People with serious mental illnesses often suffer with chronic, many times life-threatening, physical health conditions. They can have difficulty accessing primary care services or be treated by general healthcare providers who do not fully understand their needs. To ensure people with mental illnesses also have their physical health addressed, Skyland Trail, an Atlanta-based residential and day mental health treatment center specializing in depression, schizophrenia, and bipolar disorder, opened an on-site, full-time primary care clinic-one of likely only a few nonprofit community-based mental health centers that have done so.
Skyland Trail Associate Medical Director Eric Chavez, MD, MPH, examines client Chris S. in the facility's on-site primary care clinic.
Recognizing the need
The National Association of State Mental Health Program Directors reports that adults with serious mental illness treated in public systems have a life expectancy about 25 years shorter than average Americans. Additionally, according to the National Institute of Mental Health's CATIE study, patients with schizophrenia have an inherent predisposition to metabolic syndrome, which is worsened by their often sedentary lifestyles, poor dietary habits, and medications' side effects. Subsequently, people with schizophrenia experience a higher risk of morbidity and mortality than the general population.
Despite these disturbing data, a divide between primary and mental healthcare persists, a gap that Ray Kotwicki, MD, MPH, Skyland Trail's medical director, says may partially be a consequence of fundamental biases by both primary and mental healthcare professionals.
“On the mental health side, we tend to focus on our own area of expertise in a very systematic approach, and the same is true for primary care clinicians,” Dr. Kotwicki explains. “Oftentimes patients' mental concerns are so complex that we just don't have the resources to cover soup to nuts.
“Additionally, when certain healthcare providers see a serious mental illness, their biases may indirectly cause them not to ask thorough questions,” he continues. “For instance, if a physician sees a patient who is schizophrenic and complaining of chest pains, many times he assumes that patient is delusional. In reality, the patient could actually be having a cardiovascular symptom or some other physical source to his complaint. Even well-intentioned physicians may ‘write off’ physical symptoms in individuals with mental illnesses to only being part of their mental illness.”
Seeing an opportunity
Skyland Trail's primary care clinic was spawned during a 2004 strategic planning retreat of its National Advisory Board, a group of leading psychiatrists representing major academic institutes throughout the country. At that time, Skyland Trail's care model, as at many psychiatric facilities around the country, focused on patients' mental health needs, with medical care provided by their primary care providers in the community. The National Advisory Board saw an opportunity to do something unique.
“When the National Advisory Board met in 2004, one of the emerging trends echoed by many was the integration of medicine and psychiatry,” says Skyland Trail President Beth Finnerty, who has been with the organization since its inception in 1989. “The data backed up the fact that people with major mental illnesses have a shorter life expectancy, and the idea of primary healthcare at Skyland Trail really resonated throughout the group.”
With a primary care clinic part of Skyland Trail's strategic plan, a task force of staff and board members formed to see it through to implementation. One big hurdle remained: funding. So the task force decided to start small but think big.
Skyland Trail's primary care clinic opened part time in 2006 with one exam room and one part-time nurse practitioner. Securing funding from private Atlanta-area foundations, Skyland Trail opened a full-time clinic in June 2008, growing into a 1,500-square-foot facility that includes a pharmacy, two exam rooms, infirmary, laboratory, waiting and reception area, medical director's office and additional office space, and research area.
“As it turned out, there were several foundations in the Atlanta area with a similar interest in and focus on this intersection of medicine and psychiatry,” explains Finnerty. “We are fortunate and grateful for the early support from these foundations with start-up and renovation expenses.”
She adds, “Behavioral health managed care organizations are still one of the primary challenges for us. Their systems don't recognize the fact that primary care can be successfully delivered at the same place psychiatric care is being delivered. As a result, charges are often denied.”
Skyland Trail's primary care clinic.
Focusing on wellness
While Finnerty and the Skyland Trail development team sought funding for the clinic's building, the clinical staff created a wellness initiative that would be at the heart of the primary care clinic. They developed three primary care tracks into which each patient is assigned: