AUSTIN, Texas — Kerstin Taylor fought alcohol and substance abuse problems for two decades. She periodically sought help through addiction and psychiatric treatments to stay sober, but she continued to relapse.
That unrelenting roller coaster, and the emotional and mental fallout, left her with little energy or resources to take charge of her overall health. Taylor, 53, has asthma and doctors told her she was at risk of developing diabetes.
“I wasn’t doing anything to help myself,” she said about her physical health.
Then an opportunity to get coordinated mental and physical health care services helped turn life around for Taylor, who also lives with bipolar and obsessive-compulsive disorders.
Until recently, health care professionals, in general, treated the mind and body separately and cared for them under different systems. That meant someone like Taylor, who relies on public transportation, had trouble getting to referrals for physical care at locations far away from her psychiatric appointments. That made follow-ups unlikely.
In 2012, Integral Care in Austin offered Taylor a holistic approach, with access to physical health care and a program to manage chronic disease, on top of her regular psychiatric care. Many of the services were available either at the clinic or in her home, and one case manager would help Taylor handle it all.
The seamless care made a big difference, Taylor said, because her recovery depends on addressing all aspects of her health, not just her mental state.
“With chronic-disease [management], resting well, good nutrition, that’s a full package right there,” Taylor said. “It has really built me up to be a better woman.”
Now she has her own efficiency apartment in south Austin and plans to volunteer for a local animal charity. She walks regularly with a chronic-disease case manager and has taken courses to learn how to cook healthful food on a budget.
Efforts to provide integrated care are spreading, especially in public health clinics.
It developed partly out of the realization that untreated mental health conditions negatively affect patients’ physical health, thus costing the system more money.
And in 2010, the Affordable Care Act established a mandate to give parity to mental health services.
A desire to reduce costly emergency room visits also is driving the trend.
A 2007 survey conducted by the Agency for Healthcare Research and Quality indicated that 1 in 8 emergency room visits were related to a mental health or substance abuse diagnosis. Those patients were also more than twice as likely to be admitted to the hospital during that visit.
Over the past decade, the federal government has bet on integrated care to help relieve the problem. From 2009 to 2015, the Substance Abuse and Mental Health Services Administration (SAMHSA) awarded 187 grants worth over $162 million to implement integrated care models.
The Centers for Medicare & Medicaid Services also is investing in integrated care. A 2013 report by SAMHSA found that Medicaid is the largest single payer for mental health services, and nearly a quarter of the inpatient hospital stays covered by the program were for mental health and substance abuse issues.
In Texas, 64 of the state’s 73 federally qualified health centers offer some mental health services, according to data from the Health Resources and Services Administration. That’s a jump from just 36 clinics over a decade ago.
Integrated health care is “fundamental” to achieving state goals such as reducing suicide rates, lowering incarceration rates for people with mental health issues and developing a savvier mental health care workforce, according to the state’s behavioral health strategic plan.
Learning To Be Flexible And Multitask
Austin’s CommUnity Care is a federally qualified health care clinic that serves mostly low-income and uninsured patients in several locations around the city. Pediatrician Tracy Lama-Briseño sees the benefits and challenges of integrated care there every day.
She said the average person would be surprised to learn how many young children and teens deal with mental health issues.
“We do have some pretty young kids that start to present at an early age with symptoms of anxiety or sadness,” she said. “Parents separating … the loss of a loved one. All that can be pretty confusing to a young child.”
Lama-Briseño’s clinic sees about 23,000 medical patients per year, approximately 1,700 of whom use mental health services.
Sometimes the boundaries of responsibility can get blurred between mental and physical health care, she said. “I feel like I do a little bit more social work than I would like,” she said. “But in the end, it’s about taking care of the kids and the families.”
Addressing mental health in primary care gives access to people who might never seek it out, but it also opens the door to additional responsibilities for Lama-Briseño. For instance, CommUnity Care administers a two-question depression screening to every new patient older than 12 and repeats it for existing patients once a year. The results can prompt further action.
Lama-Briseño describes how her young patients can come in for one thing, like an earache, and then the visit turns into something completely different. She said it all happens quickly.
“You can’t say ‘OK, make another appointment,’” she added. “It has to be, you know, dealt with then and there. And so I definitely had to learn how to be flexible and sort of multitask.”
Lack of Mental Health Specialists
One of the challenges for the integrated model is recruiting mental health professionals. Approximately 1 million adults statewide have a “serious mental illness,” according to the Texas Health and Human Services Commission, and more than 80 percent of Texas’ 254 counties don’t have enough mental health professionals to care for patients.
The Department of State Health Services also reports that the majority of counties, especially in the western half of the state and in the Panhandle, have no practicing psychiatrists.
“My concern, actually, is that we don’t have a big enough pipeline to fill these jobs that are gonna be available,” said Neftali Serrano, executive director of the Collaborative Family Healthcare Association, an advocacy group for integrated care.
Serrano likened the problem to trying to build a plane while flying it. The health care system can’t just stop, so people need to be trained in this new way so that, as integrated care becomes more common, they’ll be ready to work, he said.
“This is not just about plopping a mental health professional in a primary care setting,” he said. “It takes … a certain kind of behavioral health professional, and well-trained physicians and nurse practitioners and [physician assistants] to do this work well.”
Buy-in from primary care doctors is another piece to the complicated puzzle of integrated care. While surveys show many support integrating mental health professionals with primary care, some lack the incentive to change their practices.
Dr. Ernest Buck is chief medical officer of Driscoll Health Plan, which serves mostly kids and families on Medicaid in a highly rural area that spans 26,000 square miles from south of San Antonio all the way down to Brownsville. Buck said most practices in his network aren’t willing to bring on a therapist.
“It’s hard to start a new model where a physician’s practice could be put at risk, particularly at Medicaid rates,” which tend to be lower than private insurance plan payments, he said.
Also, many primary care doctors simply weren’t trained to work this way — collaboratively, on a team with mental health professionals.
Bill Tierney, head of Population Health at the University of Texas-Austin’s Dell Medical School, said that when he was a practicing family doctor he rarely worked with mental health professionals.
“For 15 years, I practiced with no mental health support,” he said. “If I sent [patients] to the mental health clinic, I didn’t know whether they got there. They had a separate information system, I couldn’t see how they were being treated, and patients often didn’t want to go to see the shrink.”