Regional Medical Center (Sonora Regional) in Sonora,
Calif., John's primary care physician could find no
physical reasons for John's chronic pain, persistent
cough and weight gain. So the physician called in
Director of Behavioral Health Galyn Savage.
When Ema became pregnant, her primary care physician at
La Red Health
Center (La Red) in Georgetown, Del., performed a
prenatal evaluation that included an oral exam.
As healthcare reform encourages integration of healthcare
to treat the patient as a whole (see Models of
Care Integration Continue to Evolve), behavioral
health and oral care—often termed medical
silos—are being integrated into primary care
practices around the country. Historically, behavioral
health and oral care providers had little or no
communication with their patients' primary care
physicians. Patient care simply didn't cross those lines.
Proponents involved in the integrated care metamorphosis
say that segmented patient care doesn't have the same
positive outcomes that are being demonstrated with
When cancer disrupted her life, Norma's anxiety level
contributed to her withdrawal from family and reliance on
alcohol to help her cope. A team management approach to
her illness, which included Evans helping Norma learn
stress management tools and find alternatives to alcohol,
resulted in Norma's current state: cancer-free,
alcohol-free and happy again.
Savage's sessions with John and his wife, Susan, revealed
underlying behavioral health issues related to John's
unemployment, their subsequent financial distress and
Susan's terror of going into the work world when she had
always been a stay-at-home mother to their three
children. Savage helped the couple improve communication
and coping skills, and even referred Susan for a job.
Susan found she loved working and gained confidence in
her abilities. John assumed household and parenting
duties, and began looking into furthering his education
to improve employment options.
And Ema, whose mouth revealed extensive tooth decay, was
referred to La Red dental staff. Ema received dental
treatment as well as instruction on developing home oral
care habits for herself and her future children.
“Specialty care providers like psychologists
and dentists are not the first pathway people seek for a
health-related problem,” asserted
Ana Bridges, PhD, a University of Arkansas professor
who specializes in integrated behavioral healthcare.
“Even if a patient does seek specialty care, a
specialty clinic doesn't necessarily communicate with the
patient's primary care provider. So patients are likely
to experience redundancy in services or even worse, a gap
in timely, effective service. True integrated care
encompasses patient care from the tip of the head to the
bottom of the toe.”
Research confirms Bridges' assertion. Calling mental
health one of the biggest problems facing modern medicine
today, The Integration of Mental Health Into Primary
Care, published in June, touts the benefits of behavioral
health integration. A Sept. 2012 report,
Returning the Mouth to the Body: Integrating Oral Health
and Primary Care, labels dental disease one of the
great preventable public health challenges of the 21st
century. Both publications document high comorbidities
between physical diseases and behavioral and oral health
“What we have seen is how patients who had
physical treatable illnesses really didn't improve until
we began treating underlying behavioral health problems
taking a biopsychosocial approach,” Savage
said. “Many people who present with a medical
complaint have a psychological or lifestyle problem.
These issues can't be remedied by a medical solution.
They need help with behavioral, emotional and
La Red Dental Director Dr. Maryann Bailey routinely sees
toddlers whose mouths are already full of decaying teeth
and adult patients whose poor oral health makes it
difficult for them to eat.
“They might go to the doctor if they get sick
but many of them have never seen a dentist and they don't
practice any oral home care,” Bailey said.
“Little by little, we are getting people to
understand the importance of good dental care and how it
impacts their physical health too. But it is a huge
In Maine where TCMHS has integrated mental health
services into 12 primary care locations, CEO Catherine
Ryder says, “Our integrated care model has
resulted in patient care outcomes that are nothing short
of miraculous.” Their data demonstrates that
integration is cost effective and results in faster
diagnoses and treatments for patients. Patients, as well
as providers, report improved satisfaction.
