Preserving the Physical Health of Mental Health Patients
In the wake of a disastrous career move, Macy (not her real name) is recovering from depression, a series of intense panic attacks and self-medication for physical and emotional pain, all of which eventually caused her to check herself into the psychiatric ward of a San Francisco hospital.
Short, thin and sharp-featured, the 52-year-old is also in severe pain from degenerative disk disease, which she’s been living with for a decade; over time, she says, various doctors have prescribed increasingly high doses of opioids. But finding a physician willing to prescribe pain medication – or a place that will accept Medi-Cal to pay for a new back brace – has been a challenge; Macy is broke and in between jobs, homes and health insurers.
After her four-day hospital stay, she is discharged to a residential facility called Avenues. Run by San Francisco’s Progress Foundation, the acute residential treatment facility is an alternative to hospitalization that provides a noninstitutional bridge back to the community for individuals suffering from mental health crises. Depending on the level of care they require, residents might stay at Avenues or another one of Progress Foundation’s 10 residential facilities for anywhere from two weeks to a year.
But Progress Foundation does more than provide a place to live and mental health treatment for clients. It also works closely with a UC San Francisco School of Nursing faculty practice – Primary Care Outreach for the Mentally Ill, or PCOM – which delivers primary care to residents who need it during their stay and helps connect them to the broader health care system. Within just a few days of Macy’s arrival, Sherri Borden, one of PCOM’s nurse practitioners (NPs), has found Macy a primary care physician who understands both pain and addiction, while psychiatrist Jennifer Cummings has properly adjusted Macy’s medications.
“The psychiatrist was very nice, super knowledgeable about medication – including non-narcotic medications,” says Macy.
Tough as her situation is, Macy is one of the lucky ones compared to many who pass through psychiatric facilities. Because she owned a business and ran another, she understands insurance and how to fight her way through the bureaucratic tangles that pose barriers to getting the care she needs. She also wound up in a Progress Foundation program, which for nearly two decades has had the collaboration with PCOM.
“We believe the failure to link mental health and primary care in many settings may be a factor in the poor physical health and early deaths that affect many people around the world struggling with mental health challenges,” says NP Gerri Collins-Bride, who co-founded PCOM in 1995 and is its clinical director.
Collins-Bride and PCOM’s other co-founder, Associate Director Linda Chafetz, are leading a Health Resources and Services Administration (HRSA)-funded study (IPCOM – the “I” is for interprofessional) that will enhance what PCOM does, in an effort to create a replicable model for integrating primary and behavioral health care.
Understanding the Challenge
For those with mental illness, important health concerns often fall through the gaps between the mental health and primary care systems. “Sometimes the simplest things are not treated,” says Collins-Bride.
For example, it’s widely known that many psychiatric medications have metabolic side effects that can lead to obesity, diabetes and cardiovascular risks. Patients on these medications should be carefully monitored for clinical indicators.
“But quite often the clinicians don’t know who is supposed to do what,” says Chafetz. “Mental health doesn’t always have the capacity to track these patients, and primary care isn’t necessarily aware of the behavioral medications patients are on.” This leaves far too many questions in a virtual no-man’s-land: Who’s ordering, looking at and interpreting lab work? Who’s taking responsibility for responding to test results?
Similarly, tobacco use is a major problem among the mentally ill, but it’s often unclear who is responsible for referring to and monitoring patients in smoking cessation programs.
Psychologist Bernadette Navarro-Simeon, director of clinical services at Progress Foundation, says that clients typically arrive at the programs in severe emotional distress. Her staff must stabilize the clients and connect them with the larger health care system, hopefully in a way that closes the clinical gaps. “Coordination of service is key to assisting clients manage their lives,” she says.
Doing so involves working closely with clients to understand their needs and then doing person-to-person legwork, including phone calls, faxes, emails and helping patients with the necessary paperwork. It also involves trying to get the patient’s information into electronic medical records (EMRs) to which future providers have access in such a way that they can make sense of it, regardless of their particular clinical training.
“This is especially difficult, because electronic systems are very different for mental health and primary care, and we often don’t have anywhere to put the information so the next provider knows what these patients need when they return to the community,” says Navarro-Simeon. “If a person is homeless, who in the community will be able to say, ‘Don’t forget, you have an appointment on this date’? There’s a level of frustration all around.”
