Measures of success

A variety of criteria will help the organizations determine the success of their integrated care initiatives at the two locations. In the primary care setting, the sheer number of patients who will agree to receive counseling services will be a major determinant, given the perceived stigma surrounding mental health treatment.

Ideally, The Providence Center would like to have one behavioral health clinician available for every five or six physicians at Providence Community Health Centers; that would help reduce a wait time for counseling services that now stands at around two weeks. Burdette adds that she also would like to see more consistency in referrals to the social worker, as some physicians have become high utilizers while others rarely or never refer.

At the primary care clinic location at The Providence Center, staff anticipates being able to look at a variety of outcomes, including criteria related to chronic health conditions such as diabetes. Smoking cessation also remains a critical goal for much of the population served by the CMHC-a goal that initiatives such as In SHAPE should help address.

While one-time grants are financing the CMHC's efforts in integrated care, The Providence Center considers it important to demonstrate through its efforts that integrated services have long-term financial sustainability. Financing poses a particular challenge on the community mental health side, which in recent years has received less overall federal funding support than community health. This is an area where the two cultures sometimes clash.

“There is a boatload of misunderstanding; the [primary care] clinics don't understand the funding mechanisms of CMHCs,” Klatzker says. “They get paid to provide care to the uninsured-we don't.”

Klatzker says forward-thinking mental health organizations are going to have to craft innovative partnerships with primary care, and should be conscious of including as many elements as possible. The Providence Center's wellness services, as well as having an on-site pharmacy, are among the factors that will enhance the integration effort, he believes.

Mental health organizations will have to work closely with primary care clinics in order to make accountable care organizations a useful model. At each location, they will have to cede some of their autonomy in order to achieve success.

“The more things that are missing from this, the harder it will be,” Klatzker says. “There are going to be 1,000 variations on this.”

Alison Knopf is a freelance writer. Behavioral Healthcare 2011 April;31(3):44-47