KANSAS CITY, Mo. — Now that they have identified some of the hurdles, local mental health advocates say they hope to soon convene a forum on the best way to coordinate medical care and behavioral health services.
Last fall, the Metropolitan Mental Health Stakeholders group surveyed dozens of service providers, including officials at residential treatment facilities and safety-net clinics, to get a sense of the level of coordination already taking place.
The group is still analyzing the responses, but Co-Chair Susan Crain Lewis said, “We have enough quantification to know that nobody has totally got it licked. There is no obvious place where it is solved, and there is no obvious place where nothing is happening.”
Coordinated care, also known as care integration, can come in a variety of forms, said Lewis, chief executive of Mental Health America of the Heartland, an advocacy group based in Kansas City, Kan.
In some instances, it may be as simple as a primary care clinic that gives patients a list of mental health providers or a clinic that keeps a behavioral health professional onsite.
Lewis said the survey identified three general barriers to care coordination:
- Financing: This mainly involves ensuring that providers can bill Medicaid, and other payers, for nontraditional services. For example, safety-net clinics would find it helpful to be reimbursed for consultation time between medical and mental health personnel.
- Infrastructure: Mental health providers typically don’t have exam rooms designed for physical workups.
- Lack of staff training in integrated models of care.
Some group members said they hoped to convene an integration workshop by the spring, but it might not come together until summer, said Scott Lakin, director of the Regional Health Care Initiative.
Lewis said one goal of the workshop would be to spur action by drawing together staff from different places, perhaps prompting participants to say to one another: “OK, you and I have talked, and we are going to meet for breakfast, and we are going to get this (problem) hammered out.”
The local effort coincides with several larger initiatives to improve coordination in the health care system as a whole and for patients with serious mental illnesses.
For instance, as a result of the 2010 federal health reform, hospitals now are paying penalties through Medicare if too many of their patients require readmission.
That is one way the Affordable Care Act aims to encourage better coordination between inpatient and outpatient services. Currently, experts say, there can be disconnects, particularly with mentally ill patients, when supports aren’t there to help them manage their physical health problems.
In Missouri, the Departments of Mental Health and Social Services are collaborating on a Medicaid initiative that designates community mental health centers as healthcare homes for some of the unhealthiest behavioral health clients.
And in Kansas, the Sunflower Foundation has launched a major grant program to facilitate better coordination of care for mental health patients in the safety-net system.
Foundation officials have expressed concern about the mortality rate of seriously mentally ill patients who die from preventable diseases that have gone unmanaged.
The Missouri Medicaid initiative is showing promise, said program coordinator Dorn Schuffman, a former director of the state Department of Mental Health who now works as a consultant.
About 18,000 patients were enrolled in the first year.
In addition to having a substance abuse problem and/or a serious, persistent mental illness, enrollees also have chronic conditions or risk factors that include diabetes or tobacco use.
According to a six-month review of the program, issued in October, department personnel started with high-cost clients that, on average, had accrued more than $24,000 each in Medicaid services the previous year.
One positive, Schuffman said, was that community mental health centers nearly met the goal of following up with clients no more than 72 hours after discharge from a hospital in at least 80 percent of the cases. The centers met that timeframe 71 percent of the time in the first six months.
Following up with patients reduces costly hospital readmissions, he said.
The department officials, however, underestimated the complexity of the cases that nurse care managers in the centers were managing and the time required. One solution under consideration, according to the six-month review, is reassessing a patient’s need for health home services.
At Truman Medical Centers, Jakob Nelson is on the front lines of the Missouri push to integrate behavioral and physical health. A Ph.D. licensed psychologist, Nelson is now working as a behavioral health consultant to primary care doctors.
The benefit, Nelson said, was that he was reaching some primary care patients who likely would not have followed up on a physician’s advice to seek mental health counseling.
But the model has taken some getting used to, he said.
Among others thing, he’s had to build rapport with the primary care doctors and adjust his mindset so that instead of doing 50-minute counseling sessions he can hop into an exam room to provide some quick mental health advice.
“I kind of orbit like a satellite and wait for a door to open,” he said, “and when a door opens, I jump in there and do what I can.”