MDNews - Minnesota

The Right Fit In Minnesota, a younger initiative led by the Institute for Clinical Systems Improvement (ICSI) offers an integrative approach to primary care from 22 medical groups in seven states. Claire Neely, MD, Medical Director of ICSI, notes that a reciprocal relationship between comorbid medical and behavioral health conditions often makes managing either condition more difficult for patients. "Patients with depression find it hard to manage their medical diseases," Dr. Neely says. "Treating depression makes it easier for people to manage their diabetes, to exercise and eat right, and to take their medications — and the other way around, too. [For] people [who] have a lot of difficulty with their medical diseases, it may be difficult for them to manage their depression." ICSI instituted the Care of Mental, Physical and Substance Use Syndromes (COMPASS) program to more effectively treat patients whose medical conditions — often diabetes or cardiovascular disease — frequently involve behavioral health concerns. Similar to the Cherokee Health Systems model, ICSI facilities incorporate a care manager — who may be a medical assistant, nurse or social worker — to coordinate patient care and help manage the behavioral health component of care. The intake process involves a thorough evaluation of medical, social and economic conditions that may impact patient care. Next, the care manager takes the information to a systematic case review, where a psychiatrist and internist evaluate possible medical and behavioral health goals and then send a care plan recommendation to the primary care physician. Because ICSI works with established medical practices, the behavioral care aspect must be tailored to the strengths of each practice. Dr. Neely notes that some facilities aren't equipped to treat substance abuse issues, but some handle complex mental illness. Overcoming Challenges ICSI's initiative spans seven states and enrolls approximately 1,200 patients. Dr. Neely explains that providing effective behavioral health care to a large patient population raises a number of considerations, the most important of which is how the community perceives mental health. "We run into these differences across the country in dealing with different cultural groups," Dr. Neely says. "There are different comfort levels with the word. One of our groups doesn't even use the word 'depression' because it raises so many barriers in the patient population. They call it stress or mood problems." "Mental health treatment is best located, for most patients, in the primary care provider setting. Referrals don't work well. Expertise should be moved to the front line." SPECIAL CLINICAL SECTION: MENTAL HEALTH concerns that might impede treatment. "On the spot, physicians will refer the patient to the behaviorist for a quick assessment and consultation," Dr. Freeman explains. "It happens as part of the primary care visit. Then, there's a quick hallway conversation about what the behaviorist found and what needs to happen [in terms of treatment]." Assimilating behavioral health consultation into the primary care setting, and coordinating the two elements with a shared electronic health record, reduces the possibility of patients falling through the cracks before receiving behavioral care attention and brings together all members of the team to reach consensus about the proposed treatment plan. Dr. Freeman notes system-wide physician surveys have indicated the program's acceptance among physicians. In an unsolicited show of support on a primary care provider satisfaction survey, physicians wrote in that they would never work without a behaviorist again. — Dennis S. Freeman, PhD, CEO of Cherokee Health Systems This isn't an issue confined to cultural roots, though. Dr. Neely explains that for effective behavioral care integration, medical groups must accept that the discipline belongs in their practices, and anecdotal evidence shows they are. "Over the years, I've done a lot of work trying to improve care and implementing initiatives, mostly in the primary care setting," Dr. Neely says. "This is the first project I've ever done that all physicians involved find [to be] valuable and fruitful work." ■ MDNEWS.COM ■ MD NEWS Twin Cities | 17

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