Building Bridges to Better Health

Left to Right: Chika Akera, Associate Medical Director; Esperanza Ospina, Physician Assistant; Leslie Lessenger, Behavioral Medicine Specialist; Nancy Facher, Manager of Integrated Behavioral Health; Maria Escalante, Medical Assistant

Integrating Behavioral Health with Primary Care

"From our work in this community, we know there is a lot of pent-up demand for mental health services." - Jane Garcia, Chief Executive Officer, La Clínica de La Raza

In Brief: To better meet the full spectrum of patients' physical and mental health needs at its Contra Costa clinics, La Clínica de La Raza is integrating behavioral health services into primary care visits at both its Pittsburg and Monument clinics. Research has shown this approach to be clinically and economically effective even though public reimbursement policy in California does not reimburse these combined services when provided on the same day.

Our initial 2007 grant supported a planning process and staff training. Additional grants awarded in 2008 and 2009 have allowed La Clinica to move into full implementation and evaluation, including creating a plan for financially sustaining the program once CHF funding concludes. In the program's first year of implementation, 644 patients received behavioral health services and the U.S. Department of Health and Human Services' Federal Partners Senior Workgroup on Mental Health recognized La Clínica as a "Best Practice Setting."

The Health Issue: For a variety of reasons, many La Clínica patients are reluctant to acknowledge their mental health needs and in many healthcare settings have no easy way to access mental health providers. Therefore, these patients 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 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: By "nesting" behavioral medicine specialists at their primary care clinics in Contra Costa County, La Clínica is dramatically improving the way it meets the mental health needs of its patient population. In this program's first year of implementation, 644 patients received behavioral health services largely without the perceived stigma that was a concern in the planning process. In recognition of La Clínica's work, the U.S. Department of Health and Human Services' Federal Partners Senior Workgroup on Mental Health declared La Clínica a "Best Practice Setting."

Here's how it works. The behavioral medicine specialists at La Clínica provide direct patient services, and/or act as consultants to the primary care providers. If during an appointment, the primary care provider identifies a mental health need - either through a specially designed patient intake form or during the patient visit - he or she introduces the patient to the behavioral medicine specialist who is trained to rapidly assess mental health concerns and, in simpler cases, treat the concern. (For example, the provider might remind a patient suffering from sleep deprivation 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, increasing the chances that the patient will arrive for a follow-up visit. "This is not a therapy model or a long-term solution to more severe problems," says Leslie Preston, La Clínica's director of mental 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."

In year three, La Clínica will ramp-up advocacy efforts designed to change public policy on reimbursement of same day visits. Success in these efforts can lead to increased revenues that can go a long way toward sustaining the integration of services that research in other settings has shown to be both clinically and economically effective - and which this La Clínica program anecdotally confirms. Now, to support their advocacy efforts, La Clínica has begun to formally evaluate and document the efficacy of its own integrated services.

"From our vantage point, the Community Health Fund gave us an incredible gift in that we could be deliberate about designing a program that would have the greatest impact on our population." - Jane Garcia