In the world of health care reform, the word “upstream” means investing in early intervention, treating small problems in clinic before they become large enough to require hospital stays.
Family Health Centers of San Diego, the region’s largest community clinic network, has done so well in this regard with mental health care that the nation’s top public health official dropped in Tuesday to have a look around.
Dr. Mandy Cohen, director of the U.S. Centers for Disease Control and Prevention, toured the City Heights Family Health Center on El Cajon Boulevard, taking in the facility’s careful blend of resources from family medicine and prenatal care to physical therapy and chiropractic.
Mental health care, explained Dr. Christopher Gordon, president of Family Health Centers, is embedded in the day-to-day process of care at the more than 90 sites that the organization operates.
On intake, no matter why they came in, each patient answers two quick questions, whether they’ve been bothered by having little interest or pleasure in doing things and whether they’ve been feeling down or depressed. Those who answer in the affirmative are asked to answer nine additional questions and, depending on the results, they may end up with an immediate mental health care visit, often without leaving the building.
“With everything integrated we can call a therapist and say, ‘hey, this person’s score might need some attention,’ and we can have a warm handoff right away,” Gordon said.
Family Health Centers’ approach to offering comprehensive services to its patients was part of the reason why a visit was included on the CDC director’s nationwide tour promoting mental health services and suicide prevention. Another draw, she added, is the eight-story building going up just to the east of the clinic. The mixed-use, mid-rise structure will house a 20,000-square-foot mental health clinic with upper stories made from repurposed steel shipping containers creating 41 new housing units, 18 of which are reserved for unhoused San Diegans.
“The really remarkable thing about that new building is that they’re including housing,” Cohen said. “If you don’t have stability in your housing, stability in your food security, it’s hard to get well, and so I love that they included housing as part of their new building.”
The idea of integrating mental health care into primary health care is an idea that has been growing for decades since University of Washington psychiatrist Jürgen Unützer created a “collaborative care” model that calls for integration of mental health care into front-line primary care practice.
Most recently, Rady Children’s Hospital began using such a model in some of its primary care clinics with significant positive results. Having front-line doctors screen young patients for signs of depression, researchers found, correlated with a 44 percent reduction in symptoms of anxiety and a 66 percent reduction in depression symptoms. And an internal analysis of patient referral patterns also found that those who were screened in doctors offices showed up less frequently in the San Diego children’s hospital’s specialized psychiatric emergency department.
Domonique Hensler, senior director of systemwide care at Rady, said in an interview in early April that the ongoing challenge with expanding integrated psychiatric care in pediatric doctor’s offices has not been training family medicine physicians to conduct screenings for signs of depression nor getting social workers to do immediate consultations, but rather getting health insurance companies to reimburse the work.
“Some are starting to remove their prior authorization requirements or already have, and that’s a game changer, but others still have a foot in both worlds,” Hensler said. “Some of the health plans sub delegate out to a third-party vendor, doing mental health care carve-outs with another agency.”
Medi-Cal, health insurance of last resort for California’s neediest residents, also has several programs that can support integration of mental health care within doctor’s offices, though existing programs don’t quite fit the system that has been created in its pediatric clinics, Rady analysts said.
Luke Bergmann, director of behavioral health for San Diego County, said in a recent interview that federally qualified health centers such as Family Health Centers have enhanced ability to get such services covered under Medi-Cal, a fact that Gordon confirmed.
What will it take to get this mode of care fully situated throughout American health care?
Talking to experts in different parts of the country, she said, is part of the process. Cohen said that understanding how medical providers are successfully integrating mental health into routine office visits can help change the system.
“Then I can go to my partners at Medi-Cal or at Medicare and say, ‘look, this is the best evidence,'” Cohen said.
