EXECUTIVE SUMMARY
Hospital staff must identify patients with behavioral health issues and physical problems, and include both conditions in the treatment and discharge plans in order to prevent readmissions.
- Patients with behavioral issues often have trouble adhering to their treatment plans, which increases the financial risk hospitals are beginning to bear as healthcare shifts to value-based reimbursement.
- Hospitals are beginning to integrate treatment for mental and physical issues by placing clinical social workers in the ED to screen patients, contracting with a nearby mental health clinic, and assigning their own behavioral health staff to the ED.
- Case managers should refer patients to community resources, preferably with a patient-centered medical home that can provide care for both issues.
- Integrated care begins in the ED, but the staff typically has little training on how to recognize and treat behavioral health disorders.
When patients have mental health issues and physical problems, the plan of care must include both medical care and treatment for the behavioral health issues to achieve successful outcomes.
“Providers should take a holistic approach to medical care by simultaneously assessing and treating the physical complaint as well as any mental health needs before sending patients home. When mental health issues, such as depression, are not treated at the same time as physical complaints, the depressive symptoms often keep patients from effectively following their doctor’s orders,” says Patrick Hernandez, DBH, MSW, LMSW, CPRP, management consultant for Berkeley Research Group, LLC.
He points out that about 20% of Americans have some mental health or substance abuse issue, and that 60% to 70% of those have at least one chronic physical condition. If these patients don’t get treatment for both the mind and the body, they’re likely to be high utilizers of healthcare resources, he adds.
People with emotional disabilities often stop taking care of their health, Hernandez says. For instance, patients with diabetes who already struggle to keep their blood sugar levels under control may stop taking their medication when they experience a depressive episode, and could end up in the ED with elevated blood sugar or ketoacidosis, he adds.
People with recurring mental health issues have higher mortality rates than others, Hernandez points out. “Statistically, patients diagnosed with mental illness are not as healthy as people without mental health pathologies. This population experiences more hypertension, obesity, hypercholesterolemia, and have higher rates of smoking. People with diabetes experience higher rates of depression when compared to the non-diabetic patients,” he says.
Many hospitals are seeing a steady increase in the number of patients coming through the ED with behavioral health issues as well as physical complaints, says Nancy Magee, BSN, MSN, RN, senior consultant for Novia Strategies, a national healthcare consulting firm. (For more on identifying mental health issues in the ED, see related article in this issue.)
Often, the behavioral health issues are a major part of the problem because they interfere with patients’ ability to follow their treatment plans, she adds. Many medications required to manage behavioral health conditions have unpleasant side effects, and patients may stop taking them. This makes the behavioral health condition worse, and can compromise their physical health as well, Magee points out.
Patients with mental health problems who are treated in the ED or admitted to the hospital for physical problems may not get the comprehensive treatment they require, Magee adds.
“It’s important that hospital staff is able to identify patients and treat underlying mental health conditions, as well as their physical symptoms and disease. Coordinating care for patients with coexisting conditions like this can be very challenging,” she adds.
Healthcare professionals have recognized the connection between mental health issues and physical problems for a long time, but only recently have providers started to combine the two, says Henry Chung, MD, vice president and chief medical officer at Montefiore Care Management Organization, and associate professor of clinical psychiatry at Albert Einstein College of Medicine in New York City.
“In the 1970s and ‘80s, primary care physicians were treating people for stress-related and mental health problems that resulted in physical symptoms. Patients did not generally want to use behavioral health services, but stayed with their primary care providers,” Chung says.
Part of the reason is that the stigma connected with mental health issues makes many people reluctant to seek treatment, he says. “But more than that, before the Affordable Care Act mandated it, few insurance companies offered behavioral health benefits,” Chung says.
As the Affordable Care Act (ACA) moved toward quality-based reimbursement, healthcare providers had the incentive to begin looking at combining behavioral health treatment with treatment for physical conditions, Chung adds. (For information on linking patients with behavioral problems to medical homes, see related article in this issue.)
“It’s not like doctors and health systems didn’t know that creating integrated services was a good idea. They knew it, but the Affordable Care Act’s emphasis on quality pushed the risk onto the health systems and individual providers — and people began to recognize that it was financially beneficial for patients to get primary care and mental health care at the same time,” Chung says.
