By JULIE MINDA
Increasingly across the U.S., health care policymakers, payers and providers are recognizing the value of integrating mental health care into the medical health care continuum.
From left, peer recovery support specialist Jerome Reeves, social worker Sarah Krecic and Chief of Behavioral Health Michael Biscaro share perspectives after a peer support session with a client at the Integrated Care Clinic at St. Vincent Charity Medical Center in Cleveland. St. Vincent Charity has prioritized such multidisciplinary work as part of its move toward increasingly integrating mental health care into the care continuum.
A sampling of ministry systems that are prioritizing this shift says they are determining how best to approach integration by paying attention to national trends and the dynamics of the markets they serve. Much of the focus now is on adding a mental health component to primary care, and on increasing routine screenings to assess mental well-being. Providers acknowledge that patients in every medical care venue have undiagnosed and untreated mental health concerns and they expect to broaden behavioral health service integration beyond primary care; some have already started to do so.
Representatives of PeaceHealth, Providence St. Joseph Health, Sisters of Charity Health System and SSM Health spoke to Catholic Health World about their progress in mental health integration. Each system is taking a slightly different tack.
All are focused on improving access to mental health services and outcomes for patients.
Establishing a foundation
Michael Biscaro, chief of behavioral health at St. Vincent Charity Medical Center of Cleveland, says that system had a well-developed psychiatric emergency department, inpatient behavioral health program, and addiction treatment program when it set out to expand and integrate its mental health services last year. In the midst of the COVID-19 pandemic, St. Vincent Charity, which is part of the Sisters of Charity Health System, built out its continuum of services to include outpatient mental health care.
It opened an integrated care clinic to expand outpatient mental health and to work towards creating a fully integrated clinic where staff can provide behavioral health and primary care. The expansion of behavioral health staff and services is central to its efforts to create a coordinated, connected network of medical and behavioral health care, Biscaro says.
Nurse Julie Bryant adjusts her headset as she prepares for a Zoom meeting while working at SSM Health's Behavioral Health Urgent Care in a St. Louis suburb. The clinic is the first of its kind in Missouri.
Karen Elshout/© CHA
St. Vincent Charity also brought behavioral health and substance dependence screenings onto its medical floors and the ambulatory care clinic, with hopes to expand screening to primary care. It also established one phone number for getting information for all of its mental health services, built awareness of the mental health services among medical practitioners and brought social workers into inpatient medical units and the hospital's outpatient medical clinic, to help assess patients' mental health needs.
St. Vincent Charity provides ongoing education and training on mental health care to medical clinicians. It is providing hands-on experience in integrated care to its medical residents as they provide care for patients in its inpatient psychiatry and detoxification units.
Biscaro says communication and partnership and buy-in among all of the care providers is essential to the integration process. "The time is now for all of us to step up, and integrated care is a transformative way to do so," he says. "And who could be better than Catholic health systems to lead the care for mind, body and spirit?"
When Providence Health & Services merged with St. Joseph Health in 2016 to form Providence St. Joseph Health, the combined organization made a commitment to prioritize and improve mental health care services and model ways to integrate mental health into the medical care continuum. It established the Well Being Trust to advance the mental, social and spiritual health of the nation.
Dr. Arpan Waghray, chief medical officer of Providence St. Joseph Health Behavioral Medicine, says the system brought together behavioral health leaders across Providence to identify core metrics that could lead to the greatest impact measured in terms of lives served and saved. Such services include treatment for depression, suicide care and care for opioid use disorder.
Providence screens all patients for suicidality and most patients are given a screening to assess substance dependence. The system is creating dashboards that will allow it to compare mental health outcomes in its clinics across the system. Waghray says, "All of this work is being done with a specific focus on equity, aiming to identify care disparities and dive in deeper to find answers."
He says the system also facilitates the sharing of best practices in mental health care across clinics and across its regions. For instance, in its guides for integration of behavioral health in emergency departments and primary care, Providence provides practical direction for responding to common behavioral health issues. The guides are intended to standardize approaches to behavioral health conditions across the Providence system.
