2007 APA Gold Award: Integration of Community Psychiatry Into Primary Care Centers in Harris County, Texas

Until 2004 almost all behavioral health services in Texas's Harris County Hospital District (HCHD) were provided by psychiatrists in one psychiatric outpatient clinic. At that time patients were experiencing at least a six-month waiting period for new appointments. In July 2004 the Menninger Department of Psychiatry at Baylor College of Medicine, which provides behavioral health services to HCHD, and HCHD launched a pilot project to address behavioral health needs by placing a psychiatrist one-half day per week in three of the 11 HCHD community health centers. The plan was to increase timely access to services that patients needed. With the success of the pilot program the Community Behavioral Health Program (CBHP) was created in July 2005 in collaboration with Baylor, HCHD, and the Houston Council on Alcohol and Drugs. Psychiatrists and psychotherapists were recruited, hired, and placed in the district's community health centers to work side by side with the primary care physicians, nursing staff, social workers, and substance abuse counselors. By year's end, the wait time for new patients at the psychiatric outpatient clinic was one month or less, and new and nonurgent patients were seen at the community health centers within eight weeks.

In recognition of creatively integrating psychiatric care with primary care, for expanding capacity to address severe shortages in psychiatric services, and for improving the lives of persons living with serious mental illness, the HCHD CBHP was selected to receive an APA Gold Achievement Award in the category of community-based programs. The winning program in the category of academic or institutionally based programs is described on page 1369. Each Gold Award winner receives a plaque and a $7,500 prize made possible by a grant from Pfizer, Inc.

Transforming access to psychiatric care

In 2004 Baylor's Menninger Department of Psychiatry and HCHD, one of America's largest public health care providers, began to transform the way HCHD provides psychiatric care. Baylor psychiatrists Britta Ostermeyer, M.D., and John Burruss, M.D., transitioned it to a fully integrated system. HCHD serves a catchment area of close to four million people in the Houston area and is one of the largest U.S. health care providers for people on public assistance. It operates two general hospitals, a community hospital, 11 community health centers, eight school-based centers, a dental center, a homeless health care program located at shelters, and a center for patients with HIV-AIDS. Until 2004 all of the district's psychiatric patients were seen at the county's only psychiatric outpatient clinic, located at Ben Taub General Hospital. With the integrated system, patients can find care at any of several community health and other facilities within the system.

Ninety percent of the 1.2 million patient encounters within the district annually take place in the primary care community health centers. In 2004 one-fourth of all patient encounters included at least one psychiatric diagnosis. Because people with severe mental illness are eligible for services by the Mental Health and Mental Retardation Authority of Harris County, the most common psychiatric diagnoses within the hospital district are some form or combination of a mood, anxiety, or substance abuse disorder. The HCHD could not afford to hire an additional 20 to 30 psychiatrists. The only solution was to reorganize.

Reasons for integrating care

Previously, patients had to wait an average of six months to be seen at the Ben Taub Psychiatric Outpatient Clinic. Realizing that the waiting period was unreasonable and that behavioral health services should be provided at the primary care centers as well, all collaborators agreed that a new, integrated system of care had to be created to provide more efficient psychiatric services to all patients within HCHD. A primary goal of doing so was to cut down on the waiting periods for patients to receive psychiatric treatment.

Integrated psychiatric services are highly appreciated by patients and health care providers. Integrating psychiatric services at the same site that other health care services are provided offers convenience to patients and significant cost-effectiveness to health systems and consumers. Integration also helps to remove barriers to psychiatric care by directly placing psychiatrists into primary care centers, which patients are familiar with and which allows psychiatry to achieve more parity as a medical specialty. As of 2005 more primary care physicians than psychiatrists were being reimbursed by private insurance carriers for providing psychiatric services.

