A growing aging population, healthcare reform, earlier diagnosis of disease states and an overall sicker population with more comorbidities than ever before has created the need for a more collaborative relationship between primary care and behavioral health care providers. The traditional individualized and specialty-emphasized approach to patient care, which has long been the norm, is no longer feasible. The difficulty lies therein in finding the best system to achieve the universal goals of a healthier population, an improved healthcare experience for patients, and a reduction in overall healthcare costs. Collectively, there has been a great momentum toward integrating care which provides a cost-effective solution to help high utilizers of both medical and behavioral health services. For Federation, the role of the Physician Assistant has proven to be an invaluable asset which has allowed the agency to bridge the gap between primary care and behavioral health services.
With varying levels of integration, providers find themselves deciphering where they fall in the continuum of collaboration, with full-integration being the goal. Much emphasis is placed on co-location and the sharing of one system. While this may sound ideal, for most organizations, reaching this target may come with many obstacles.
Federation is an agency that serves individuals across all of Nassau, Suffolk and New York City, a wide geographic area that is dense. On the road to integration, the agency has thought critically about how to logistically integrate services for their members. While they operate two community centers and one wellness clinic, they also operate over 880 units of supportive housing and also have a robust care coordination program and outreach program. As a provider who serves a wide geographic region, having one primary care provider co-located in one site would not benefit the majority of their members. Furthermore, many clients do not want to terminate their established relationship with their own primary healthcare providers within their community. For Federation, they took this universal obstacle and created an opportunity for integrated care to be offered to its many members by hiring a Physician Assistant in the unique role as the agency’s integrated care specialist.
Federation now utilizes the services of the physician assistant (PA) across a majority of the programs they operate. The PA plays a unique role within the agency and serves as an intermediary between behavioral health providers and primary care doctors or their specialists. The role bridges the gap between service providers breaking communication barriers and allowing clinicians to have a more comprehensive quality approach to the whole patient. After proper consents, the PA assists the medical team by providing the client’s primary care providers and specialists’ information on their psychiatric condition that may affect or exacerbate their medical conditions. Appreciative primary care providers welcome the exchange of information which allows for the free flow of communication for the duration of the patient’s care. Many primary care providers now can review patient’s physical symptoms that many times may be underlying mental health issues. In addition, the medical knowledge the PA holds allows her to syphon through a client’s lengthy medical history to decipher pertinent medical information to present to the psychiatric team and know what additional medical information will be needed and obtain it prior to the patient’s appointment. Through this process, medications are often identified to treat comorbid medical conditions that the patient may not mention upon intake. All the preliminary work prior to the initial visit ensures the patient receives their optimal treatment in a timely manner rather than a back and forth between providers. Throughout the patient’s care, the PA ensures proper studies are ordered to monitor the patient’s physical health conditions that psychiatric medications can cause and exacerbate. Many times for individuals managing behavioral health issues along with chronic disease, these tests can be instrumental in them receiving proper treatment which can be life-saving. When the physician assistant calls hospitals and medical offices, the delay from the medical records department for the exchange of critical medical information becomes nearly eliminated. The physician assistant is available and deployed for all members throughout Federation’s various programs.
Individuals managing behavioral health issues and comorbidities many times struggle with managing their care including the many providers they may have to see and/or medications they may be prescribed. Physical health conditions mimic symptoms of a patient’s mental health diagnosis but can exacerbate, interfere and alter treatment for a patient’s behavioral health care management. Psychiatric medication can affect the endocrine system so checking a patient’s baseline thyroid and screening for diabetes is crucial before starting and during treatment to ensure levels do not change. Rheumatologic diagnoses such as lupus, fibromyalgia and rheumatoid arthritis have long been implicated in a number of neuropsychiatric conditions. Whether it is the toll of dealing with chronic pain or the inflammatory process affecting the brain chemistry, a patients’ physical and emotional health should be treated simultaneously. Psychiatrists often need to be a consultant for many patients being treated by a neurologist, orthopedic or a pain management specialist.
In another instance, Federation looked at high need catchment areas in Queens, where their PA worked closely with behavioral health clients who were also noted to have either diabetes and/or cardiovascular disease. These individuals included our most high-need utilizers receiving ACT (Assertive Community Treatment) services to individuals in a variety of housing arrangements including residents in our CR-SRO on the grounds of the Creedmoor Psychiatric Hospital to individuals who live the most independently in our scattered site supportive housing apartments. We also included individuals residing in a specific Adult Home within the catchment area who receive our care coordination services.
The Physician Assistant carefully reviewed clients’ medical history to assess when the last screening tests were performed. If a client was identified as being due for bloodwork, the Physician Assistant either referred the client to their primary care provider or orders the appropriate screenings. Utilizing telemedicine, the Physician Assistant coordinated the screening request with the on-site behavioral health care team to arrange transportation for phlebotomy or setup a home draw. Home draws can be important for individuals without transportation or are psychiatrically homebound. If needed, Federation’s behavioral health staff accompanied the individual to the lab. Results were then forwarded to the client’s primary care provider for proper management or referred to a primary care if no primary care provider is specified by the client. This intensive coordinated care was focused and supportive and greatly reduced the chance for the continuum of care to have gaps.
To coincide with the work of the Physician Assistant, Federation has also partnered with HRH Care to provide a mobile clinic at several of its sites. This clinic provides primary care services to individuals who are receiving behavioral health services just inside at the community centers or mental health clinic. Individuals can simply step outside and received needed medical care while not having to miss valuable program time. For many with transportation issues, this convenience makes a world of difference and can be a major factor to them seeing a primary care doctor.
Finally, Federation has also partnered with Northwell Labs to provide on-site blood draws. Once a month, Northwell Labs provides a phlebotomist at four Federation sites to complete the draws. Prescriptions are ordered through the PA, the psychiatrist and/or NPP and lab results are integrated directly into the electronic health record. Any labs that come back indicating a more serious problem receive immediate attention as the PA serves as the direct intermediary who closely monitors the results that come in.
While the aim of integrated care may be to have behavioral health providers and primary care providers co-located at all facilitates, the road there can include many different variations to providing integrated care. At the end of the day, the common goal of all these variations is to help individuals manage both behavioral health issues and chronic conditions while helping them live as independently as possible while reducing the number of avoidable hospital visits. For Federation the role of Physician Assistant as the Integrated Care Specialist has opened the dialogue with primary care providers allowed for comprehensive care that treats the individual holistically, and ultimately raised the bar on the care we provide to our members.