FEATURE ARTICLE

Integrating Mental Health
and Primary Care

By Gary Bravo, MD

A cutting-edge trend in public mental health systems is the integration and collaboration of mental health services with primary care, primarily in community clinics. In Sonoma County, this trend can be seen in the growing partnership between local federally qualified community clinics and the county’s Mental Health Services Division, resulting in a dramatic expansion of mental health services offered at the clinics. Funding from the Mental Health Services Act (MHSA) has fueled this collaboration and prompted a new model of integrated care for underserved and underinsured populations.

Providing mental health services in community health clinics makes sense for many reasons:

Better identification and treatment of the mental health needs of patients served at the community clinics. Mental health issues are prevalent in patients who visit community clinics. Primary care physicians’ knowledge, competence and comfort for identifying and treating mental illness in these patients is enhanced by close collaboration with mental health professionals.

More timely delivery of specialty mental health services because of ease of access to mental health practitioners within the clinic. When a referral needs to be made to mental health, there can often be a “warm hand-off,” where the patient is introduced to the mental health clinician immediately. It also is simpler and more convenient for patients to be referred down the hall to clinicians that the primary care physician knows, than across town to strangers.

Fewer barriers and less stigma for patients who are reluctant to use mental health centers. Often referrals to specialty mental health services involve waiting periods and screening criteria, which are disincentives for patients to follow through on the referral. In addition, many patients do not feel safe going to mental health centers, for fear of the stigma of being labeled mentally ill, or from stereotyped fears of the mental health system.

Increased communication and collaboration between primary care and mental health systems. Ideally, behavioral health staff at the community clinics have close and open communication with the county mental health clinics, so that patients who need increased services can be referred and followed up easily.

Culturally competent services. Community clinics have historically delivered care to much of the uninsured and immigrant population, and to those of lower socioeconomic status. As a result, the clinics have developed culturally competent services for their diverse populations.

Better delivery and integration of medical services to patients with mental illness. People with severe mental illness have a life expectancy 25 years shorter than those without.[1] This is due to multiple factors: low socioeconomic status, difficulty accessing health care, sedentary lifestyles, cigarette smoking, comorbid substance abuse, and sometimes cognitive disorganization and denial of illness. In addition, the second generation antipsychotics, which are some of the most prescribed medications in the world, seem to contribute to development of the metabolic syndrome.[2] This insidious combination of weight gain, insulin resistance, hypertension and hyperlipidemia increases the likelihood of a cardiac event. One of the Mental Health Division’s goals is to partner with community clinics to monitor for metabolic issues and reduce risk factors.

Community clinics are mandated by their federal charters to provide comprehensive medical services, including behavioral health, to their patients. In Sonoma County, MHSA funding prompted the expansion of mental health services at the community clinics. Requests to use MHSA money to provide mental health staff at the clinics were presented at a series of public meetings. As a result, some MHSA funding was given directly to community clinics to hire psychiatrists, psychiatric social workers, psychologists, and other mental health clinicians.

In addition, the county’s Mental Health Services Division assigned psychiatrists directly to the Southwest Community Health Center, the Petaluma Health Center, and the Indian Health Clinic, as well as a child and adolescent psychiatrist for Southwest and Indian Health. These psychiatrists provide telephone, curbside and round-table consultations, as well as seeing referred patients directly for diagnostic assessment and possible use of psychotropic medications. The goal is to refer back to the primary care physician whenever possible.

Because of budget cuts, Mental Health Services recently terminated the Resource Team program, which provided assessment and psychiatric services for the county’s Medi-Cal population who did not rise to the level of “severely and persistently mentally ill.” About 250 of approximately 500 patients who were evaluated to be stable on their medications were referred to the community clinics. Although these referrals are still a work in progress, one sure result has been closer collaboration between Mental Health Services and the community clinics, which have responded by increasing their capacity to provide mental health services.

What are the problems associated with integrating mental health care into community clinics? The main issue identified by clinics throughout the state is the lack of expansion space to accommodate more practitioners. Fortunately for Sonoma County, the Southwest Health Center recently expanded its capacity to provide mental health services when it took over the Chanate Family Practice Clinic, which for years has served as a training center for the Santa Rosa Family Medicine Residency. In addition, MHSA dollars are being used to provide a psychiatrist from Mental Health Services for consultation and teaching at the Family Practice Psychiatry Clinic.

An ongoing issue with the collaborative model is the tension between different conceptions of how to define those patients whose psychiatric problems can be handled solely in the community clinics and those that meet “target population” criteria—such as schizophrenia or bipolar illness—for treatment by Mental Health Services. Community clinics often don’t have the time, the outreach, and the follow-up capabilities to adequately serve noncompliant patients with personality disorders, substance abuse issues, or somatic disorders. Yet these same patients don’t have the qualifying “target population” diagnoses for county treatment. There is also a gray zone between “moderate” and “severe” mental illness. Regular meetings and frequent case conferences can lessen some of this tension, as well as increase the community clinics’ ability to rapidly refer patients to the county’s emergency services when necessary.

Reimbursement restrictions in community clinics are another barrier to integrated care. While Medi-Cal gives community clinics a higher rate of reimbursement than Mental Health clinics, regulations restrict reimbursement to one encounter per day. This is a widely denounced policy that lawmakers are trying to change.

All told, our cutting-edge model of integrated behavioral health care has fostered a partnership between community clinics in Sonoma County and the public mental health system. This partnership should benefit local patients who suffer from mental and comorbid medical illness.

E-mail: gbravo@sonoma-county.org

References

1. Druss BG, “Improving medical care for persons with serious mental illness,” J Clin Psychiatry, 68;S4:40-44 (2007).
   
2. Newcomer JW, “Antipsychotic medications: metabolic and cardiovascular risk,” J Clin Psychiatry, 68;S4:8-13 (2007).

Further Reading

National Association of State Mental Health Program Directors, “Integrating behavioral health and primary care services,” www.nasmhpd.org (2005).

American Association of Community Psychiatrists, “Position paper on interface and integration with primary care providers,” www.comm.psych.pitt.edu/find.html (2002).

National Council for Community Behavioral Healthcare, “Behavioral health/primary care integration,” www.thenationalcouncil.org/galleries/business-practice%20files/4%20Quadrant.pdf (2006).