Montefiore has developed several programs to increase the behavioral health services provided in primary care practices. The New York-based health system’s Collaborative Care program gives primary care practices a virtual behavioral health team to assist with patients’ behavioral health needs. In March, Montefiore launched a program to assist small physician practices in treating common behavioral health issues. (For details, see related articles in this issue.)
Patients covered by Medicaid often have high rates of substance abuse and mental health needs compared to non-Medicaid populations, Hernandez says. “If hospitals and primary care physician offices don’t integrate behavioral healthcare into their practices, patients will flock to emergency departments for treatment. The emergency department will become a revolving door for those seeking relief from mental health symptoms. We already see mental health numbers rising in the emergency department,” he adds.
The problem is particularly acute with homeless patients, Magee points out. “If the emergency department staff or the case managers on the floor can’t connect patients to community resources, they are likely to return,” she says.
It’s difficult to follow up with homeless patients, Magee adds. “They need a place to go where they will be safe and where they can be found,” she says.
The University of Illinois Hospital in Chicago collaborates with Chicago’s Center for Housing and Health to find subsidized housing for homeless patients who frequent the ED. The hospital developed the program in response to a growing homeless population with substance abuse issues and other behavioral health problems, in addition to chronic conditions, says Stephen Brown, MSW, LCSW, PMP, director of preventive emergency medicine. (For details on the program, see related article in this issue.)
Patients in the program have experienced significant decreases in healthcare costs and reduced ED visits, Brown says.
“The answer to the problem of the mentally ill homeless population is more subsidized housing, not more medical facilities. The majority of homeless patients with mental health issues would do well if we had more subsidized housing. Our society has all the resources to fix the problem of homelessness and mental illness, but we can’t because everyone operates in silos,” he says.
Healthcare providers across the country are beginning to integrate behavioral health and physical health, but are facing financial barriers and staffing issues as they change the healthcare delivery process, Hernandez says.
The least expensive way is to add clinical social workers to the ED staff to coordinate care for behavioral health patients and link them to outside agencies, but this doesn’t provide comprehensive integration, he says.
Some providers have taken the process a step further and set up their own treatment centers or contracted with a behavioral health provider for a clinic that is near the ED. This enables a smooth handoff to the behavioral health staff after treating patients’ medical issues.
“These kinds of arrangements require contractual agreements and increase liability for the provider, but it’s a step in the right direction toward integrating medical and behavioral health treatment,” he says.
Magee tells of a hospital program in California that collaborates with a psychiatric outpatient facility to provide care for patients with behavioral health problems presenting to the ED. Once the treatment team stabilizes the patients medically, a social worker takes them to the clinic where the behavioral health team takes over.
“In well-developed programs like this, the social workers often arrange follow-up clinic or home visits by a mental health practitioner. This is no different from what disease management programs do when they arrange and coordinate follow-up care,” she says.
Other health systems provide home visits or follow-up phone calls to behavioral health patients and partner with community agencies who can provide support for the patient in the short term, she says.
The most effective way for hospitals to provide coordinated care for behavioral health patients is to have behavioral health consultants on staff, working in tandem with the medical staff, Hernandez says. “The behavioral health consultant provides a comprehensive mental health assessment, then gives recommendations to the medical provider to help build a more effective plan for the patient and may provide focused psychotherapy during the visit,” he says.
Incorporating mental health and medical screening tools can be effective in getting patients to the right treatment setting more quickly, Magee says. Case managers should be familiar with the available tools and how to use them, she adds.
“Most of us in nursing were trained in a medical model with limited exposure to behavioral health. In today’s world, we need to be knowledgeable about mental health issues, how to identify them, how to manage them, and how they affect the patient’s recovery and ability to follow the discharge plan,” Magee says.
Acute care case managers still have a lot of opportunities to improve the way patients with mental health comorbidities are identified, Hernandez says. He advises health systems to invest in the kind of screening assessments that identify patients who may have a behavioral health need.
He suggests that case managers on the hospital unit perform a risk assessment on all patients to identify any behavioral health issues and, depending on the level of risk, either collaborate with a social worker on a discharge plan or suggest a psychiatric consultation if the patient’s issue is acute.
“Case managers should be on the lookout for patients suffering quietly. If their behavioral health issues aren’t handled, they’ll continue to suffer and they will continue to be readmitted as their mental health needs continue to go untreated,” he says.
Hospital staff must identify patients with behavioral health issues and physical problems, and include both conditions in the treatment and discharge plans in order to prevent readmissions.
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