Project Narrows Divide Separating MH, Developmental Disability Care

“You'd think that people who deal with developmental disabilities and those who work in mental health would be professional neighbors, but it's not so,” said Pauline Lucero-Esquivel, M.A., coordinator of a collaborative project serving people in New Mexico with both diagnoses. She spoke at the annual meeting of the National Association for Rural Mental Health in Albuquerque in June.

In New Mexico, funding for the developmentally disabled programs is separate from that for mental health programs. Staff members mainly worked in one area or the other, leaving a gap into which patients could fall.

To overcome those divisions and provide better, more coordinated care, a coalition of agencies and organizations developed a pilot project to try to bridge that gap.

The project adopted an innovative strategy linking four local clinics in the state with services from the Department of Health and the Department of Human Services, managed care organizations, the University of New Mexico Health Sciences Center, and the Developmental Disabilities Planning Council, an advocacy agency.

Participants set out to decrease barriers to services, increase clinicians' skills, and improve communication among all involved, especially in rural settings around the state.

Rather than hand down decrees from on high, the participants began with a long series of discussions that involved everyone connected with the project. Meetings began in spring 2001, and the first clinical consultation took place in Taos in November 2002. Eventually, three other rural clinics joined the program—in Shiprock (August 2006), Roswell (June 2008), and Silver City (October 2008).

The primary goal was to find ways to coordinate care and solve problems for people who were “bouncing around the system,” as one participant said. That meant sharing information, while finding ways to maintain confidentiality in both the clinical sense and also in small-town settings where gossip is rife, extended families are common, and a practitioner may see more than one member of a family.

Myriad staffing, clinical, and administrative challenges required a lot of discussion long before the first patient was seen.

In the past, representatives from the health department and the university were seen by rural service providers and patients alike as outsiders all too willing to show up, tell the locals what to do, and then disappear, said neuropsychiatrist Alya Reeve, M.D., an associate professor of psychiatry and neurology at the University of New Mexico and a co-investigator on the Continuum of Care Project, one of the groups involved in the larger project. A good deal of listening at the local level was needed to learn what each clinic wanted.

“We had to go out to the clinics and not expect people who work there to come to Albuquerque,” said Reeve. “Also, we knew that whatever we did would feel, sound, and act differently in the different parts of the state.”

The landscape, weather, economy, and ethnic mix were different at each site, so approaches needed to be tailored accordingly.

The Taos site was a long-established community mental health center and got an early start because a local psychiatrist wanted to know more about treating patients with developmental disabilities. In Shiprock, the clinic site was an Indian Health Service clinic. In Roswell, it was a combination of the student health center at Eastern New Mexico University and a private mental health practice that ran an inpatient unit. In Silver City, a primary care clinic containing a behavioral health unit served as the base.

The discussions revealed ways to open the flow of information among all participants. A case manager's knowledge of a patient's workplace or other setting might prove to be a critical link for the team psychiatrist, while the psychiatrist might learn to ask the case manager or social workers for a wider range of background information.

Team members also learned when others were ready (or not) to move on to subsequent phases of the program, said Lucero-Esquivel. “People needed to feel comfortable talking to and working with others, so they didn't feel out of their element.”

Team members from state agencies and the university included clinicians and administrative personnel. Someone who understands contracts and billing is essential, said Lucero-Esquivel. Each local team included a clinic coordinator, clinicians, financial and administrative support, and patient, family, and community supports. The local teams identified meeting goals.

“We don't come from the big city with our money and our expertise and tell them how to do things. We really follow their lead and see what their needs are,” said Lucero-Esquivel.

Some discussions focused on suggestions for a patient's needs, others on learning about research or new ways of treatment, and still others on helping people navigate the complex system.

Beyond the technicalities, though, lay the value of cultivating relationships among all team members.

“Investing time is important,” said Lucero-Esquivel.“ That helps to better understand people's intentions and reduce the chance of miscommunication.”

Over time, as the local teams gained experience, the need for face-to-face meetings, originally scheduled quarterly, lessened. The project team members gradually became a consulting resource, doing more work through phone calls, validating the local expertise, and making greater use of telehealth systems.

Evaluation of the process using questionnaires and interviews found that providers not only felt more competent as time went by, but also felt that it allowed them to develop best-practice models of the collaboration. Everyone involved gained a deeper understanding of what developmentally disabled people with mental health problems needed and how team members could make those services more accessible. ▪