Statewide Campaign in Maine Promotes Broad Integration
TCMHS is among 42 grantee sites and more than 150
practice sites with projects in various stages that focus
on integration of behavioral health and/or oral care,
which are both identified as key elements in Maine's wide
sweeping integration effort. Federally qualified health
centers (FQHCs), hospital-affiliated primary care
practices, regional mental health organizations,
school-based health clinics, state government, statewide
organizations and peer-run mental health advocacy and
support organizations are participating in integration
projects that Maine Health
Access Foundation (MeHAF) funds and oversees. Nearly
$10 million has been invested in the multi-year process
initiated in 2007, according to the Foundation's Senior
Program Officer Becky Boober.
At Penobscot Community
Health Care (PCHC), an FQHC based in Bangor, Maine,
whose service area includes surrounding small towns and a
large rural area, about 40 mental health specialists and
25 dentists are among team members that share physical
space and patient electronic health records, meeting
regularly to coordinate individual patient care. One of
only 30 sites nationwide to receive an
“exemplar practice” award from the
Robert Wood Johnson Foundation, PCHC has grown in 10
years from one clinic site with 25,000 annual patient
visits to 17 service sites providing approximately
350,000 visits for almost 70,000 patients.
PCHC's integrated behavioral health encompasses a public
housing clinic, clinics for homeless people, a homeless
shelter and pharmacies for medication management.
Specialty care and structured programs address specific
mental health needs, such as ongoing support for people
with severe mental illness.
“When we integrated oral care, the response was
overwhelming,” CEO Kenneth Schmidt said.
“Without even advertising, we instantly had a
dental waiting list of 5,000 people. We are up to 49
dental operatories and still are overwhelmed. We have
people coming from all over Maine because dental care
isn't available where they live or dentists in their area
don't accept Medicaid or uninsured patients.”
PCHC's status as one of 44 federally designated teaching
health centers in the United States helps meet staffing
demands. PCHC annually trains more than 300 students,
interns and residents majoring in various healthcare
professions, including general and pediatric dentistry.
Dental residents supplement staffing, and Schmidt said
some have joined PCHC staff after graduating.
Regional and Clinic-based Integration Efforts Offer Big
It doesn't take a statewide effort to benefit from
integration. Healthcare reform encourages behavioral
health integration and oral care for the federally funded
FQHCs, which has contributed to FQHCs becoming leaders in
the integration transformation.
In the 11 years since it opened, La Red has evolved from
its original function as a 24-hour hotline to a regional
FQHC with a new 25,000-square-foot healthcare facility in
Georgetown and a second site at Seaford. Primary care,
behavioral health and oral care are co-located under one
roof in Georgetown. In addition to expanded space for
family medicine, lab and other primary medical services,
the facility has six behavioral health offices, a child
observation room, child therapy room, behavioral health
group counseling and education rooms, and eight dental
Primary care providers do oral evaluations and screen all
patients for mental health disorders. In the first year
of integration, identification and treatment of patients
with mental health needs increased by 379 percent.
Dental patients increased by 165 percent. La Red dental
staff collaborates with physicians to address medical
conditions that warrant dental supervision. All pregnant
and new moms are referred for oral care instruction.
“Everything we do centers around education
first,” Bailey said. “We are
beginning with the baby's birth, teaching young women
what not to put in that baby bottle and how to clean
their baby's very first tooth. It's hard to stress enough
how important it is to incorporate these home changes.
But it's so rewarding to see children out of pain, able
to chew, and having more confidence when they smile. At
first, there was a lot of fear and the people we serve
weren't very trusting of us. But now they are referring
friends and family.”
To stretch staff resources for oral care and in response
to a patient population that is largely Hispanic,
bilingual promotoras have been hired and trained to
provide families with basic education and home care
supplies. Delaware Technical and Community College dental
hygiene students extend La Red staffing by doing exams,
pediatric X-rays and simple treatments such as fluoride
La Red's mental health integration includes routine
screenings for domestic violence and sexual abuse.
