Integrated Care: Meeting Mental Health Needs After the Gulf Oil Spill

In developing overall behavioral health recovery efforts for the state, MBHCP in Louisiana (MBHCP-LA) drew heavily on national models utilizing federal, state, and community leadership, with emphasis on community engagement and provider and stakeholder collaborations. The programmatic design for MBHCP-LA is adapted from the evaluation framework model developed by the CDC (9). In Louisiana, most of the affected and designated communities in MBHCP had little access to behavioral health services before our program began. If individuals or families needed care, they had to drive long distances, often to a metropolitan area, to access specialty care at already overtaxed clinics. The symptoms of behavioral health problems often affect a person’s willingness or ability to seek treatment. Therefore, it can be assumed that most of the individuals with mental health problems identified by LSUHSC clinicians in the integrated care program were receiving limited interventions.

In designing a working model for integrating behavioral health care into primary care clinics, the team researched existing national and international programs, with special focus on communities lacking local mental health resources (10,11). Such programs generally reflect one of two designs: a colocated psychiatrist who provides traditional mental health services within primary care clinics, with varying degrees of direct collaboration with primary care providers; or a centralized consultation-oriented model, with trained clinicians or case managers and with clinical and educational consultations provided at a distance by a psychiatrist who oversees several clinics. Both of these models have strengths; however, the MBHCP-LA team determined that neither approach alone was fully adaptable to the postdisaster needs in close-knit, largely rural communities that also faced successive disasters, cycles of economic concerns, and limited availability of general medical and mental health resources.

In establishing a program of behavioral health integration in primary care clinics, MBHCP-LA sought support and guidance from community stakeholders, community providers, and the five primary care clinics closest to the affected communities in parishes identified in the class action settlement. MBHCP-LA clinicians met with administrative and provider staff at the clinics to identify the current resources, patient loads, projected mental health concerns, and specific needs of each clinic. On the basis of these discussions, it appeared beneficial to have psychiatrists and psychologists directly embedded in the clinics, working collaboratively and fostering trust among primary care providers and patients. Considering the geographical distances and illness burden of the patient populations, MBHCP-LA developed a team-based approach with centralized care management to coordinate the field efforts of the mental health specialists. It was also decided to carefully integrate telemedicine into the project, taking care not to sacrifice the trust that direct face-to-face communication builds. This approach allowed the team to establish a network of care tailored to the individual needs of each clinic and provider. The network includes several levels of care: universal behavioral health screening, acute and emergency supportive care, and ongoing treatment.

The program model that the MBHCP-LA team developed and implemented is an interprofessional stepped-care collaborative—one which allows mental health clinicians to provide high-quality care for the greatest number of patients in an efficient, time-sensitive manner without sacrificing the level of care. Regular collaborative and consultation meetings with the primary care and mental health providers are essential to increase primary care providers’ effectiveness in handling behavioral health issues. In this way, patients can be treated adequately by the primary care provider, with clinical decision support from the psychiatrist or psychologist. If the behavioral health problem is complex or outside the level of comfort of the primary care provider, direct assessment of the patient is provided, and the patient’s treatment is managed within the primary health care clinic by utilizing both on-site and telemedicine services. Emergency consultations are available 24 hours a day, seven days a week via telephone and telemedicine; in addition, patients are triaged to be seen in person or by telemedicine within a week. This level of consultation has been successful in preventing two or three emergency room evaluations weekly and ensures that patients who require hospitalization are thoroughly evaluated through consultation with specialists before activation of emergency transport.

The care management component of the collaborative program provides ongoing support services for all behavioral health patients. Care management allows the specialist's services to be utilized in the most efficient manner and ensures a high level of continuity during treatment. Care managers monitor progress, concerns, adverse reactions, and adherence to the treatment plan. They alert the specialist or primary care provider in a timely, sensitive manner in regard to patient concerns when remediation and further planning are needed. Care managers also manage interprofessional communication and assist in scheduling appointments for patients with primary care or mental health clinicians. The five primary care clinics currently being served refer a total of 50 to 75 new patients a week to the team; the numbers will increase in 2014 with the addition of three clinics that are being rebuilt in affected areas.

The MBHCP-LA interprofessional collaborative program is training adult and child psychiatrists, psychologists, social workers, and adult and child psychiatry residents in a later stage of their training, under supervision, to participate in the provision of services. All components of the model are being evaluated, and initial results are promising. Staff have noted that symptoms of mental disorders were previously underreported and undertreated.

Since early 2013, a total of 355 adult patients have been screened for symptoms of mental disorders at intake to services at the five primary care clinics. Beginning in May 2013, follow up evaluations that include the same measures have been carried out by MBHCP-LA clinicians and research associates. Of this group, 146 (41%) received follow-up evaluations by one month and 95 (27%) by three months. PTSD symptoms are measured with the PTSD Checklist, civilian version (12), depression symptoms with the nine-item Patient Health Questionnaire (PHQ-9) (13), and anxiety symptoms with the seven-item Generalized Anxiety Disorder Scale (14). Significant decreases in psychiatric symptoms were found at the one-month follow-up, with further declines at the three-month follow-up. [A table showing changes in scores over time is available as an online data supplement to this column.] Somatic symptoms are assessed with the PHQ-15 (15) and have also shown significant improvement.

Anecdotally, clinic staff have reported appreciation of the collaborative program and satisfaction with services provided. Staff also describe an increased sense of confidence and competence in their ability to evaluate and treat mental health symptoms. They also report increased resilience if and when another disaster occurs, given their improved knowledge as well as their ability to call on mental health partners at any time.

Under the MBHCP-LA, an interprofessional collaborative program was designed to provide critical integrated behavioral health care services in primary care clinics for populations most affected by the Gulf oil spill. These communities have been affected by repeated disasters, and they are also faced with disparities in care, including few, if any, locally available mental health providers. Under the MBHCP-LA, care is provided intensively by an interprofessional team effort that includes primary care providers, psychiatrists, psychologists, social workers, and care managers. Services are provided directly in local clinics, as well as by telemedicine. Real-time emergency evaluations of patients are conducted during clinic hours, and telemedicine consultations are conducted 24 hours a day, seven days a week.

These efforts have resulted in fewer hospitalizations and barriers to care, and they provide the highest-quality mental health care, with continuity between primary care providers and specialist mental health clinicians. Many patients have been referred for mental health interventions, and follow-up data show significant improvement in symptoms of depression, anxiety, and PTSD. Of note, a related decrease has been seen in somatic symptoms. The approach could be used by other communities at risk of disasters to develop more effective responses to aid recovery and build sustainable services. The collaborative approach also provides a model for rural communities that experience disparities in care and for communities with few or no locally available mental health clinicians to build better and sustainable mental health consultation and services in primary care clinics.

The authors report no competing interests.