Letter

To the Editor: In the April issue Drs. Smith and Sederer ( 1 ) do a terrific job presenting a rationale for the "mental health home." There is no doubt that our fragmented behavioral health system is inadequate for individuals most at risk. There is no reason to think that the public's demand that general hospitals substantially improve both process and outcomes shouldn't apply to the behavioral health industry. The coordination and delivery of behavioral health services must improve, and the mental health home concept warrants a close look.

At the heart of the model the authors see "generalists working with the entire individual and coordinating care among a range of behavioral and rehabilitation service providers." I couldn't agree more, although an empathic relationship is a must, and no one framed this better than Deitchman ( 2 ), who felt that the "chronic client in the community needs a 'traveling companion not a travel agent,'" or Lamb ( 3 ), who advocated for "therapist-case managers." Coordination without an empathic worker-consumer relationship is bound to fall short of expectations for improved service delivery.

Coordination will also fall short if the mental health home team's added value is limited to advocacy. Advocacy is helpful but not adequate to overcome the system's numerous structural weaknesses. Achieving continuity of care for individuals most at risk would require the team to have resources and authority to acquire services.

In 2007 Jersey City Medical Center's Behavioral Health Center established a "clinical home" pilot for adults with co-occurring disorders and histories of high recidivism and treatment nonadherence (I was vice president for behavioral health at the time). Every behavioral health program—partial hospital, outpatient department, emergency department, residential facility, and intensive case management—can function as a clinical home. The clinical home duties are above and beyond that program's routine services and are considered "enhanced." The pilot assigns "navigators" to consumers with high use of emergency or inpatient services who will not accept community-based services or are ineligible for intensive case management or assertive community treatment. The evidence to date is that the clinical home reduced recidivism and enhanced treatment adherence for consumers whom the system had given up on.

The model is unique in that the clinical home clinician (or team) follows the consumer through all services. If the partial hospital accepts responsibility for a consumer and that consumer needs hospitalization, the partial hospital worker follows the consumer through the inpatient stay. If the emergency department is the clinical home and the consumer wants partial hospitalization, the emergency department worker escorts the consumer to the program until linkage is established. Consumer choice must supersede program and system concerns.

One reason that the pilot works is that all the services are under one agency. No doubt this model would create potentially insurmountable turf issues in multiagency systems, but there can be no minimizing the value of a mental health home, where one team has the resources and authority to acquire services valued by the consumer. Certainly the mental health home warrants significant demonstration project funding.

Dr. McCreath is president and chief executive officer of Hall-Brook Behavioral Health, Westport, Connecticut.