Unexpected Help, in Unexpected Places

In a busy New Hartford, NY shopping plaza a steady stream of patients make their way into an old store front that has been converted in to primary care clinic; most are here to receive treatment for things like the common cold, chronic conditions and annual check-ups. But since 2017, visitors to the clinic have also found an unexpected benefit, in the form of on-site behavioral health services.

The Mohawk Valley Health System (MVHS) has partnered with the Central New York Care Collaborative (CNYCares) to expand access to behavioral health services across the Mohawk Valley region. Through these efforts, MVHS now employs six licensed clinical social workers (LCSW) that offer services at 16 MVHS primary care offices throughout Utica and Rome (including outlying areas) to assist in identifying and treating behavioral health conditions. Behavioral health services consist of a wide-range of offerings including mental health, well-being, counseling, and addiction treatment.

The Process
Jodi Kapes, director of Behavioral Health for MVHS, explains “for most people the first place you go when you’re experiencing health related issues is your primary care provider.” Its commonplace for patients to receive services for health related conditions at a primary care office, but MVHS is now offering services to address behavioral health needs as well. “It really boils down to giving people access to services they need,” says Kapes. “Incorporating behavioral health services in primary care offices where people were already being seen for other health issues felt like a natural fit and comfortable place to address patient needs.”

One of the key elements in making the integration process work was buy-in from physicians. Kapes says that the approach was actually met with great enthusiasm. “Most of the physicians ended up being almost more excited than we were because they were seeing a huge increase in people with behavioral health issues in their practices, and were almost afraid to ask questions because there was nobody on-site to help deal with the answers.

“Now when a patient comes in and they're describing their issues and the provider is thinking, ‘this patient has been here repeatedly with stomach pain for the past three months – and we can’t find anything. Maybe – it’s anxiety?’ they now have a resource right down the hall to help that patient.”

The DSRIP Catalyst
MVHS’s effort to integrate behavioral health services into primary care locations grew from the New York State System Reform Incentive Payment (DSRIP) program, an ongoing effort to reduce unnecessary hospital use, with projects selected to address particular community needs. One of those projects is focused on integrating primary care, behavioral health and substance use services together. Through the DSRIP program, healthcare, behavioral health, and community-based agencies receive funding to implement projects and improve patient outcomes.

The integration model allows patients to receive more comprehensive services in one location. In addition, through coordinated treatment, quality of care improves and costs are lowered.  

For many hospital systems across New York State, efforts like the DSRIP program have been the financial catalyst to more adequately address the needs of the communities they serve.

Robert Scholefield, MS, RN, executive vice president/chief operating officer for MVHS said, “The problems associated with behavioral health aren't going to go away. If anything, they’re going to get worse. We need to prepare ourselves for that, today.

“Locally, we have a high population of behavioral health patients that just haven't had access to services. And the biggest impact that we see are patients that are coming into our emergency departments and inpatient units,”

“This investment in our primary care clinics speaks to our commitment in improving access to services that our critical to the community.”

MVHS’s commitment to provide services that improve health and wellness across the region does come with some challenges.

Michael Attilio, MD, vice president of MVHS Medical Group/Physician Practices explains, “Treating a behavioral health patient in the Emergency Department who will likely spend a few days in the hospital following that treatment creates a tremendous strain on resources and doesn’t provide an appropriate level of care for patients.  

“Many of the patients we’re seeing in the ED have behavioral health issues that can be addressed through our primary care offices. In many cases, the truly severe diseases (i.e. paranoid schizophrenics) are the ones that require more specialized services which is not the major challenge we’re seeing in the community. The major challenges are the types of conditions that can be treated through case management services which our integrated staff are uniquely positioned to do.”

Kapes says that the most commonly seen condition in the MVHS primary care clinics is generalized anxiety disorder, and recent statistics support this trend. A 2018 online poll from the American Psychiatric Association found a 39 percent rise in anxiety for U.S. adults compared to just one year earlier.

“A lot of the people we see aren't long-term therapy people,” says Kapes. “They have something acute going on right now that they need help with. We help them get through this episode, hopefully in a short amount of time, so they can move on with their lives.”

And for Dr. Attilio the MVHS integration program is about focusing on the right kind of treatment. “We see the bigger picture, and from a clinical perspective, a community health perspective, this is just the right thing to do, period.”

Overcoming Stigmas
For many patients, one of the biggest challenges in addressing behavioral health is overcoming the stigma. Kapes explains that one of the things her staff does constantly is reassure patients that it’s not uncommon to have these experiences.

“I've had several cases where people come in and say, ‘I'm not really sure why I'm here, but this and this and this is going on right now,’” says Kapes. “It almost becomes a light bulb moment when we identify something that could be affecting them emotionally and physically. It gives us a chance to let them know this is very normal. Lots of people go through this. It’s also a chance for us to talk, reframe some thoughts and offer some alternatives to dealing with these challenges,”

For some patients, the simple convenience and comfort of a familiar environment – like their primary care office – is the difference between getting help and never receiving behavioral health services. 

Valerie Lighthall works as an outpatient clinical supervisor at MVHS. In her role, she’s part of the care team with clinical providers in a primary care office.

“If they [a primary care doctor] can bring one of us in to meet with a patient, there's a 99 percent chance that the patient will keep their follow-up appointment and get the help they need,” says Lighthall. “I've had a lot of patients tell me that it's so much easier for them to come to the primary care office; they tried to go to behavioral health clinics in the past and for whatever reason,  they felt stigmatized or they didn't like the environment or the atmosphere. This is a lot easier for them.”

Lasting Impact
With 16 sites currently integrated, MVHS has made great strides to improve access to care across the region. In fact, in 2017, MVHS’s integrated behavioral health services team saw 844 unique patients, for a total of 1,644 encounters. More impressive than the number of cases, is the story behind each encounter.

“I can think of one patient in particular who was being seen in the ED 10 to 20 times a month,” says Kapes. “The ED visits weren’t necessary as her challenges were something that could be addressed through one of our primary care offices.”

The ability to offer patients alternative resources in the community can make a big difference. “By simply having a social worker connect with this patient in one of our primary care offices, she went two months without an ED visit,” said Kapes. “That's huge for us.”

Reducing unnecessary ED visits is also one of the primary goals of the New York State DSRIP program. In 2017, MVHS’s integration efforts resulted in a 5 percent reduction in avoidable ED readmissions.

It’s these types of results that have encouraged MVHS to continue to offer coordinated services.  

“We view this work as being truly just the beginning,” says Lisa Volo, director of Population Health at MVHS. “Our vision for behavioral health services extends beyond the integrated program. We’ve begun working with local community-based organizations to potentially develop a behavioral health response team.”

The response team model would offer mobile services that can be deployed across the region and provide assistance to individuals experiencing crisis. Response team services can include: assessment, counseling, and peer support. Response teams also work closely with local agencies (law enforcement, behavioral health agencies etc.) for referrals and long-term treatment services. Offering these types of response services can help address access challenges in more remote locations across the Mohawk Valley.

Volo believes these types of programs can have a lasting impact. “When you look at all the different partnerships across the community from County agencies, to the hospital, and community partners willing to collaborate we can begin to develop programs that make a huge difference,” says Volo. “It’s a chance for us to look at ways we can improve services and bring them into the communities that need them the most”.