TCPR: Dr. Gardner, you are the head of psychiatry at an integrated health clinic. Please tell us why it important for psychiatric services to be integrated into primary care settings.
Dr. Gardner: Integration destigmatizes and defragments care for providers and patients. For example, people with severe mental illness have a life expectancy 25 years shorter than non-mentally ill people (Park J et al, eds. National Association of State Mental Health Directors, Medical Directors Council Technical Report: Morbidity and Mortality in People with Serious Mental Illness. Alexandria, VA: October 2006).When care is integrated, the psychiatrist can participate in the whole body care of a patient, advocate with colleagues for the care that the patient deserves, and step in when there are issues that impede care, so that care doesn’t stop. This type of care helps us focus more fully on our patients’ individual needs.
TCPR: What are some of the consequences when care is not integrated between primary care and psychiatry?
Dr. Gardner: Mild to moderate psychiatric disease often goes unidentified and untreated in primary care—maybe as much as half of the time. This is partly because primary care physicians sometimes worry that they may find something and then not know what to do. But when you put the mental health provider in the building with them, the fear goes down and they are much more willing to engage in psychiatric health and behavior screening that might find these unidentified issues. I’m talking about very treatable conditions: anxiety disorders, depression, and alcohol dependence. We’re also more likely to identify psychological factors that interfere with patients’ medical problems. Unhealthy behaviors that the primary care system has trouble changing can be easily addressed with a simple 15 to 30 minute pop-in by someone with expertise in mental health. For instance, if the patient has diabetes but the primary care provider can’t figure out why they will not check their sugars, a simple discussion with a psychiatrist might reveal that their mother died of diabetes and every time they check their sugar they re-experience that trauma. A few minutes with a mental health professional might change that person’s life.
TCPR: Can you describe briefly what your clinic is like and how it integrates psychiatric and primary care?
Dr. Gardner: Penobscot Community Health Care is a health system in northern Maine that is made up of eight clinics that integrate psychiatric providers and primary care providers side by side. We primarily target people with Medicaid/Medicare, the underinsured, and the uninsured. We started in 2004 with one psychiatrist—me—and a mental health substance abuse counselor. We now have 36 mental health providers including psychiatrists, an addiction medicine specialist, psychologists, psychiatric nurse practitioners, master’s level psychotherapists, and case managers. We offer pretty much everything you would see in a community mental health center, including psychiatric consultation, evaluation, and med management for all ages; substance abuse counseling and medication to treat addiction; individual and group psychotherapy; and case management—all integrated within the person’s primary care health home. All of our providers share one electronic health record for our patients, as well. So the primary care note from yesterday will be there with my note from psychiatric medication management today. Same medication list, same problem list; everybody knows what everybody else is doing.
TCPR: And there are no obvious distinctions between primary care and psychiatry when people come to the clinic?
Dr. Gardner: Everyone comes through the same door and checks in at the same desk. You wouldn’t know I was a psychiatrist until I introduced myself as one. Our offices are arranged side by side. The psychiatric health offices are all arranged interspersed with the primary care rooms. So there is always communication—there has to be. All patients enter through the primary care route. They start by seeing the primary care provider for an evaluation with psychiatric health and behavior screenings. From there, the patient and the primary care provider direct what pieces of the team are needed to help the patient. Even when a new patient comes in with a primary mental health complaint, he or she will still get a full integrated health care experience—seeing a primary care practitioner (PCP). So we don’t see anybody who doesn’t have a PCP with us because we don’t intend to do anything except integrated care here.
TCPR: And your mental health services are provided by a variety of clinicians?
Dr. Gardner: Yes, because we see all levels of severity and a wide diversity of need among our health system’s patients. We try to match the severity and need with the type of clinician that fits the patient best, with a goal being that everyone on the team is working at the top end of their training. The top utilizers of health care spending many times have high medical needs and high mental health needs, and often psychiatrists are best able to address these needs because we have been educated at that level of integrated severity and biopsychosocial need.
TCPR: Is this model the same as the “patient-centered medical home” or “accountable care organization” [ACO] that have become buzzwords in health care reform?
Dr. Gardner: Yes, it is a patient-centered medical home. A patient-centered medical home is a health center with a full range of comprehensive health services that is built around service to the patient, not the provider or insurer. The model responds to people in a patient-specific way, not a disease-specific way, which I think is a big difference. These health systems track prevention, wellness, and chronic conditions, with care coordinated across all levels. Patients are accommodated on the level that they need in a way that meets their individual need—this could include emailing communication with them and having late office hours. An ACO is at least partially based around coordinating care between multiple healthcare systems so as to get better quality outcomes and in turn better payment. The patient-centered medical home is a piece of that because treating people in a patient-centered medical home within the ACO would be less expensive than treating them in a hospital within the ACO.
TCPR: It seems that our healthcare system is evolving in a direction that encourages the type of model you use.
Dr. Gardner: I think if we want to decrease costs and improve outcomes, then we are going to have to bring services together. It is fairly clear that the current system is not as effective as it could be for the dollars that we spend. The Affordable Care Act is going to encourage integration for lots of reasons. Mental health and substance abuse care as essential benefits will be key to providing quality health care. When payment is linked to quality outcomes, I think you have to have mental health and substance abuse involved, because so many cases of high utilization have a high mental health/substance abuse component. I believe our drive to get paid will outweigh any drive to divide us.
TCPR: So in your particular setting, how do you measure outcomes?
Dr. Gardner: We think the best way to look at outcomes is by looking at the whole person’s health. We do this with a health survey called the SF12. [Eds note: you can find the SF12 at www.sf-36.org/tools/sf12.shtml] This survey measures eight domains that we track in our patients. We can also look at our Medicaid records.
TCPR: And what types of outcomes have you seen?
Dr. Gardner: We have seen decreases in ER utilization, cost, inpatient days, and specialist visits, along with increased primary care provider visits, and from the patient’s perspective, more happiness and more wellness. Here’s an example: If I have a diabetic patient with schizophrenia, one of the most crucial outcomes from my point of view would be that his hemoglobin A1C level stays normal. I would expect that my schizophrenia treatment would be the same whether I were segregated or integrated, but what might improve more in the integrated model is the person’s whole health. So I would want to look at those measures of weight and blood pressure and diabetes to see if the integrated care model makes a difference.
TCPR: Have you been able to quantify that you are providing treatment for a lower cost by integrating care?
Dr. Gardner: We are an outpatient community health center, so the cost savings that we get are more for the system in general than our particular office. So the fact that integrated care can lead to fewer hospitalizations and ER visits saves money, but not necessarily for my health center itself. In the big picture, you want more patients going to the primary care health homes because they treat at the lowest level of illness severity and they are the cheapest place to get care.
TCPR: For the psychiatrist who is not working in the integrated setting, how can we prepare ourselves for a future where we might work in this environment?
Dr. Gardner: I think the skill set we have as psychiatrists is perfect for what is needed and that we don’t need any particular additional skills. Just having the courage and the acceptance to enter into this new way of doing things is all a psychiatrist needs to prepare. I see the psychiatrist as a bridge between primary care physicians in the general health system and licensed mental health professionals in the specialized mental health systems because we understand the culture of both. We speak the same language.
TCPR: Thank you, Dr. Gardner.