Community Benefit - Mental Health: Report from the First Round of CHNAs and Implementation Strategies

January-February 2016


In the September-October 2015 issue of Health Progress, we evaluated the community health needs assessments and implementation strategies of member hospitals in terms of how they were targeting childhood obesity. Now we will look at what the CHNAs told us about the important issue of mental health.

Our analysis indicated that member hospitals are targeting mental illness in their communities from many different angles. Of the 203 randomly selected member hospitals, 145, or about 71 percent, identified mental health as a priority in their community health needs assessments.

Forty-nine percent of the implementation strategies we studied included mental health activities. The remaining hospitals that decided not to include mental health in their implementation strategies likely did so during their needs-prioritization process, in which needs are assessed based on pre-existing hospital resources, community demographics and financial feasibility.

We selected 50 hospitals for further investigation, representing 23 different hospital systems and four independent hospitals across 29 states. Proposed mental health programs concentrated on prevention, access to care, integrated care and/or community engagement. Of note: though we kept them separate from our mental health category, substance-use disorders constituted a large number of the reported community health needs and subsequent implementation strategies.

Prevention strategies are critical for decreasing the prevalence of mental health disorders in that they can prevent, reduce the severity of, or delay the onset of mental health conditions and their associated symptoms. One approach for prevention is through education and marketing campaigns. These efforts help to increase awareness about resources available to community members, in addition to helping decrease stigma surrounding mental health conditions. Other prevention-based programs include mental health screenings or advocacy efforts.

A few hospitals included in our study proposed high-value strategies focusing on prevention. Exempla St. Joseph Hospital in Denver, a member of Sisters of Charity Leavenworth, participates in a multicounty partnership called Reaching Everyone Preventing Suicide. This comprehensive program entails educating and training at-risk individuals and their families. The partnership also conducts screenings, risk assessments and referrals to mental health facilities.

Other hospitals opted to target specific vulnerable populations within their communities. For example, Mercy Medical Center in Cedar Rapids, Iowa, has implemented a prevention program that includes educational presentations on mental health in local homeless shelters, in addition to partnering with one of the shelters to reserve at least one bed for Mercy patients that have no discharge destination.

In terms of advocacy, Mercy General Hospital in Sacramento, California, has been leading the California Hospital Council within its community mental health partnership to push for the reinstatement of mental health services in Sacramento county. Budget cuts closed the crisis stabilization unit and reduced the number of residential treatment beds and other mental health services in the county, prompting Dignity Health to target this advocacy area.

Trinity Health's St. Mary's Good Samaritan Hospital in Greensboro, Georgia, has been working to raise awareness among legislators about mental health issues and advocate for reimbursement restoration. In doing so, St. Mary's Good Samaritan Hospital has created fact-based impact statements about how the local mental health crisis affects school dropout rates, crime rates, substance abuse and the spread of sexually transmitted diseases.

A second theme among the implementation strategies was increasing access to mental health care. Access initiatives can be viewed as four sub-strategies: addressing transportation obstacles; increasing the number of service and treatment outlets; increasing the pool of psychiatrists and providers; and maintaining resources.

Lack of transportation options greatly hinders access to mental health services. Some hospitals offer free transportation to facilities or negotiate low-cost solutions with transportation organizations. Other hospitals bypass the issue of transportation altogether by, instead, bringing mental health services directly to patients. For example, Bon Secours St. Francis Hospital in Charleston, South Carolina, coordinates with local mental health departments to operate the Highway to Hope Mental Health Mobile Unit. This mobile unit travels to remote areas with limited access to transportation services in order to provide professional outpatient psychiatric care.

Another approach gaining popularity among member hospitals is to implement telehealth, or more specifically, telepsychiatry, programs to expand prevention, diagnostic and treatment services. Some hospitals such as Catholic Health Initiatives' Mercy Hospital in Devils Lake, North Dakota, are evaluating the need and financial impact of implementing such programs from scratch. Other hospitals, such as Catholic Health Initiatives' Our Lady of Peace in Louisville, Kentucky, have developed strategies to expand their existing telehealth infrastructure to employ psychiatric services.

Member hospitals also are addressing access to mental health services by expanding their own facilities. Avera St. Anthony's Hospital in O'Neil, Nebraska, is working to establish a specialty outpatient clinic for therapeutic mental health services. Similarly, St. Mary's Hospital in Waterbury, Connecticut, has been evaluating an initiative to develop a community crisis center or behavioral health walk-in center to expand access.

Increasing the pool of psychiatrists and other mental health providers can greatly enhance opportunities for access to care. St. Mary's of Michigan Medical Center in Saginaw, Michigan, part of Ascension Health, included among its intervention strategies initiatives to increase the number of psychiatrists at its facilities through advocacy for higher reimbursement. The hospital also included efforts to increase the number of mental health providers that are culturally and linguistically competent to aid with the deployment of appropriate prevention and treatment methodologies. Providence Valdez Medical Center in Valdez, Alaska, has undertaken strategies to try to attract and retain mental health providers at its facilities through competitive salaries and "well-being plans" for providers that are intended to reduce burnout and subsequent turnover.