Providence assembled a network of psychiatrists and social workers to provide tele-behavioral health to 36 rural sites, including critical access hospitals that previously had no behavioral health services. Now, those medical facilities can offer a behavioral health specialist consult within 30 minutes, seven days a week. Through this work, last year Providence served an additional 10,000 patients who previously would not have had access to behavioral health care, says Waghray.
Michelle Schafer, regional vice president of behavioral health for St. Louis-based SSM Health, says the system's primary care locations conduct behavioral health screenings to detect and make referrals for behavioral health issues before they escalate to crisis. The system's primary care locations have behavioral health practitioners available to further assess and treat patients, either on-site or through virtual visits.
Nearly a year ago, SSM Health opened its Behavioral Health Urgent Care in suburban St. Louis to provide immediate assessment and triage of urgent mental health needs. It is the only such specialized urgent care in the state of Missouri. Patients who would benefit from ongoing care are referred to SSM Health behavioral health providers or linked to community mental health centers and other local not-for-profit organizations that provide services to those with chronic mental illness.
In October, SSM Health responded to increasing behavioral health care needs among youth by opening the urgent care facility to patients younger than age 18. That group now makes up 20% of its volume.
"Our goal is to offer ongoing care and a path to wellness by working with a host of community partners who can meet individuals where they are," Schafer says. "When we can identify and stabilize people who need mental health services — especially those among our most vulnerable
populations — we can raise the overall health of the community."
No wrong door
In PeaceHealth's Oregon network, Carla Gerber is clinical manager of behavioral health services and Joan Tompkins is manager of behavioral health operations. Gerber says that system has been using grants to integrate mental health services across the continuum of care for 18 years and has made significant progress. PeaceHealth Oregon screens for depression among primary care patients and for suicidality among all emergency department patients. It screens primary care patients aged 12 to 24 for psychosis, in the hopes of intervening with those at risk, with preventive care.
Tompkins adds PeaceHealth has brought mental health services into primary care settings and primary care services into mental health settings — in a process it calls reverse integration. This way, patients can access mental health and medical services wherever they are most comfortable receiving care.
PeaceHealth also is bringing mental health and primary care services to the vulnerable through a multidisciplinary mobile team that goes to local shelters to deliver care.
"We need to figure out how to change the system to meet the patients' needs rather than trying to force people to change to meet the needs of our system," she says. "We want to provide the services right where people are more likely to be."
Megan Bush, director of intake and access for the behavioral health practice area of St. Vincent Charity, says the pandemic's broad toll on the nation's mental health put mental health conversations in the mainstream and is helping to reduce stigma and to build awareness of the importance of improving access to mental health services. She says such changing attitudes could help to speed the progress toward fuller integration of mental health care into the care continuum.
Her colleague Biscaro says, "A silver lining of the pandemic is that it highlighted how challenged the health care system is …
"And we're seeing momentum for change now."
AHA report sets out ways mental health can be woven into other care venues
"Behavioral Health Integration: Treating the whole person," a 2019 report from the American Hospital Association's Center for Health Innovation, defines integrated care as the systematic coordination of physical and behavioral health care in acute care, primary care, emergency care, post-acute care, health homes and/or community-based services. The authors say that effective integration goes beyond mere collaboration and coordination between medical and mental health practitioners: "The aim of integrated care is one system of care for physical and behavioral health delivered by the care team with different clinical specialties along the entire care continuum."
The report recommends a variety of approaches for achieving that level of integration, and it says that systems can take progressive steps along the integration path. Ministry providers are using these and other blueprints to incorporate mental health services into the care continuum. The report recommends systems:
- Conduct behavioral health screenings with patients of medical facilities to identify people at risk.
- Use electronic health record systems to prompt medical practitioners to assess patients for behavioral health conditions.
- Educate primary care physicians on behavioral health and related screenings and assessments.
- Enlist outpatient clinicians in documenting patients' behavioral health symptoms and needs in the electronic health record.
- Embed behavioral health clinicians in medical settings.
- Open units or facilities equipped to treat chronic physical conditions and psychiatric needs.
- Open behavioral health urgent care centers that are integrated into the medical urgent care system.
- Collaborate with community-based mental health service providers.
- Partner with community providers on data collection and analysis having to do with community mental health.
- Invest in tele-mental health to extend mental health providers' reach.
— JULIE MINDA
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