In 1984, at the very first senior staff meeting I attended when I arrived at The Bridge (the non-profit mental health and substance abuse rehabilitation agency in New York City) the spotlight was on client healthcare issues. Our then part-time psychiatrist had recruited a heroic primary care physician friend who was willing to accept the Medicaid payment (then some pitifully small amount) to conduct a full primary care screening of 10 randomly selected Bridge clients, all of whom were diagnosed with serious mental illness. At that first meeting I attended our psychiatrist reported the results: the 10 clients had almost 70 documented medical conditions that were serious enough to require treatment.
What to do? For a few years the heroic primary care doctor treated those 10 clients (and a few others) and we gave him a beautiful plaque in gratitude. But we had many, many more clients that needed medical care who the doctor could not take on because of the economics of his practice. Since there was no government funding stream that mental health agencies could use to provide primary care services, we turned to foundation support for a number of years. Beginning in the late 80s, with foundation funding, we engaged a part-time nurse who conducted some very basic health screening (no lab work), and worked with staff to identify medically needy clients and refer them to providers in the community, primarily hospital clinics (although few hospitals had primary care clinics at the time). Still, far too many clients were using emergency rooms as their primary care doctor and far too many continued to have untreated medical conditions.
In the early 1990s we became aware of a new potential resource: The Rent-a-Doc Program operated by St. Vincent’s Hospital. For a fixed sum (the program did not bill Medicaid for its services) a primary care physician and LPN would provide part-time hours on site at The Bridge. We couldn’t resist, given the level of medical need and the dismal experience of our clients using the healthcare system. But we had to accomplish two tasks: raise enough money to pay for the team and provide them with a proper space. Both tasks involved substantial fundraising which the board and staff dedicated themselves to and managed to accomplish.
The arrangement worked beautifully. The St. Vincent’s team occupied a space in or headquarters building which also housed our day treatment, mental health clinic and vocational programs. We wrote out an annual check to St. Vincent’s and more than 200 clients received excellent primary care.
The problem was sustainability. We exhausted the funding from the foundations that supported the initiative. It was then that we forged our ongoing relationship with the William F. Ryan Community Health Center, a Federally Qualified Health Center (FQHC) that provides services in numerous Manhattan neighborhoods.
The partnership with the Ryan Center is now more than a decade old. Due to increasing demand, and with a recent Federal grant to do some renovation work to qualify the space, the Ryan Center will expand its Bridge services to 40 hours a week. The arrangement is simple: Ryan bills Medicaid for its services; their billing does not interfere with Bridge billing for its mental health and substance abuse services. The Bridge provides the space free of charge, Ryan provides its own equipment and supplies.
Communications between Ryan and Bridge staff is a priority. When Bridge clients enroll in the Ryan clinic, they sign a bi-directional release allowing Ryan and Bridge staff to share medical information. Formal and informal staff communications occur on an ongoing basis.
The results of this partnership are outstanding. A record number of Bridge clients are receiving primary care services with follow up specialty services provided by St. Luke’s Roosevelt Hospital. Clients with serious medical conditions are treated and tracked closely by Ryan and Bridge staff. It’s not surprising that the FQHC partnership model with community behavioral health agencies has been singled out as an effective means to integrate care. We at The Bridge have so many stories of lives saved and lives improved.
At the Bridge, a crucial complement to providing the opportunity for more integrated services was offering clients the Wellness Self-Management Program developed jointly by the Urban Institute for Behavioral Health and NY State Office of Mental Health. Wellness provided participants with vital health information to help them achieve and maintain overall physical health and psychiatric stability. Through participation in the Wellness program Bridge clients got a great deal of new information and many developed motivation to change both their basic health and healthcare-seeking practices.
Responding to the Complex Needs of Older Clients
The Bridge, like other community-based behavioral health agencies that work with seriously mentally ill adults, is also serving a rapidly increasing number of aging clients who have co-occurring serious medical conditions. This is particularly challenging for housing providers. Too often when agency staff is not able to provide the services needed to maintain clients in housing, the result is a move to a nursing home.
In 1997, The Bridge opened Sheridan Hill House, a residential program for 24 older adults who have serious mental illness and serious medical conditions. Each resident lives in a full Class A studio apartment. In order to meet the medical needs of the residents The Bridge formed a partnership with the Lifecare Division of the Jewish Home and Hospital. Lifecare provides a nurse practitioner on site at Sheridan Hill House who provides primary and follow up care for residents. The Lifecare nurse practitioner also works closely with Bridge staff in coordinating medical and related services and leads client health education groups. In addition to enhanced medical services a cook prepares diet-healthy meals (often with fresh vegetables and herbs from our nearby urban farm) and provides individual and group nutrition education.
As a model, Sheridan Hill House provides residents with an independent community living setting while addressing their medical needs, and avoiding nursing home placements. The medical needs of its residents are substantial. Currently six residents are in wheelchairs; 20 of 24 residents have serious hypertension; 12 have diabetes; 5 with history of stroke; 4 are undergoing cancer treatment; and 9 have COPD.
With the aging of the mental health population, it is critical that we develop housing and service models to meet their special needs. Sheridan Hill House is a promising model that, for a small fraction of the cost of nursing home care, provides integrated behavioral and healthcare services that achieve the goals of extending independent living in the community and addressing residents’ critical medical needs.
Integration of medical and behavioral health services still poses challenges. Certainly, the reforms of the New York’s Medicaid Redesign Team recognize the need to coordinate and integrate medical and behavioral health services. The implementation of health homes, in particular, reflects a recognition of the importance of integrated services. As other Federal and State reforms are rolled out – the establishment of Accountable Care Organizations, bringing behavioral health services under a managed care umbrella – the needs of people with serious behavioral conditions must be recognized and at the forefront of system and program design.