Getting started

In July 2004 Baylor and the HCHD launched the community pilot project and placed Dr. Ostermeyer shoulder to shoulder with primary care physicians and internists in three primary care centers. Her task was twofold. First, she was responsible for evaluation and treatment of scheduled patients at the primary care community centers. Second, she implemented the concept of "curbside consultations" to primary care physicians and internists, with the goal of furthering their comfort with and ability in providing primary care psychiatric interventions. Whereas some primary care physicians were eager to learn more psychiatry through curbside consultations and treat patients themselves, others initially preferred to refer patients to the psychiatrist.

As anticipated, the new community project turned out to be very successful and highly appreciated by physicians, staff, and patients. Thus Dr. Ostermeyer arranged for psychiatrists, psychotherapists, and substance abuse counselors to be placed at all centers within HCHD as well as at several partner health care facilities. Because the CBHP serves a large Spanish-speaking community, more than 95% of program staff are bilingual.

Principles of the program

The motto of the CBHP is Building a Healthier Community. Some institutions require that all behavioral health patients be seen by their psychiatrists in the beginning of the patient's treatment. In this program the goal is to get patients involved with behavioral care services as soon as possible in order to initiate some type of intervention. Thus a decision was made to allow all of the primary care physicians, psychiatrists, psychotherapists, and substance abuse counselors to directly accept patients and directly refer patients to each other in order to minimize waiting periods. Each door can open another door.

The program's psychiatrists also discussed with the primary care team a desire to have psychiatrists operate like specialists in other medical subspecialties, such as cardiologists. For example, cardiologists evaluate patients, stabilize them, and then return them to primary care physicians for ongoing care. Likewise, the psychiatrists proposed a model of stabilizing the scheduled patients who were placed into the CBHP's appointment templates and following up with them until the psychiatrists are comfortable with returning them to their primary care physicians with recommendations for maintenance care. Of course, if the patient needs to be seen again by the psychiatrist, the primary care physician can request another psychiatry appointment at the center. Psychiatrists want to be viewed as "integrated consultants" and believe that at all times, the primary care physician remains in charge of the patient's care.

In order to provide the most efficient services to all HCHD patients, Director Ostermeyer has focused on the following four areas: patient care, education, training, and research.

Patient care

In terms of patient care, the program provides appointments for initial evaluations; medication management; individual, group, family, and couple's psychotherapy; substance abuse screening; and brief substance abuse treatment at the community centers. The appointment templates of the psychiatrists, psychotherapists, and substance abuse counselors permit all behavioral health providers in the system to see additional walk-in patients who are visiting with their primary care physicians or those who are in crisis.

Education

The education focus aims to further the scope of psychiatric and behavioral interventions by the community primary care team. To accomplish this goal the program encourages curbside consultations—primary care physicians step out of the exam room while they are seeing a patient and consult with a psychiatrist on site. In addition, the program has implemented small-group learning and case conferences for primary care physicians at the centers.

A $54,000 educational grant from Abbott Laboratories facilitated the creation of a series of formal lectures on major psychiatric topics. The lectures focused on disease recognition and on how to use psychiatric medications. Each lecture was televised from the Baylor Primary Care Teleconference Studio to primary care physicians at the community centers. Primary care physicians were also educated about psychotherapy referrals. The educational grant also covered the production of 250 DVDs and audiotapes of each lecture. A set of tapes was distributed to each primary care physician and internist for individual review. In order to educate primary care center staff about mental illness in general and on the needs of psychiatric patients as well, the program taped and produced DVDs of formal lectures geared toward center staff on key psychiatric issues. Each center played a tape of a staff lecture during monthly staff meetings over a period of several months.

Training and research

Training efforts focus on rotations for primary care and psychiatry residents, psychology interns, and medical and nursing students. Research endeavors concentrate on treatment outcome data. Charles Begley, Ph.D., from the University of Texas School of Public Health is the outside evaluator for CBHP's outcomes research. From 2006 to 2007, Dr. Ostermeyer and Doris Chimera of HCHD moved a $26 million research and treatment grant from the Centers for Medicaid and Medicare into CBHP. The grant is for evaluating treatment outcomes data for a group of HCHD community patients who are receiving additional behavioral health benefits in comparison with a group of HCHD community patients who are receiving the usual HCHD benefits.

