At the end of the pilot, the CHF-funded evaluation by The The AVISA Group found considerable success and offered guidance for ongoing improvement during a Phase Two implementation, which a Contra Costa Mental Health Service Act (MHSA) grant supports. During Phase Two, La Clínica has been evolving this behavioral health integration by expanding behavioral health screening, which initially only targeted adults, to patients in five age categories, adding new elements to its screening process, and implementing new prevention strategies.
In 2011, the CHF provided additional funding to extend the ongoing evaluation by the AVISA Group to its fourth year. Additional funding supported development of a training program to help La Clínica expand age-specific, integrated behavioral health services to seniors.
In 2012, CHF funding supports:
- A fifth year of ongoing evaluation by The AVISA Group, to be compiled and printed in 2013. This is the first time La Clínica has used a professional evaluation for one of its multi-year, internal health initiatives.
- Implementation of the training program that will help the behavioral health delivery team provide consistent and uniform care for their senior patients ages 60+ years.
- Creation of a training process for medical social workers that would assure quality integrated behavioral health screening and intervention services for pediatric patients (ages 0-5) and their families.
The Health Issue
Many La Clínica patients are reluctant to acknowledge their mental health needs and, in many healthcare settings, these patients have no easy way to access mental health providers. Therefore, they are particularly prone to something that all populations do to some degree: they express mental health distress through physical symptoms. Research has shown nearly 70 percent of primary care visits have a psychosocial component. Yet during a typical primary care visit, few providers have the time, training, or resources to diagnose, much less address mental health concerns. Even if primary care providers do identify a need, it's usually difficult to convince patients to follow up with an unfamiliar mental health provider.
The Health Improvement Strategy
The pilot program emerged from a year of planning, during which La Clínica reorganized its providers and staff at its two Contra Costa clinics to integrate behavioral health services into their existing primary care system. With implementation, behavioral medicine specialists at both clinics provide direct patient services, and/or act as consultants to the primary care providers.
If the primary care provider identifies a mental health need - either through a specially designed patient questionnaire called the "behavioral health screen" or during the patient visit itself - he or she introduces the patient to the behavioral medicine specialist who is trained to rapidly assess mental health concerns and, in simpler cases, address the concern. (For example, the provider might remind a patient suffering from a sleep disturbance not to drink caffeine at night.) Some studies indicate that as many as three-quarters of mental health problems can be addressed this way in one to three visits, thereby addressing many mental health concerns before they become more serious.
For more severe problems - such as depression, substance abuse, or domestic violence - the behavioral health specialist can establish a relationship during that first visit, increasing the chances that the patient will arrive for a follow-up visit with the specialist.
"But this is not a therapy model or a long-term solution to more severe problems," says Leslie Preston, La Clínica's director of behavioral health. "If a patient has those needs we refer them on to the county or to community organizations that deal with specific problems... but we can help provide leadership in integrating behavioral health in primary care, which enables us to treat our patients as whole people."
After the first two years, an initial evaluation by the Avisa Group found that the integration of behavioral health with primary care successfully improved access to mental health services for La Clínica patients with mild-to-moderate mental health symptoms and reduced symptom severity. Provider satisfaction with the program was high, including increased confidence in helping patients with their mental health symptoms. Ongoing evaluation continues to guide La Clínica's quality improvement efforts for this program and for its advocacy efforts. Current California policy does not allow clinics to be reimbursed for both primary and mental health services when they are provided on the same day.
When CHF program funding closed at the end of 2009, La Clínica secured a Contra Costa Mental Health Service grant to expand and evolve this program. In Phase Two, La Clínica is not just screening for signs and symptoms of behavioral health issues, but also screening for risk factors such as isolation, cultural adjustment, and parenting challenges. It also conducts groups to help patients deal with many of these risk factors. Finally, La Clínica has tailored its screening processes to five distinct age categories: infants and toddlers (0-5), children (6-12), adolescents (13-17), adults (18-59), and older adults (60 and over).
Thanks to additional CHF grants for 2011 and 2012, La Clínica will continue to contract with professional evaluators, The AVISA Group. The evaluation will continue to gather data on the original adult population, but also will expand to deepen understanding of the behavioral health concerns and treatment options specific to the pediatric, adolescent and senior patients who are now part of the behavioral health integration program. It also helps inform new training efforts tailored at pediatric and senior patients.
By implementing sustainable change that will continuously improve the health of so many, La Clínica's Behavioral Health Integration Program has achieved the highest ideal for our grantmaking process.