Such frustrations are exacerbated when patients show up in a clinician’s office or pharmacy looking for treatment and medications that they need immediately. Maybe it’s hypertension medication or insulin. Maybe it’s a psychiatric medication that keeps a patient stable. But if a patient can’t recall how their insurance works or what program they’re signed up for and what they’re eligible for – and the system can’t find them readily – clinicians’ and pharmacists’ hands are often tied. Too often, clients wind up in emergency rooms to get the assistance they need, a costly alternative to services in the community.
“Also, mental health patients can be selective about which medications they’ll take, or because of their insurance coverage – or lack of it – and the way many of these people move from place to place, we may only be able to provide their mental health medications, but not their other medications,” says pharmacist Steve Protzel, who is an associate professor at UCSF School of Nursing in addition to his duties as a staff pharmacist at Safeway in San Francisco. Protzel has been a strong advocate for mental health patients for decades, and in 2012, the American Pharmacists Association recognized him in its One to One Patient Counseling Recognition Program.
The inability to supply or get patients to take all their necessary medications in a timely way can lead to unnecessary crises and relapses. If a patient misses his or her thyroid medication or insulin, says Protzel, the effects may go beyond the physical system to affect their mental health status as well.
Preventing those scenarios often involves a pharmacist getting creative about unearthing a patient’s insurance status so they can get the medication they need. It also means recognizing that in a place like Progress, those administering the medications are usually not physicians or RNs, so Protzel creates special packets and instructions. He also does regular in-services for the staff to educate them about the various medications.
Then there is the question of heading off inappropriate drug-seeking behavior. Protzel says, “Mental health clients may be crazy, but they’re not stupid. They know the system and can become sophisticated about using the proper phrases, like ‘I’m hearing voices,’ to get medications they shouldn’t be having.” He believes a more integrated EMR with a full medication profile that anyone touching these patients could access would make an enormous difference.
It would not, however, overcome all of the challenges. “This is not something you can just wave a wand at and fix,” says Protzel. Training pharmacists about these patients’ special needs and creating policies that address the many concerns are other pieces of the puzzle.
That’s why Protzel is so committed to the team that is trying to create a replicable model.
The UCSF-Progress Initiative
The expectation is that the interprofessional team can build such a model on the highly successful PCOM practice that is already in place for a patient population that faces multiple barriers to accessing care. “We know that integrating primary care into behavioral health has worked well for referrals and for most mild to moderate conditions and substance abuse,” says Chafetz.
“One of the main successes of partnering with UCSF is bringing primary care to where the clients are,” says Navarro-Simeon. “With the symptoms and behaviors of clients, they are sometimes unable to sit in a waiting room and wind up leaving without being seen.”
But models like PCOM are relatively rare, because it only recently became clear that for many of these patients, the mental health sector is their primary point of access, says Collins-Bride. She adds that not all programs need the capacity to deliver primary care on-site like PCOM, but they all need a reliable way to connect mental health patients to primary care providers.
That’s why the current study is intent on formalizing relationships among the team members from multiple disciplines, looking at ways to integrate medical records from these two different arms of the health care system and improving information flow at critical care transitions, especially at discharge from the residential programs. They will measure success, in part, by looking at process and patient outcomes for smoking cessation, metabolic monitoring, reductions in HIV and hepatitis C risks and improvements in medication safety.
For the grant, Chafetz and Collins-Bride – together with School of Nursing faculty members Barbara Burgel and Lou Fannon – have gathered a team that consists of a project coordinator, five primary care nurse practitioners, one clinical pharmacist, two psychiatrists, three psychiatric nurse practitioners, one internal medicine physician consultant and approximately 100 direct care residential counselors spread over Progress’ 10 residential programs.
As the team began its work in the fall of 2013, the project coordinator, Elizabeth Bartmess, conducted a workflow analysis aimed at formalizing the existing team-based approach and developing a standardized communication system.
In many ways, the huddle is the centerpiece of this work.