Staffing for expansion

CBHP hired several new psychiatrists, ten master's-level psychotherapists, a director, an administrator, and a psychotherapy director. Julia Wolf of the Houston Council on Alcohol and Drugs oversees psychotherapy services within CBHP. Several psychiatrists were relocated from the general hospital into the community centers for a day or two each week. In addition, the program teamed up with the HCHD Social Work Department, which already had social workers in place at each community center, and HCHD's Project InSight, which is a substance abuse screening program funded by the federal government. Several training rotations were implemented, and medical students, nursing students, psychology interns, primary care residents, and psychiatry residents joined the CBHP. Simultaneously, a steering committee was quickly established, which comprised psychiatrists, primary care physicians, psychotherapists, substance abuse counselors, nurses, social workers, and administrative community center directors. The HCHD director of community clinical case management, Anne Teske, is also CBHP's administrator and leads the multidisciplinary steering committee.

A committee of consumers and families—the Council-at-Large—meets monthly to address patient-related problems and review and approve new projects. The CBHP has instituted regular faculty meetings.

Over a three-month period, a team of psychiatrists, psychotherapists, substance abuse counselors, residents, and students were placed in all of HCHD's 11 primary care centers, five partner centers (Asian American Family Services, Denver Harbor Community Health Center, El Centro De Corazon, the Federal Detention Center, and Good Neighbor Community Health Center), the HCHD Program for the Homeless, and its school-based center (Southside Community Clinic). The centers have one to two days of psychiatric services, three to five days of individual and group psychotherapy services, and two to four days of social work services per week. On any given day someone from the behavioral care team is always on site so that a behavioral health provider can see patients with more urgent problems. The primary care nurse has learned how to give depot injections of antipsychotic medications to psychiatric patients at their primary care center. Over the winter of 2005–2006, two additional school-based centers were staffed with behavioral care in collaboration with John Sargent, M.D., the director of child and adolescent psychiatry at the general hospital.

Funding

As in most public settings, financial resources for such a transformation were very limited. The program directors applied for and received a grant of approximately $450,000 from the Hogg Foundation for Mental Illness to fund integrated care services for the first year (July 2005 to June 2006). This grant and additional money from HCHD allowed for the expansion of CBHP in July 2005. HCHD provided about $700,000 in additional support, which secured the significant expansion of the program in collaboration with Baylor College of Medicine, the University of Texas Health Science Center at Houston, and the Houston Council on Alcohol and Drugs. In addition, as noted above, Abbott Laboratories contributed $54,000 toward educational support.

Outcomes

As of December 2005 HCHD patients are now able to be scheduled for a new patient appointment with a psychiatrist within four weeks either at their primary care community center or at the Psychiatric Outpatient Clinic at Ben Taub General Hospital. Patients with more urgent needs or patients in crisis can be seen by a psychiatrist, psychotherapist, or substance abuse counselor as a walk-in on the same day, a significant preliminary achievement. Patients and primary care physicians are thrilled with and highly appreciative of the new integrated community program. In November 2005 the CBHP had an official kickoff celebration (over 120 persons attended) with presentations on the program and the integration of behavioral health services into primary care settings. Program leaders have presented an overview of the CBHP at several local and regional meetings.

CBHP has 26 centers and partners and continues to grow. In June 2006, when the one-year Hogg grant expired, HCHD took over and has since fully funded the program. HCHD at large and Baylor have financially secured the program and firmly agree to maintain funding for this valuable and highly successful new community program. The program is universally appreciated and liked by patients and their families, primary care physicians, psychiatrists, therapists, center staff, and administrators, and it has indeed succeeded in its mission to build a healthier community.

For more information contact Britta Ostermeyer, M.D., Neuropsychiatric Center, Rm. 2.216, 1502 Taub Loop, Houston, TX 77030 (e-mail: [email protected]).