The final component of access enlargement is through the creation or maintenance of mental health resources. In Evanston, Illinois, St. Francis Hospital, a Presence Health affiliate, is working to create a directory of existing mental health resources within the community that can be used to match residents based on their needs. St. Francis also has proposed plans to provide its crisis line telephone number to more providers and members of the uninsured population, in addition to tracking the crisis line's usage for outreach metrics.

The field of integrated behavioral health care is burgeoning among CHA members and other hospitals nationwide and typically entails coordination between behavioral health and primary care providers. St. Elizabeth Regional Medical Center in Lincoln, Nebraska, has proposed an integrated service delivery model that facilitates integration between primary care, specialty care, pharmacy and dentistry services. This model also incorporates case management — specializing in comorbidities among high-risk populations — and education for providers and law enforcement about appropriate referrals.

Exempla St. Joseph Hospital in Denver reported an alternate approach to integrated delivery. Their proposed model mirrors that of the Northern Colorado Health Alliance, featuring the partnership of a behavioral health center, primary care clinics and hospital system. The premise is that a patient can enter any one of the three branches and have access to the services of the other branches. The model also includes the co-location of mental health and primary care services, cross-training staff so they can work across various sectors, and a coordinated medical chart system.

Swedish Health Systems in Seattle is among hospitals seeking to coordinate care through the implementation of an inpatient psychiatric unit or behavioral health unit within the emergency department. The Swedish Health Systems unit will treat both voluntary and involuntary patients and expects to have hospitalists, sub-specialists, imaging and surgical services on-site. Its primary focus will be to provide care for adult mental health patients in an acute-care setting.

Other member hospitals reported novel integrated care strategies including bridge appointments, crisis intervention services, partial hospitalization programs, computer-assisted medical priority dispatch systems to discourage inappropriate ED use, and securing jobs and temporary housing for recently discharged patients.

Many hospital efforts targeting behavioral health have capitalized on collaborative partnerships with external organizations. For example, three member hospitals independently partnered with the National Alliance on Mental Illness. Through these partnerships, the hospitals were able to offer support and education for residents living with mental illness and to provide community education. One facet of this program is the Family-to-Family education program, which offers a 12-week course for friends and families of individuals coping with serious mental illness.

Support groups were another recurring strategy among member hospitals. Many groups were intended for individuals suffering from mental illness and functioned in a traditional support group setting. However, some groups varied in their format and included peer support, social clubs or activity-focused groups, such as yoga. Others were organized exclusively for the friends and families of mental health patients, and some of the groups focused on specific mental health illnesses or issues, such as Alzheimer's disease or bereavement support.

Hospital-organized or hospital-sponsored training programs for community members were also suggested for combatting behavioral health issues. For example, Ascension Health St. Vincent Carmel Hospital in Carmel, Indiana, has included in its action plan training for primary care providers and faith-based service providers to screen individuals for mental health issues, educate them on behavioral health resources in the community and educate them on integrative therapy services. Other training targeted chaplains, religious persons, health professionals, law enforcement and individuals who volunteer to lead peer support groups.

Many of the hospitals included in this study incorporated strategies targeting younger age demographics. Early mental health interventions and support mechanisms are critical, as symptoms of mental illness can be obscured by the behavioral changes typical of puberty and adolescence.

The majority of youth-targeted programs are established in schools, whether through school health and wellness programs, training for teachers and administrators, peer interventions, counseling services or school-based health centers.

Springfield Regional Medical Center in Springfield, Ohio, has implemented the Good Behavior Game in local schools. An evidence-based program reviewed by the U. S. Substance Abuse and Mental Health Administration, the Good Behavior Game has led to a reduction in mental health difficulties and/or their symptoms, including ADHD, conduct disorders, depression and PTSD, in schools where it has been implemented. Other hospitals are working to build safety nets for young adults and college students with mental health issues through anti-stigma initiatives and training for faculty, resident advisers and faculty. Additional strategies include educational programs directed at adolescents within the juvenile justice and child welfare systems, and training for their caregivers.

Despite the tremendous amount of mental health research currently being conducted, understanding of the field is still nebulous. The causes of mental health disorders are not cut-and-dry, and their treatments will not be either. Thus, perhaps the best solutions to the current mental health crisis will necessarily be multi-faceted as well and incorporate aspects of prevention, access to care, integrated care and community engagement.

The next round of Community Health Needs Assessments must report on the impact of programs included in the hospital's implementation strategies. CHA will review these reports and engage in discussion about best practices with its members. Our goal is to generate comprehensive and forward-looking solutions for CHA member hospitals that promote mental health and well-being across the continuum of care and within communities nationwide.

STEPHANIE DONAHUE is a health policy and advocacy intern in the Catholic Health Association's Washington, D.C. office. She is a senior at Georgetown University.


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