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Complete Care Integration: You Can Lead a Patient to the Doctor…

Every moment of a medical appointment is crucial to the wellbeing of an individual challenged by mental illness and treated with psychotropic medication. It is an opportunity to educate and intervene at the earliest possible stage, or to anticipate and alleviate issues that have already begun. For those chronically dealing with who and are already experiencing the effects of metabolic changes, weight gain and hypertension often associated with the latest medications, the appointment is an opportunity to set the course right without any further delay. Unhealthy behaviors such as cigarette smoking are also prevalent in the community and can be addressed without negative consequences for those challenged by mental illness.

There are many hurdles in practicing medicine. Few patients are primed to arrive, communicate the pertinent facts, be succinct, get help and be on their way—quickly. However, after speaking to physicians about their experiences treating those most affected by mental illness it is clear these patients can present unique needs. This scenario sums up one of the more common issues:

“I met with the patient and he told me about his knee pain. We spent a good deal of time because he was very focused on it. I prescribed pain meds, ordered an x-ray and on the way out he reached into his pocket and pulled out a piece of paper from his psychiatrist. It said: ‘Please evaluate for hypertension. Patient’s blood pressure has been spiking in the afternoon at day program.” The patient’s case manager gave him the note and asked him to give it to me at his appointment. On the way in he hit his knee on the bus and that was his problem at the moment. As a medical professional how might you handle that patient? As a consumer how would you have handled it differently? What could a psychiatrist or case manager have done to help improve that situation? As behavioral health professionals what can we do to ensure our clients get the help they need from their physicians?

According to the National Association of State Mental Health Program Directors (NASMHPD), and the National Institute of Mental Health have found that those chronically challenged by mental illness are dying anywhere from 8 years to 25 years earlier than the general public. With an open mind, a little patience, and some easily attainable skills, we can begin to whittle away at that life expectancy gap.

Certainly, lack of focus is not the only reason the mentally ill are dying younger. The NASMHPD’s landmark 2006 report documented a variety of issues including that those challenged by mental illness receive less aggressive medical treatments and less aggressive interventions for unhealthy behaviors. With higher patient loads and the expectation of doing more with less—less time, fewer resources— the situation is extremely challenging.

Initiatives, such as state trends towards the coordination of care for those challenged by mental illness through “Health Homes” are a step in the right direction. For the most effective care however, coordination and improved communication isn’t enough. Medical personnel will need to be educated in how stigma and anxiety are negatively impacting care. They will need to gain skills in managing difficult and sometimes stressful patient situations. They will need to explore the role mental illness and its treatments have in negatively impacting the overall health of challenged individuals.

It is this current state of knowledge that has led to the development of this program and piloting of our project educating health care professionals. We have found that educating medical personnel to most effectively and safely interact with those challenged by mental illness can help ensure a safe environment for the medical staff and a better experience for the patient. In our experience working with behavioral health professionals to better coordinate with their patients’ medical professionals can enhance care and provide consumers better experiences and at the same time their medical providers can work more effectively and efficiently. Program development required an integrated effort involving consumers, medical and behavioral health professionals and family members.

While initiatives to coordinate care between medical professionals and behavioral health care staff no doubt can improve care, even the most skilled or experienced behavioral health care workers may unknowingly be affected by, and propagate, stigma. This can negate some of the hoped-for benefits of care coordination and should also be anticipated and dealt with. While doing in-service training for behavioral health staff at several hospitals we have found many of the same mistaken beliefs about those challenged by mental illness as we have found in the community. However, an anti-stigma training initiative can help to correct this.

We have found that developing any program to improve the care medical professionals deliver, to enhance the role of the behavioral health professional in care integration, and to involve consumers and their families in the process demands that certain facts be communicated and a certain skill set must be developed. The areas to include are:

  • Anti-stigma education
  • Priorities, concerns and care management skills specific to the needs of this population
  • Understanding of the process from the consumers’ and family’s perspectives
  • Crisis Prevention and Intervention
  • Monitoring and Follow Up

A program including these areas may have a quick, lasting and substantial impact on improving and prolonging the health and life expectancy of those severely challenged by mental illness. We are working with regional health care providers and NY State elected officials on both further testing and expanding this initiative. For those systems that want to start to improve the process on their own, we can offer a suggestion that has been reported to have an immediately positive impact. Checklists are an invaluable tool. Behavioral health providers, medical providers, consumers and their families should all be encouraged to co-develop and utilize this useful tool. A behavioral health provider can use a check list to make sure their consumer is adequately prepared for their upcoming medical appointment. The family (if significantly involved in their regular care) should have a check list to remind the client what they need to take with them for the appointment. The consumer should have a check list, and should get in the habit of checking it to remind them of the issues for their physician and any paperwork they have to hand in. The physician, who is often most distant from this process, should have a check list go to help them ensure that they will work the most efficiently with any tangential, forgetful or difficult patients.

For example, a simple medical appointment checklist could look like this:

  • What brings you here?
  • Do you have any papers to show me?
  • Before we get into that, anything else?
  • Did anyone tell you to come see me?
  • Did your other doctor want you to see me?
  • Did any other staff or family send you to me?
  • What did they tell you if they did?

Difficult or agitated patients, complicated physical factors and stigma make medically managing those challenged by serious mental illness a demanding endeavor. Through education and planning excellent care and best practice can be assured. An ongoing and effective partnership between consumers, their families, their behavioral health providers and their medical providers is the key.

Larry Hochwald is co-chair of the Staten Island Mental Health Council and a co-founder of Advanced Resources, inc. a nonprofit set up to explore innovative initiatives including those discussed in this article.  Nat Etrog, LCSW, is co-chair of the Queens Mental Health Council and Vice President, Department of Psychiatry, St. John’s Episcopal Hospital.  Steven Werfel, MD has practiced in hospital and clinic settings and is an advocate for care integration and the rights of those challenged by mental illness.

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