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Integrating Primary Care into Assertive Community Treatment

The great health disparities and poor health outcomes experienced by people with serious mental illness are even more significant for the people served by Assertive Community Treatment (ACT) teams. Individuals are eligible for ACT services if they have been hospitalized more than four times in the past year, often for failing to comply with treatment because of lack of insight into their illness, as well as executive function challenges and substance abuse, homelessness, social isolation and disenfranchisement. They receive high intensity services that often involve twice weekly home visits by a multidisciplinary team that includes a psychiatrist, nurses, social workers and peer counselors. The goal of ACT is to reduce hospitalizations and support psychological, social, and vocational recovery. Teams also attempt to link individuals to primary care and other health services but have long noted the lack of adequate primary care for clients. This is not just about availability of primary care; many people served by ACT teams will not access traditional health care services, just as they have not accessed traditional psychiatric services.

Integrated Care and the Role of Psychiatry

For people with both high behavioral and physical health needs, the National Council’s Four Quadrant Clinical Integration Model proposes, among other interventions, the co-location of a primary care provider (PCP) in behavioral health settings where people with serious mental illness are already engaged in care. Onsite primary care has been shown to improve the rate of diagnosis of medical conditions and the quality of medical treatment for people with mental illness (see Druss and von Esenswein’s 2006 review in “General Hospital Psychiatry”).

Individuals often see behavioral health counselors more frequently than other providers, so it is a relationship that represents a rich opportunity to support health behavior changes and risk management. Psychiatrists can have a unique role in helping people manage health risks and needs, using motivational enhancement and trauma-informed approaches in addition to managing psychiatric medications that cause metabolic side effects. In some situations, psychiatrists may also prescribe medications to address cardiometabolic risks, especially when clients are not engaged with primary care. Vanderlip et al’s “Framework for Extending Psychiatrists’ Roles in Treating General Health Conditions” (American Journal of Psychiatry, 2016) guides psychiatrists as to when it may be appropriate to provide primary care interventions for those who have difficulty accessing adequate care, with the goal of addressing physical health disparities for people with mental illness.

ACT Primary Care Pilot

In 2018, ICL and CHN launched a pilot integration of primary care for ICL’s ACT teams, supported by the New York Community Trust and the Altman Foundation. ICL has six ACT teams, four of which moved into their new East New York Health Hub home when it opened last year. A range of ICL’s behavioral health services are also in the Hub along with a CHN federally qualified primary care health center.

Where previously it had been challenging to engage ACT clients in making and keeping appointments in primary care clinics with providers they did not know, having these services available and integrated into the Hub facilitated the teams’ ability to bring ACT clients to primary care. They were often in the building for other reasons, including for a weekly ACT lunch. The importance of being able to make “warm hand-offs” between ICL and CHN within the Hub cannot be underscored. This idea of a warm hand-off is crucial when we talk about integration because the clients’ willingness to participate in health care interventions is very much predicated on a sense of trust. The people served at ACT have long histories of PTSD and the relationships they have built with ACT staff take on much greater significance in terms of accepting care. From the provider perspective, the opportunity for ICL and CHN to do multidisciplinary case conferencing to manage health risks is also paramount in providing effective care.

Since the opening of the Hub and this active collaboration between ICL and CHN, we’ve observed a sharp increase in the number of ACT clients who have had a physical exam, accepted recommended cardio-metabolic monitoring (body mass index, blood pressure, hemoglobin A1c and cholesterol screenings), and other health interventions.

However, a majority of ACT clients are not able to come in to the office, some rarely leave their homes for a variety of reasons mostly as a result of traumatic life experiences. For these clients, CHN placed family nurse practitioners on ICL’s ACT teams to make home visits; these Primary Care Providers (PCPs) made visits with other team members to support the psychiatrist in assessing a clients’ physical health status and treatment of health conditions. In a number of situations, this integration proved invaluable: Decisions about the use of insulin, best practice testing for sexually transmitted illnesses, and evaluation of pressure sores, were among the interventions ACT psychiatric providers could accomplish with this on-the-ground consultation from the PCPs.

This pilot has been greatly informative regarding the structure and “dosing” of primary care needed for ACT teams but continued testing and discovery is needed. Initially, each PCP was assigned two days a month to an ACT team. There was discussion about whether the PCP should spend more time on the ACT team, i.e., one day a week, to facilitate being a routine part of the team in the same way that psychiatrists are part of the team. However, three months into the pilot, most of the people willing to have a physical exam had had one, either in the clinic or by the home-visiting PCP and further follow-up could be managed by the psychiatric providers. Where PCPs did continue engagement with a few clients, it was likely this work could also be done by another member of the team. The PCPs, newly graduated nurse practitioners, provided crucial feedback including about the ambiguities of their role. They felt they were not equipped to do many medical investigations and procedures in the field and, at the same time, they did not always feel comfortable serving as consultants regarding complex clinical situations. This information is very helpful as we look to the next phase of this project.

Conclusion

Learning from the successes and challenges of this pilot, what we believe might be most helpful is a dedicated primary care consultant for the ACT teams – someone knowledgeable and passionate about the care of people with serious mental illness and who can provide support to the teams in three ways: 1) Participate in regular case conferences to discuss shared high-risk clients and new referrals; 2) Offer on-call capacity to answer questions from providers in the field; and 3) Do select in-person or telehealth visits to clients in the field.

It is not yet clear what the precise amount of time might be for a PCP to spend with each ACT team. It may be that each team requires different arrangements, depending on factors including proximity to primary care offices and telehealth capacity. In the IMPACT (Improving Mood Promoting Access to Collaborative Treatment) model CHN has adapted for its clinics, the psychiatrist meets weekly for one hour with a “depression” care manager to discuss patients whose psychotropic medications are managed by the PCP. A mirror-image best practice model of PCP consultation to psychiatrists in the management of common health issues may be what is needed. ICL and CHN will pursue that in the next phase of the ACT primary care pilot.

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