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No single path to integration

April 1, 2011
by Gary A. Enos, Contributing Editor
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A Rhode Island CMHC incorporates primary care both in-house and out in the community
President and ceo dale k. klatzker, phd, with new director of integrated care, nelly burdette, psyd.

President and CEO Dale K. Klatzker, PhD, with new director of integrated care, Nelly Burdette, PsyD.

The community mental health organization based in Rhode Island's capital city would list more than a few ingredients in a recipe for successful integration of behavioral health and primary care services. A wellness component, commitment at the highest level of the organization, and a dedicated staff function in integrated care would qualify among the many must-haves, judging from the early experiences of The Providence Center.

Perhaps most importantly, according to the community mental health center's leaders, successful pursuit of integrated care must be guided by the thought that there isn't merely one care model that will prove beneficial. In addition, the behavioral health and primary medical cultures stand little chance of co-existing if individuals care too much about who gets the credit.

“The CEOs of our two organizations started to work together and developed this energy,” says Jackie S. Fantes, MD, associate medical director for Providence Community Health Centers, which is partnering with The Providence Center on projects on each organization's home turf. “We came to the realization of, ‘Wow, we can work together; this is great.’”

The two organizations have teamed up on a pair of initiatives designed to benefit distinct populations. Since last summer, a licensed clinical social worker from The Providence Center has been housed at one of Providence Community Health Centers' primary care clinics, available to primary care patients mainly for brief counseling for mental health issues such as depression and anxiety.

And in a groundbreaking project (which was scheduled to open for business at the start of 2011) the primary care organization is establishing an on-site primary care clinic with one physician and two other clinical staffers at The Providence Center's main adult treatment site. The clinic is expected to serve seriously mentally ill clients who despite a number of physical health concerns have never established a consistent relationship with a primary care physician.

In November, The Providence Center took another uncommon step for a CMHC: It hired a director of integrated care specifically to oversee initiatives that are expected to increase in importance as terms such as “accountable care organizations” begin to dominate the language in the healthcare marketplace.

Nelly Burdette, PsyD's experiences, which in the past have mainly involved work with primary care professionals, include a former role at Cherokee Health Systems in Tennessee, one of the first CMHCs in the country to have demonstrated success with fully integrated behavioral health and primary care services under one roof.

“There has not been as much experience around the country with medical services embedded in behavioral health,” Burdette says. “Doctors are not trained to be in a mental health facility. For many of them, seeing one or two of our patients a day would produce enough stress for them for the day. Our professionals see 10 of these patients a day.”

Services at primary care site

The first manifestation of cooperative discussions between CEOs Dale K. Klatzker, PhD, of The Providence Center and Merrill Thomas of Providence Community Health Centers came to life last summer at one of the primary care organization's clinic sites in Providence.

Through a private foundation grant, The Providence Center houses a social worker at one of Providence Community Health Centers' primary care clinics (The Providence Center has a similar arrangement under the foundation-supported effort with a second community health center in Rhode Island). The social worker is familiar with intake processes through her prior work in emergency services with the CMHC. In her role at the primary care clinic, she receives referrals from primary care physicians in situations where a medical patient might be experiencing symptoms of a mental health issue.

Providence Community Health Centers' Fantes explains that the program maintains some open access to the social worker's time for clinic patients, and pre-scheduled appointments are made for some patients as well. The LCSW operates under a general guideline that if she doesn't believe a patient's problem can be sufficiently addressed in four 45-minute sessions, she should refer that patient elsewhere for more specialized mental health treatment.

“If she starts to do a whole bunch of counseling, that limits the time available for referrals,” says Fantes.

For many of these clinic patients, the opportunity to see a mental health professional at a primary care site reduces the stigma they likely associate with receiving mental healthcare. Ironically, patients with serious mental illness who are longtime clients in the public mental health system often express the same hesitation about receiving general medical care. This dichotomy helps explain why integrated care in general is becoming focused to tailoring services to the patient, not to judging whether one location ultimately will be considered the “better” setting for integrated care.

Thomas sees the social worker's presence as playing a pivotal role for the primary care organization's patient population. “We have a lot of patients with depression at our medical clinics,” he says.