On a sunny San Francisco day, in the cramped downstairs meeting room of Avenues, NP Sherri Borden meets with psychiatrist Jennifer Cummings, Bartmess and, via telephone, Protzel. The room, next to Cummings’ office, is stacked with unused furniture and has sliding glass doors looking into the yard.
Borden begins by letting Protzel know they have been having trouble getting clients’ nicotine patches filled. Protzel explains there could be multiple reasons – missing client information, some coverage only covers specific products – but they work through a possible fix, and Protzel promises to look at the problem more closely after the huddle.
The next topic involves Progress’ struggles with getting the medication hydroxyzine filled. A prescription antihistamine, hydroxyzine can be used for some psychiatric disorders when a clinician is reluctant to prescribe a benzodiazepine. Again, the group works through some of the legal and financial hurdles and identifies a way to ease and speed the process.
The talk then turns to specific patients, including one who struggles to remember to take her oral medications, which leads to difficulties for both her and the people around her, including physical threats. The solution is a long-lasting injectable version of the medication, but it’s costly, not covered by her insurance, and the family can’t pay. The group brainstorms possible solutions, including contacting the manufacturer’s patient assistance program and researching whether the client might be better served by another insurance plan.
“These days we are getting a higher acuity of patients,” says Cummings. The group discusses how medication becomes especially important with these more acute patients, because if Progress providers can’t stabilize them, patients commonly wind up in a downward spiral where they are completely out of reach of the health care system.
“The important thing to know,” says Borden, “is that the huddles are not always for solving problems; sometimes they just give us a chance to think for a while.”
The huddle at Avenues did not involve other staff members, but they often do, says Navarro-Simeon, and this is important. Many of the staff who work most closely with clients are paraprofessionals, who need to be aware of and understand the effect of each client’s medications, but they also bring important insights to the huddles for the NPs and psychiatrist.
“I have a 40-hour staff, but not a 40-hour psychiatrist and nurse practitioner,” says Navarro-Simeon. “The huddle and the in-services [Protzel] does help the staff understand the medication concerns, but it also takes advantage of how the environment and constant interactions with all of our staff are essential for treating and stabilizing our clients.”
The Technology Piece
Beyond improving and formalizing the processes for team-based care, the IPCOM study is looking at ways to link the existing electronic health record for mental health, known as Avatar, with other electronic medical records. The team is also evaluating options for linking patients to a web-based portal so they can, in effect, take their records with them and avoid some of the typical snarls that compromise their care.
“Right now, each system has different confidentiality rules,” says Collins-Bride. “If someone is seen in a primary care clinic, those people often don’t have access to mental health records and vice versa.”
“Another concern is that most behavioral health care is provided by nonmedical people, so looking at somebody’s labs in medical lingo can be meaningless and time-consuming,” says Chafetz. “The hope is that a central record would state things in plain language, so people in behavioral health would at least know what kind of appointment they need to help clients make next.”
The group is coordinating its efforts with a county system overseen by San Francisco General Hospital that is building a “lifetime medical record,” says Navarro-Simeon.
At the moment, clinicians with the proper credentialing have a “super token” that enables access to Avatar and a patient’s other medical records, assuming they exist electronically. The new system, says Navarro-Simeon, is envisioned as a broader client care management system – a giant database that goes beyond Avatar and an EMR to include the records of shelters and emergency rooms.
Especially for a transient population, the theory is that such a record would make follow-up health care much easier and avert the necessity of time-pressed clinicians sifting through multiple systems and records. Instead, the lifetime medical record would draw from all of the system’s records to allow specific searches and enable specific alerts, so every provider who touches a patient can get the information they need quickly.
The more immediate focus of the IPCOM team, however, remains creating replicable human systems that truly meet the combined behavioral and primary health care needs of the many individuals who pass through the mental health system. This includes increasing the numbers of NPs trained in this interprofessional approach to care.
“I’m hopeful,” says Navarro-Simeon. “We’ve been working with UCSF a long time, and we’ve made a lot of progress. This grant enables us to step back and understand how to keep these clients from rotating through the system. So much of that is about coordinating care.”
If the PCOM team is successful, patients like Macy from around the country can dramatically reduce the amount of time they walk around in pain.