Can a hospital, its affiliated community-based physician group practices, and a community mental health center work together to ensure access to mental health services? In south-central Massachusetts, the answer is a resounding “yes!” What follows is a case study of how collaboration between primary care and behavioral health providers led to increased services for mental health consumers.
Located in south-central Massachusetts approximately one hour west of Boston, the Blackstone Valley has a population of 205,000 in 17 cities and towns. The region has experienced rapid growth in the past decade and is now a mix of exurban and rural areas.
In this region, Milford Regional Health System is the largest provider of medical services, with a hospital (Milford Regional Medical Center), a multispecialty physicians' group practice with 20 locations and 80 physicians and nurse practitioners (Tri-County Medical Associates), and a small community health center (Tri-River Health Center). Riverside Community Care, a community mental health center, is the largest mental health provider in the area, and also serves 46 other communities in eastern Massachusetts. Riverside provides a broad spectrum of services, including outpatient, mobile psychiatric emergency evaluations, psychiatric day treatment, and early intervention, as well as supported housing, group homes, and prevocational services.
In the Blackstone Valley, the availability of behavioral health practitioners in general, and psychiatrists in particular, is quite limited. The area is not adjacent to any teaching hospitals, and private psychiatrists have been reluctant to locate practices in the region. In addition, Milford Regional Medical Center does not have a psychiatric inpatient unit.
For many years, outpatient providers were unable to meet the growing demand for behavioral healthcare services, and PCPs were frequently left to treat their patients' behavioral health conditions without adequate support from specialists. In 1993, Milford Regional Health System made efforts to respond to the behavioral health needs of the physician group practices by hiring two part-time psychiatrists to manage referrals from its PCPs. These psychiatrists provided ongoing medication management, which resulted, over time, in limited availability for new patient referrals.
During this same period, Riverside developed a contractual relationship with the hospital to provide psychiatric coverage in its emergency department, as well as consultation on patients on the hospital's medical units. The provision of these services was successful, and a positive relationship developed at the two organizations' executive level.
To address the longstanding and paralyzing access issues in the Blackstone Valley, the hospital, Tri-County, and Riverside entered into a partnership to dramatically improve access to behavioral healthcare services and psychiatric consultation for the physicians. Tri-County shifted referrals from the two part-time psychiatrists to what became known as the Urgent Behavioral Health Center (UBHC), operated by Riverside and funded through a mix of third-party and contract dollars. With Riverside's participation came a robust and multidisciplinary system of service delivery and expertise in behavioral health.
The UBHC's outpatient psychiatric consultation model is similar to the standard medical specialist consultation model. The PCP refers the patient to mental health specialists at UBHC who:
consult with the referring physician;
stabilize and briefly treat the patient; and
return the patient to the PCP for ongoing medication management, when appropriate, or refer the patient to area outpatient clinics or group practices.
To better accommodate the needs for behavioral healthcare services, a shift was made from a psychiatrist-only practice to a multidisciplinary team comprised of independently licensed psychologists, social workers, and psychiatrists. Adding mental health clinicians allowed for a greater capacity for both clinical triaging services and initial assessments. In turn, psychiatrists could be used in more specialized ways to ensure access to prescribing medications and consultations with referring physicians.
Licensed clinicians at UBHC triage patients by phone—on the same day as the call—and schedule intake within two to three business days. During intake, patients are assessed and continue in the UBHC program for stabilization and brief treatment or are referred for longer-term and/or more intensive care. If no appropriate provider is immediately available, patients continue treatment at UBHC until the referral can be completed.
Patients appropriate for stabilization and brief treatment at UBHC typically meet with a clinician weekly and focus on alleviating symptoms. If pharmacologic intervention is indicated, a patient is referred to a UBHC psychiatrist within three to five business days. Once stabilized, patients receiving medications are returned to their PCPs for continued prescribing or referred to outpatient mental health clinics for ongoing management of complex major mental disorders and polypharmacy situations.
Throughout the course of brief treatment at UBHC, clinicians and psychiatrists frequently communicate with the PCP about the patient. Collaboration between PCPs and Riverside's multidisciplinary staff allows scarce and expensive psychiatry time to be used when most needed. At the same time, a PCP can quickly access a psychiatrist for a telephone consultation. Communication and coordination among PCPs and Riverside specialists have become one of the partnership's hallmarks.
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