Though mental health services take an occasional starring role in public discourse about health care, as they did after the horrific December school shooting in Newtown, Conn., they're mostly a bit player-ignored, underfunded and only newsworthy when someone didn't get enough of them to avert tragedy. Robin Henderson, a clinical psychologist, could be accused of bias for believing that improving mental health care is key to improving overall care and controlling costs, but she recently proved her point with a project focusing on "frequent fliers" in the emergency department. They were almost all Medicaid patients, and almost all of them had some kind of secondary mental health condition, addiction, or pain, apparently unrelated to what had brought them to the ED, and not severe enough to have flagged them for medication or therapy. They were referred for primary care to a "medical home" setting that included behavioral health consultations. "They were instructed what to do if they felt a migraine coming on, and what to do to reduce anxiety," Henderson says. The initial cohort of 144 patients had 44 percent fewer visits to the ED in the first six months after starting the new care regimen, saving Oregon Medicaid about $750,000. "We know that 12 percent of the people are responsible for more than 72 percent of the [Medicaid] spend," Henderson says. "For us, that's 3,600 people. We can manage those people better."
On mental health information
I fought against EHRs initially [because of privacy concerns], but now I think we have to change the way we document [mental health information] for it to be useful to primary care. It doesn't need to be a diary of everything in a patient's life, but it should show how mental health issues are impacting their ability to live, and what primary care can do to help.
On mental health information systems
We had a separate psych EHR at the hospital because the main EHR couldn't accommodate our needs. We built in a care and safety plan, and on the first interview we asked patients what would make them feel better if they started to get upset or anxious. All the providers knew what button to press to get that information, and doing what the patients asked was often enough validation to get them to calm down.
On communication
There's a group of patients with medically unexplained physical symptoms. They may have a good relationship with a primary care doctor, but they'll come into the ED 12 to 15 times a year, and the ED physicians will order tests. We create a care plan in conjunction with the primary care physician and flag their record: "If this person comes in, do A, B, and C, and if those don't work, follow up with me tomorrow." It saves a lot of expensive testing.
