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A patient visits a nurse at Family Services Inc. in Gaithersburg, Md., a low-income mental health clinic. With the help of a federal grant, it has added a medical clinic so its clients can get physical care as well.

Caring for body and mind together

Mental health clinics add medical care to help vulnerable

On a recent day at Family Services Inc., a low-income mental health clinic in Gaithersburg, Md., clinic director Amy Van Grack was treating one of her regular patients when she realized the patient was homeless, pregnant and hadn’t seen a primary care doctor in months.

So Van Grack walked the patient down the hall to meet with one.

In addition to therapists, counselors and psychiatrists, FSI in December added a medical clinic to its site. The idea: People with behavioral health disorders are more likely to get the physical treatments they need when a doctor is readily available, affordable and near their mental health care provider.

In bringing on physician Sacari Thomas-Mohamed to head up the medical side of the clinic, FSI is at the leading edge of a trend toward what’s called health care integration – the idea that medical professionals of all stripes should work together to treat the range of ailments a patient might be experiencing at one time.

FSI is one of 93 clinics across the country that’s been given part of $174 million in grant money by the Substance Abuse and Mental Health Services Administration over the next four years to help them accomplish just that.

Although SAMHSA is still evaluating its grantees’ results – the official report is due at the end of this year – the agency said the clinics have together seen improvements of 10 percent to 46 percent across a variety of their patients’ health indicators, such as body mass index and blood pressure.

People with serious mental illnesses, such as schizophrenia, die 25 years younger than the general population on average, according to a 2006 study by the National Association of State Mental Health Program Directors. Factors such as transportation problems, fear of stigma and lack of insurance keep them from making and keeping regular doctors’ appointments.

Three relatively young FSI clients died within two years, which inspired the clinic to apply for one of the SAMHSA grants in 2010 to help them start integrating.

“People under the age of 55 were dying of diabetes, heart attack and stroke,” FSI director Arleen Rogan said. “We wanted to see how to make a difference in that.”

Integrated care

FSI’s program is an extreme manifestation of integrated care – most clinics opt for simply asking psychiatrists and doctors to compare notes or to share health records. But increasingly, clinics and hospitals are streamlining access to care for patients who have co-occurring mental and physical health disorders.

“With the advent of health-care reform, services are going to need to be less redundant, more efficient, more patient-centered, less provider-centric,” said Mark McGovern, a psychiatry professor at Dartmouth University who has studied mental health integration.

Integration predates the Affordable Care Act, but the health care bill did call for the creation of models that allow patients to be managed by interdisciplinary teams of doctors. Payments will also shift from services to outcomes, so doctors will have more incentives to work together to cure a patient for good.

Before the medical office opened in December, FSI’s mental health patients could walk across the street to see doctors at a clinic that had agreed to collaborate with FSI’s psychiatrists. They worked together on difficult cases, and they were making progress with dozens of patients who had co-occurring problems, such as obesity and depression.

Still, appointments at the health clinic were missed, prescriptions went unfilled, working moms rushed back to work after therapy sessions rather than stop in for a blood pressure check.

“Even though it’s across the street, it might as well be across the country,” Rogan said.

Now if mental health workers suspect high blood pressure or diabetes, FSI staff members escort patients from the psychiatrists’ offices straight to Thomas-Mohamed, who leaves open plenty of walk-in appointments to accommodate them.

Therapists are taught to be more aware of somatic concerns, asking patients about blood pressure and smoking cessation. They’ve also put therapists at the medical clinic across the street for patients who still see doctors there.

Even though its medical services are FSI’s newest advancement, the center also provides housing services, counseling for battered women and drug users, group therapy and other treatments.

“They’ve been helping me for years,” said one patient who has schizophrenia and spoke on the condition of anonymity. “You get to meet people through the lunch programs and groups. I try to participate every day.”

If it sounds as if providing such comprehensive services to such an impoverished population would be almost prohibitively expensive, that’s because it is. FSI said that, while they are funded through grants and other mechanisms, they are grappling with how to pay for some of their services in coming years.

FSI’s $2 million grant covers nursing salaries, some contractors, diabetes education and wellness programs, and it lasts for four years. When the grant runs out, they aren’t entirely sure what’s next.

In Maryland, for example, mental health clinics can’t bill for nursing services, Rogan said, and “we’re still trying to figure out how to fund the nurses after the grant runs out.”

Challenges, rewards

Then there are the challenges that doctors face when treating a profoundly mentally ill population. Appointments take longer, past visits are forgotten, changes in habits or new ailments go unmentioned.

“People could be walking around with high blood pressure and thyroid problems, but they don’t think about them as problems because they have had them for so long,” Thomas-Mohamed said. “They have too much else to deal with, and everything can overshadow the primary health-care interest.”

SAMHSA’s program started three years ago with 13 grantees, and there are now 93 around the country – mostly community mental health centers that want to bring on medical services. As the psychiatrists started trying to incorporate somatic concerns, the learning curve was steep.

“We had folks who didn’t even understand how they would start weighing people on scales – that was so far outside the scope of their organization,” said Trina Dutta, the lead for primary and behavioral health care integration at SAMHSA.

But there have been signs of progress. Of the 592 people who have been enrolled in FSI’s three-year integration effort, many have seen blood pressure decline, weight stabilize and cholesterol levels drop. Fewer patients report being depressed, but the number of smokers has remained the same.

One 29-year-old man, an obese smoker with hypertension and hypothyroidism, lost 27 pounds through diet and exercise after a year with FSI.

A 33-year-old woman who had schizoaffective disorder weighed 372 pounds, but with diet advice from an FSI nurse, she lost 31 pounds in a year.

In addition to nudging the numbers closer to the healthy range, experts say health integration represents an important step in making health care prioritize patients’ needs.

“There’s a difference between a system of care that’s provider-centered, rather than patient-centered,” McGovern said. “We have a back that might ache, but we also might be sad about a loss, and that affects how our feet and backs feel.”

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