“There are psychiatric components to all of the chronic diseases that need to be addressed,” says Linda Reed, R.N., vice president of integrative and behavioral medicine and chief information officer. “If you can embed those kinds of services up front, you can facilitate coping throughout the whole care process and you don’t wind up with hospitalizations.”
Integrating behavioral health into those departments removes the stigma associated with mental health care and improves patient compliance with treatment, says Lori Ann Rizzuto, director of behavioral and integrative health services. For example, behavioral health is integrated into the diabetes curriculum. “You have the nutritionist, the diabetes educator and the psychologist. It doesn’t seem to be odd in any way because they’re part of the team.”
The health system has geropsychiatric units at three of its hospitals. Services are designed to address the specific difficulties faced by older adults, including a higher incidence of depression and isolation. “Most of the time, people come in and they’re treated for their medical problems, and their behavioral or psychological problems are put on the back burner,” Reed says. “This is the other way around.”
In its EDs, Atlantic has made accommodations to better serve patients with mental health conditions. Communitywide shortages of inpatient psychiatric units mean that patients might wait days for a bed. Atlantic hospitals have space set aside in their EDs for behavioral health patients to prevent overstimulation that can worsen their conditions. There, patients are started on active treatment plans so time isn’t wasted while they wait for an inpatient psych bed, Rizzuto explains.
Atlantic also is beginning to integrate behavioral health clinicians into some of its employed practices outside the hospital. “One of the things we’re struggling with as a health system is the expense of doing that,” Reed says. “What does it cost? Who funds it? Do you get enough benefit on the other end for the funding? At some point, will the payers fund it?”
The system owns a 650-physician multispecialty practice, and one challenge is to figure out where the need for behavioral health is the greatest, Reed says. It might be primary care, diabetes care or cardiology.
Atlantic is starting by focusing on practices that share the hospital’s culture and participate in risk contracts. “We’re finding the people who we think are really charged up and understand what we’re doing,” Rizzuto says. “They understand the difference between what the costs are up front and what the value is downstream.”
Behavioral Health Network: Linking up all the providers
The 2010 closure of a state mental health hospital caused alarm in the St. Louis-area health care community over the increased demand it would have on an already overburdened system. To come up with solutions to the problem, local hospitals and community mental health centers partnered to create the Behavioral Health Network of Greater St. Louis.
The organization developed the Hospital-Community Linkages Project that facilitates referrals from hospitals to community mental health centers and improves care coordination between them. The project is funded primarily by the state and also by an annual fee paid by participating hospitals. It targets patients who are uninsured or on traditional Medicaid, who aren’t already linked with a service provider, and who have a serious mental illness.
On the inpatient side, each of the 11 participating hospitals and seven CMHCs has a dedicated liaison. When a hospital is discharging a patient from its inpatient psychiatric unit, the liaisons participate in discharge planning, schedule an outpatient appointment and transfer medical information, says Wendy Orson, the network’s CEO. The initiative is expected to generate 700 or more referrals from inpatient units this year.
In the project’s ED component, emergency department staff or the hospital liaison calls Behavioral Health Response, a nonprofit mental health crisis response provider with 24/7 mobile outreach services. If the mobile outreach team is available, it goes to the ED to meet the patient and schedule an outpatient appointment. If the patient leaves before the team gets there, it follows up within 24 hours. The program generates about 540 referrals from EDs each year.
Implementation of the ED project at Barnes-Jewish Hospital required a culture change, says Robert Poirier, M.D., chief of clinical operations and emergency services and a Behavioral Health Network board member. ED clinicians needed training to adopt the process of screening patients for eligibility and referring them early so that the response team is able to arrive before the patient leaves.
The network attributes a 47 percent reduction in ED visits and a 57 percent drop in inpatient days to the project. Only 18 percent of clients are readmitted into the hospital in the six months following admission to a CMHC. A study of the project’s Medicaid patients showed an annual cost reduction of about $5,450 per patient for the health care system.
“Even though it may not be run by the same organization, [the project] still could be considered an accountable care organization because everybody is accountable to each other,” Poirier says. “If there are problems on the outpatient side, the inpatient side is eventually going to notice because the patient comes in and needs to be admitted. On the inpatient side, if we don’t connect to the outpatient side, we treat them and a week later, when they’re off their meds again, they’re bouncing back and costing more.”
Lee Memorial: Helping ED patients get outpatient services
Florida’s Lee Memorial Health System is taking several approaches to connecting ED patients with mental health and/or substance abuse problems to the outpatient care they need.