Integrated medical care aims to break down wall in treating illnesses of body, mind
Rosalyn McFarland provides primary care to some of the most challenging patients in the health care system: people with severe and chronic behavioral health conditions.
But McFarland, a nurse practitioner at Whole Health Clinical Group in West Allis, has the advantage of working closely with its psychiatrists, psychologists and other therapists, pharmacists and case managers.
The result is more collaboration and better coordination of care.
It's an example of a change slowly beginning to take hold in the U.S. health care system: integrating primary and behavioral health care.
The Institutes of Medicine recommended integrating primary and behavioral health care more than 20 years ago, and supporters contend that the model can improve care and lower costs.
It also is part of the realization that the historical separation between physical and mental health doesn't serve patients well.
"Behavioral health was carved out of the medical world many, many years ago, and people are finally beginning to see there were some mistakes around doing that," said Peter Carlson, president of behavioral health for Aurora Health Care.
The U.S. health care system spent $220 billion on behavioral health in 2014, more than any other medical condition, including cancer and heart disease. Behavioral health conditions, ranging from depression and anxiety to severe chronic conditions such as schizophrenia and other psychotic disorders, affect nearly one in five people.
The Centers for Disease Control and Prevention estimates that 20% of primary care office visits are related to behavioral health conditions. Patients with behavioral health problems also are more likely first to seek help from their primary care doctor.
Yet many of those patients are referred to what essentially is a separate health care system.
Supporters of integrating primary and behavioral health care contend that treating depression, anxiety or other behavioral conditions shouldn't be any different than treating diabetes, high blood pressure or other medical conditions.
"It's an illness like any other illness, in the sense that something goes wrong somewhere in the body," Carlson said.
One model for integrating behavioral health and primary care focuses on making it easier for primary care physicians and other clinicians to consult with psychiatrists.
But the model thought to have the most potential is having psychiatrists, psychologists, therapists and nurses work with doctors, nurse practitioners, physician assistants and others who provide primary care — all in the same clinic and ideally on the same team.
The model, known as collaborative care, is a proven way to improve the care for patients with mental illness, said Thomas Heinrich, a family medicine physician and psychiatrist at the Medical College of Wisconsin.
Sixteenth Street Community Health Centers has moved to a version of collaborative care. And Froedtert & the Medical College of Wisconsin and Aurora Health Care, among others, plan to test the model.
The model enables primary care physicians to treat more patients with behavioral health conditions, reducing the number of referrals and improving access.
That's in part because the primary care physicians can easily draw on the expertise of specialists in behavioral health or immediately do a "warm handoff" to a therapist at the clinic.
The primary care physicians and other clinicians and behavioral health specialists also learn from each other, Heinrich said.
"They are going to be operating in the same hallways and the same clinic," he said. "Education occurs on a daily basis in these kinds of environments."
Another feature is care managers who can follow up with patients, such as checking on side effects of medications.
"It provides the backup that the primary care doctors need," Heinrich said.
The collaborative model also is seen as a way of dealing with the severe shortage of psychiatrists by reducing referrals and freeing psychiatrists to focus on patients with the most severe conditions.
Patients may have to wait two to three months to see adult psychiatrists at Aurora, Carlson said. The wait is four to five months or longer for child psychiatrists, and even longer for addiction psychiatrists.
Merritt Hawkins, a health care recruiting company, said psychiatrists now are its second most-requested search.
"Psychiatrists are next to impossible to find," said Maria Elena Perez, a psychologist and director of behavioral health at Sixteenth Street Community Health Centers.
The community health center has a behavioral health staff of roughly 28 psychiatrists, psychologists and licensed counselors and social workers. (Psychologists have doctorates; licensed counselors and social workers have master's degrees.)
Its behavioral health staff has long been located at its clinics and available for referrals and consultations. But in the past five years or so, it began looking at new models for providing care.
In the past year, Sixteenth Street began embedding behavioral health specialists with primary care doctors, enabling them to do brief interventions and further assessments, Perez said. That has freed up its physicians.
The behavioral health specialists also can work with patients on changing behaviors, such as helping them manage chronic diseases.
In addition, Sixteenth Street has three behavioral health specialists who are available for same-day appointments several days a week.
Patients with more acute or chronic conditions that require more intensive care are referred to a therapist or psychologist on staff — although there typically is a monthlong wait for an opening.
Community health centers are located in low-income urban neighbors and rural areas. Most of their patients are covered by Medicaid programs, such as BadgerCare Plus. And people with low incomes are more likely to have a behavioral health problem than those with higher incomes.
Medicaid accounts for more than a quarter of all behavioral health spending nationally, according to the Kaiser Family Foundation, a health policy research organization. By one estimate, more than one-third of the people covered by Medicaid have a mental illness.
Of those, 61% also have other medical conditions — and treating those conditions is much harder when a patient has depression, anxiety or other behavioral health conditions. A patient with depression, for instance, is less likely to manage his or her diabetes or high blood pressure.
"We can't separate the mind and the body," said Perez of Sixteenth Street.
The model isn't designed for patients with severe mental illnesses — estimated at almost 10 million, or 4.1%, of adults.
They require the specialized care available at a behavioral clinic such as Whole Health Clinical Group.
"Our mission is to serve the people with the most need," said John Chianelli, executive director of Whole Health's West Allis clinic.
Whole Health Clinical Group, part of the Milwaukee Center for Independence, provides an array of services for people with severe behavioral health conditions.
The clinic employs 240 people, including 60 case managers who closely monitor the most vulnerable patients, visiting some as often as twice a day.
The Milwaukee County Behavioral Health Division contracts with the clinic for case management and other services.
Whole Health, which also operates 170 apartments for people with severe behavioral health conditions and a crisis resource center, is an example of an organization that provides so-called wraparound services that people with severe mental illness often need in their day-to-day lives.
Providing primary care extends that model.
McFarland, the clinic's nurse practitioner, provides primary care to about 500 of the clinic's 1,100 patients.
She is part of an interdisciplinary team that meets every Tuesday to discuss complex patients who may be at risk.
Case managers will identify patients who may be at risk of a crisis, such as someone who is not taking his or her medications or not following up on referrals. And the clinic's pharmacists have expertise in the complex drugs used to treat severe mental illness and their side effects.
"One person can't do it all," McFarland said. "We have to do it as a team."
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