All primary care clinics now have a social worker, and half have a psychiatrist. The remaining psychiatrist slots are expected to be filled by year’s end, says Brian Wong, M.D., Montefiore Medical Group’s director of adult behavioral services.

The new care model includes universal depression screening for patients at the primary care clinics at least once annually, but ideally at each visit, Wong says. The self-administered screening starts with a two-question tool. Patients who screen positive then get a nine-question tool. Primary care physicians refer patients who again score positive to the social worker who, in some cases, is able to see the patient in the same visit. After a full psychosocial evaluation of the patient, the social worker consults with the psychiatrist, and they decide whether the patient needs a referral to the psychiatrist.

Most patients receive therapy, often centered around problem solving, from the social worker. The primary care physician handles prescriptions for common, less-severe mental health problems. The psychiatrists spend about half their time consulting with the social workers and primary care physicians and the other half working directly with patients with the most severe mental illness.

“What it’s done is improve access for patients to either be seen by a psychiatrist or have a psychiatrist’s input [so that] the primary care physicians can prescribe,” Wong says.

Asif Ansari, M.D., medical director at the Montefiore Medical Group—Grand Concourse in the Bronx, says that before the program began there, primary care physicians weren’t asking patients about their mental health often enough. “Now that we have a system approach to this, there is that net where these screens are being managed and looked at by a social worker on-site,” he says. “No one slips through the cracks.”

Having social workers and psychiatrists on the care team provides relief for primary care physicians. “At the same time it makes us step up and be a part of that care, because in the collaborative method, there has to be back-and-forth communication among the therapist, the psychiatrist and the physician,” Ansari says. “When I see the patient next, I have to follow up.”

As Montefiore moves more toward population health, the collaboration between primary care and mental health clinicians will be crucial in managing patients with chronic diseases complicated by behavioral health issues. “Mental health and physical health are intertwined,” Wong says “When [patients are] suffering from depression, we know they are not able to take care of their diabetes or their hypertension and take their medications and make dietary modifications or exercise.”

To illustrate the collaborative care model’s impact, Ansari tells of a new patient who’d recently moved back to New York following his divorce. He told Ansari that before his move, he had gone to a New Jersey emergency department because he felt like hurting himself and was referred to a psychiatrist but never went. The patient later almost committed suicide.

In addition to providing medical care, Ansari was able to connect the man that day with a social worker to get the ball rolling on his mental health care. “He came in because his diabetes was out of control, but if you don’t ask, you don’t know.”

CASE STUDY

Atlantic: Building a full continuum of behavioral health

Over the years, Atlantic Health System in New Jersey has built a continuum of behavioral health care that reaches from inpatient mental health and emergency department services to outpatient therapy and even partial hospitalization and residential care. Now it’s working to fold behavioral health into its hospital-owned, community-based practices.

Atlantic has embedded psychologists in many departments, such as diabetes, pain management, oncology, cardiology and bariatrics.