Primary care providers refer patients to mental
health providers for age-specific diagnosis and
treatment. La Red plans to improve mental health access
with the addition of telepsychiatry in the near future.
One of only four FQHCs in Delaware, La Red serves
approximately 6,500 patients. About one-half of patients
have no health insurance.
Sonora Regional, where Savage works, began integrating
behavioral health with primary care about six years ago
and has since begun oral care integration. Sonora
Regional is one of 50 rural health clinics (RHCs) owned
Health. All Adventist Health RHCs provide primary
care with various levels of integration including
behavioral health and/or oral care. Headquartered in
Roseville, Calif., the faith-based, nonprofit Adventist
Health operates the largest network of RHCs in California
as well as owning and operating hospitals, outpatient
centers, home care and hospice agencies, and retirement
While patients receive the most obvious benefit of
integration in terms of improved response and treatment
time, Savage says providers also benefit by
participating in a coordinated team care model.
“By sharing information and meeting together
regularly to discuss the best integrated care for each
patient, providers from various disciplines learn from
one another. They have the reward of seeing patients
diagnosed and treated more effectively. Because of that
earlier diagnosis and improved care system, patients also
spend less time in the system. That places less stress on
already strained rural providers with heavy patient
Co-location, “Warm Handoffs,” Improve
Patient Access and Care
Primary care physicians, mental health providers and
dentists are in particularly short supply in rural areas,
making rural integration models even more beneficial,
Bridges said. Co-location of services improves patient
access and reduces transportation barriers.
Co-location, using promotoras to assist families with
transportation, and requiring an appointment deposit has
improved patient attendance at appointments in La Red's
rural Sussex County service area, Bailey said.
“Warm handoffs” also produce improve
the likelihood that patients will make and keep
appointments. When Norma's physician recognized that
family and financial issues were impacting her ability to
cope with cancer, he initiated a warm handoff where he
personally took Norma to meet a behavioral health
provider there. TCMHS, which has contractual arrangements
with the primary care clinics, has co-located providers
into each clinic.
“We are definitely seeing that the warm handoff
improves patient access and perception,”
Maine Primary Care
Association (MPCA) Chief Operating Officer Darcy
Schargo said. “A few years ago when a provider
had a patient with complicated issues, the patient would
have been referred for a behavioral health appointment
weeks later. Often, patients didn't make or keep those
appointments. When their provider hands them off to a
specialist now, they see that specialist as part of their
Patients are 85 percent more likely to keep their first
appointment since Sonora Regional introduced warm
handoffs, Savage said. “The primary care
physician (PCP) introduces me in the exam room as a
colleague who is going to help the patient with the
issues that have just been revealed to the PCP, usually
depression, anxiety, substance abuse issues or
environmental issues which are negatively impacting
health. The PCP leaves the exam room and I speak
with the patient for a few minutes. I give information on
how to cope with the current crisis and I may teach a
technique to do that. I make sure the patient has someone
to contact for immediate support once the patient leaves
the clinic. Then I walk the patient over to the
receptionist who schedules an appointment for this new
Integration partners also need support systems as they
develop their programs. MPCA offers a peer organization
coaching model where FQHCs pair as learning partners to
enhance their levels of integrated care.
“We provide mentoring and peer learning support
for the community health centers (CHC/FQHCs),”
Schargo said. “We have growing core
competencies they will embrace in the next couple years.
We are further along with behavioral health integration
but oral health integration is one of the strategic
priority areas we plan to really grow in the next three
years. Our goal is to have all our CHCs fully integrated
“It's a great time to be in the transformation
of healthcare,” Schmidt reflected.
“When staff, providers, managers and everyone
working together in healthcare has the same vision of
always looking at how we can do this better and how we
can help patients be healthier, then we in community
health are going to significantly improve health and
reduce costs. I feel fortunate to be involved in this
integration evolution in the last stage of my
* The Rural Monitor is no longer using patients' last
names, to ensure patient privacy.
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