May 16, 2018
Eastern Plumas Health Care’s new Behavioral Health Program, jump-started by funding through a federal grant aimed at improving “the way care is delivered through California’s safety net hospital system,” has taken a big step forward recently. The grant has allowed EPHC to begin caring for the mental and emotional health of their patients in conjunction with the medical care they’ve already been receiving. Clinic Director, Rhonda Grandi, who wrote the grant, felt this was the project most needed by EPHC’s patients, given the high number of patients with a behavioral health diagnosis.
“Previously,” said Grandi, “the only means of treatment for these patients was through telemedicine.” Now, patients are seen one-on-one either by Trish Foley, LMFT, or a Psychiatric Mental Health Nurse Practitioner or Psychiatric Physician’s Assistant with the help of consulting psychiatrist, Dr. Gail Prichard, in Truckee. “Patients have been very responsive to seeing providers in person,” said Grandi.
Foley sees the patients who will benefit from counseling services (psychotherapy). The psychiatric provider for the past couple of months was Mark Cross, Psych PA, who was hired on a short term contract to fill the gap in service for those patients needing medication management. This week, Irene Wojek, Psych NP will join the staff on a permanent basis. Besides medication management, she brings mind-body relaxation techniques and other non-medication alternatives to patients who will benefit from this holistic type of care.
What holds the program together, according to Grandi, is RN Case Manager Tracy Studer. She meets all new patients who have been referred to Behavioral Health by their primary care providers. Studer explained that by conducting a thorough review of newly referred patients’ medical records and working with their primary care providers, she can learn a lot about them. Often, she said, “a provider will call and offer a scenario about a patient they’re concerned about. Sometimes, I can offer ideas on what services might be appropriate on the spot. If not, I’ll look into the case and then determine where the patient should go.” She said she goes through the same mental list when she receives a patient referral.
Through chart review, Studer can view a patient’s past medications. She can glean a lot from a patient’s medical and family history. Certain prior behaviors are a good clue, she said, especially when dealing with the more serious cases. After that, she will talk with the Behavioral Health team, which now includes Foley and Wojek, along with the patient’s primary care provider. Studer will also contact Plumas County Behavioral Health (PCBH) to determine if the patient has been seen by them. If the patient is already getting care at the County, said Studer, they usually need to stay there.
After Studer’s initial review, patients will be placed with the appropriate provider. Mild to moderate patients join EPHC’s Behavioral Health program for care. If, however, their case is more complex and they need to have medications prescribed, or they are not currently well managed on their medications, they are referred to County Behavioral Health.
“What’s working great is the team and the process of reviewing patient referrals,” said Studer. “It’s getting more seamless. Patients don’t always end up with us when they’re referred.” This makes it easier to treat the patients who stay here. It also offers patients needing more intensive treatment the care they need, she added.
In order to identify which referred patients need to go to County and which stay here, they use the Anthem Blue Cross behavioral assessment “tool,” as well as an in-person assessment. “People who are well managed on their medications,” said Studer, “and are receiving a more serious level of treatment, but are stabilized – we will still see them here.”
Patients who are referred to PCBH will still see their medical providers here, but the more intense level of treatment they need is better served there. They can get help with housing, life skills, jobs, and more. “A good indicator of whether a patient needs to get the help that the County offers is if they don’t adhere to their medication regimen,” said Studer. “Their coping skills typically aren’t as good, either.”
And, these patients can come back when they’re well managed. “The County can call and say they’ve been discharged,” said Studer. She follows up on these patients, both with PCBH and with their primary care providers, offering a safety net that ensures they won’t get lost in the process. “The communication is much better than it was previously,” she said.
One issue they’ve had to work through, said Grandi, is that sometimes both the patient, and their medical provider just want the patient to stay in Portola. In the past, the more complex patients would be handed off by their doctor to the telemed psychiatrist. This allowed patients to continue to receive care close to home, which they most often wanted to do. It also didn’t require the physician to be an active participant in the process. But, said Grandi, “Once they see it work, they learn to trust the process.”
Grandi and Studer agree that it’s still a work in progress with primary care providers who were used to referring patients out and are now being asked to be more involved in their ongoing mental health care. But, by working with them on implementing the collaborative process, providers can see that “this is just a new way of taking care of their patients,” said Grandi.
The team also has a weekly case management meeting in which they talk about patients of concern and patients who do not seem to be improving. “We’ll ask, ‘What are we missing?’ ‘What else?,’” said Studer. Sometimes they ask Dr. Prichard, the consulting psychiatrist, and she’ll make medication recommendations.
In addition, Studer has recently received training through the University of Washington AIMS Center on “Problem Solving Treatment.” The AIMS Center is the go-to organization for this collaborative medical and behavioral health care model. They’ve trained over 6,000 clinicians around the world. This training allows Studer to recognize those patients with depressive symptoms and teaches her ways to help them reduce these symptoms. And, even when these patients make progress, they can always check back in with Studer if they need to.
The new Behavioral Health Program weathered some ups and downs during its first year, but staff are getting comfortable now with this productive and collaborative model of care. As the program becomes more stable, it is beginning to settle into a “good flow” as Grandi put it; they are seeing an increasing number of patients and getting positive feedback and measurable results. Finally securing committed, long term staff for the program will also help a lot, Studer said.
The Program is coming to the end of its one year contract with the AIMs Center, whose clinical consultation services support the step by step implementation and operation of Collaborative Care programs such as EPHC’s. The Center played a vital role in helping EPHC’s program staff “understand how collaborative care should work,” said Grandi. “They stepped us along through a lot of challenges,” Studer agreed.
“They’ve been a good guide. This was uncharted territory for us. It’s nice to have someone to bounce off of who has done this all over the country,” added Grandi. “We’ve arrived at a point where we don’t rely on them any more. We’re getting the feel of the flow and how it all works.”
Grandi explained that EPHC is doing a “hybrid” model. The AIMS Center model utilizes the patient’s medical provider for medication management, in concert with the consulting psychiatrist. EPHC has both Trish Foley, LMFT, for patients who need counseling, and Irene Wojek, the Psychiatric Nurse Practitioner. In EPHC’s model, the Psychiatric provider meets with the patient, which seems like a worthwhile addition here. And, she will work directly with medical providers so they can support their patients’ behavioral health treatment. “The services are pretty well lined out,” said Grandi.
In consultation with the AIMS center, they’ve discussed how to “reduce the stigma” that can be attributed to patients with mental health issues, said Grandi. “But, our patients are so ready for this, it’s pretty awesome.”
The experience for patients and staff, for the most part, has been so positive that stigma just doesn’t seem to be an issue. And, for Grandi’s part, “they’re all just our patients – this is just another specialty in our clinic.”
“90 percent of our patients want to be here and are doing really well,” Studer agreed. A significant element in this program is measuring behavioral change through self-assessment surveys. “They do assessments for anxiety and depression, and for most patients, they’re able to see for themselves how much they’ve improved–and that’s really a positive thing to see . . . I even see a difference in how they walk,” said Studer.
Studer clearly has found her calling. She loves her work and the patients she serves; she loves, she said, making a difference.