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Barbara B. Walker, Ph.D., provides behavioral health services once per week at a local primary care office. She is clinical director of the division of behavioral medicine at The Miriam Hospital, in Providence, Rhode Island. (photo by Kathryn Hardy) |
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By Phyllis Hanlon
Since the turn of the century, consumers and practitioners have begun to realize that physical illness and psychological health can no longer be categorized as separate and distinct. Achieving a delivery system that integrates both physical care and emotional intervention is a monumental undertaking. However, Rhode Island is tackling the task.
For the last two and a half years, a contagious energy has been spreading throughout the healthcare community in the Ocean State. The Allied Advocacy Group for Collaborative Care, the Primary Care Physician Advisory Committee (PCPAC), the Integrated Primary Care (IPC) initiative and several integrated practices are the result of that storm.
A. Kathryn Power, M.Ed., former director of Rhode Island's Department of Mental Health, Retardation & Hospitals (DMHRH), and co-chair of the Allied Advocacy Group, says, "In building that momentum, we've attracted researchers, insurers, health plans, academia, private providers and state government. We have built a collective group of people that represent all the sectors that are necessary to make this kind of change." In June, Surgeon General Richard H. Carmona, M.D., voiced his support at a forum that addressed the issue of integrated healthcare delivery.
Power's co-chair Michael Fine, M.D., reports that collaborative or integrated practices have been established in Woonsocket, East Providence, Providence, Pawtucket, Central Falls and Warwick. These models include community mental health centers as well as private and hospital-based practices, "practices that we believe are the flagships for Rhode Island's health care future," Fine says.
Inspired by Alexander Blount's book "Integrated Primary Care: The Future of Medical and Mental Health Collaboration," Barbara B. Walker, Ph.D., clinical director of the Division of Behavioral Medicine at The Miriam Hospital, participates in the drive toward medical/behavioral integration by providing behavioral health services once a week at a local primary care office. Her commitment is grounded in the conviction that each patient deserves to be treated as a "whole" person. "I always teach the interns that the person in front of you is a bio-psycho-social entity," she says. "You have to address each of those areas and understand each one and how they are related to each other before you can help the person."
As expected, the road to successful implementation of an integrated healthcare system has not been smooth. "The piece that's missing is how we make this work financially," Walker says. Currently, no reimbursement is provided when a behavioral healthcare specialist speaks with a medical professional. "When you do collaborative care, you have to talk to each other," she says.
The fiscal feasibility of integrated healthcare does worry insurers, but the news is hopeful. Donald P. Galamaga, MPA, CCP and president of the Mental Health Association of Rhode Island, says, "There are some natural tensions. Insurers would rather have the PCPs become more adept at handling behavioral health interventions themselves." But there has been some openness on the part of insurers. Blue Cross/Blue Shield of Rhode Island has been observing a small, integrated practice and reimburses for behavioral interventions, according to Galamaga. "Insurers will demonstrate a greater willingness to invest as they see the benefits to the model."
Power notes that next year Blue Cross/ Blue Shield of Rhode Island will sponsor a national symposium that assembles interested practitioners to discuss the idea of integrated practice.
Cultural perspective presents another significant challenge. Individuals diagnosed with a physical illness, ranging from hypertension to obesity, might require behavioral intervention as part of a successful treatment plan. However, the stigma of seeing a psychologist prevents many patients from adhering to that prescription. "Ninety-five percent of the patients I see in the primary care office have never seen any type of mental health professional, nor would they go see one," Walker says. She adds that 75 percent of primary care referrals never follow through on doctor's orders.
James Szabo, LICSW, manager of family outpatient services at the Community Counseling Center, which follows the integrated model, agrees that patients seen in an integrated system tend to be less concerned with the embarrassment of a mental illness diagnosis and also have a lower dropout rate. "Client's perceptions change when they are able to access all services through the same door and not have to go off to that 'special mental health' building," he says.
In spite of these challenges, Galamaga has found a high level of cooperation among the key parties. "I think the story at the outset sells the need to cooperate," he says. He points out that some PCP organizations are offering continuing education units for physicians who obtain more knowledge in the area of mental health and some psychiatrists are learning that patients with serious psychological problems need a special strategy to handle their physical needs.
Galamaga says that acceptance and successful implementation will rely on specialized training and education. Through alliances with academic institutions such as the School of Medicine at Brown University, future doctors will be educated and acclimated to the integrated model of healthcare.
Paul Block, Ph.D., co-director of Psychological Centers, in R.I., concurs that a strong sense of cooperation exists among practitioners. "In general, most PCPs are invested in access to mental health services for patients," he says. "They see the lack of care and the difficulty in getting therapy to supplement their pharmacology." According to Block, integrating healthcare will be an incremental process rather than a sea change. "This will be an agenda item of importance in the mental health area for the next 10 or 20 years unless we give up," Block says.
Power sums up the state's efforts this way: "I think it's going to require an extraordinary level of commitment, an extraordinary vision, and frankly, an extraordinary will to be able to do this because this is not just a simple 'let's experiment with a little pilot program.' This is a fairly profound shift in the way we think about delivering healthcare."
With this initiative, Power believes Rhode Island is paving the way for the rest of the nation.
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