"Mental health home" proposed to boost care for psychiatric illnesses

Jim Dearing, DO, a family physician in Phoenix, often refers patients with significant mental health issues to a psychiatrist. But he rarely hears back from the specialist. In addition, his patients sometimes come to him with a prescription in hand, but are unable to name the doctors they saw or articulate the care plan.

"Psychiatrists treat them to the left, I treat them to the right, and patients get lost in the middle," said Dr. Dearing, who is on the American Osteopathic Assn. board of trustees.

To increase the coordination of care between physical and mental health and make this situation less likely, two psychiatrists published a paper in the April Psychiatric Services. They suggest creating a "mental health home" for patients with serious mental ills.

Their goal is to increase the access to behavioral, social and medical services that these patients require and to reduce the risk of repeated hospitalizations, incarcerations and homelessness. Access to primary care, in particular, is important because many of the newer medications used to treat mental illnesses put patients at increased risks for diabetes and other metabolic problems.

"We work primarily with a population of seriously mentally ill people, and they have the most disability and the most difficulty, not only with mental illness, but with all sorts of comorbidities. We're struggling with this population to coordinate services and integrate primary and specialty care," said Thomas E. Smith, MD, lead author and associate professor of clinical psychiatry at Columbia University's College of Physicians & Surgeons in New York. This proposal "is taking the same principles and overall approach of the medical home but tailoring it to individuals with serious mental illness."

The idea of a medical home for those with serious mental illnesses or other health problems is not new, and the details in the Psychiatric Services paper have much in common with community mental health centers, a concept first established in the 1960s. These organizations still exist, although many now operate much differently.

"It's old wine in new bottles, and it's absolutely the exact right thing to do," said Carl Bell, MD, director of the Institute for Juvenile Research in the Dept. of Psychiatry at the University of Illinois in Chicago. He also is chair of the American Psychiatric Assn.'s Council on Social Issues and Public Psychiatry.

The APA is working to understand the implications of the medical home concept on the specialty because the care model has been put forward for a broader base of patients by the AAP and AOA as well as the American College of Physicians and the American Academy of Family Physicians. These organizations issued "Joint Principles of the Patient-Centered Medical Home" in March 2007. Their principles defined the comprehensive primary care approach as one involving an ongoing relationship with a physician who leads a team and coordinates care across all areas of the health care system, all stages of life and all aspects of a person's well-being. It includes patients' active participation in decision-making. It also involves enhanced access through open scheduling or other options.

The American Medical Association signed on to the concept in November 2008, although the organization is continuing to study funding issues for the medical home model. A report on the topic is due from the AMA Council on Medical Service at the Annual Meeting in June.

Generating a buzz

So far, the response to the mental health home proposal has been enthusiastic.

"The article is absolutely right on," said Kim Griswold, MD, MPH, associate professor of family medicine and psychiatry at the University at Buffalo in New York. "If anyone needs a medical home, it's a person with serious mental illness. We have neglected this population." She researches primary care access for this population.

The model has been promoted mostly as a way to improve primary care, and proponents were happy to see specialists express interest.

"There's a longstanding problem integrating mental health and physical health. The fact that the mental health community is interested in the medical home is a very good sign," said Robert Phillips, MD, MSPH, director of the AAFP's Robert Graham Center for Policy Studies in Family Medicine and Primary Care.

But concern stems over the possibility of creating multiple medical homes. In addition, care in the proposed mental health home will tend to be coordinated by a behavioral health clinician who is unlikely to be a physician.

"The family is at the center of the medical home, and they are not well-served by the fragmentation of having two homes. We have got to collaborate in such a way to provide for the needs in one home," said Jane M. Foy, MD, professor of pediatrics at Wake Forest University School of Medicine in North Carolina. She also is chair of the AAP Task Force on Mental Health.

Creating a mental health home faces similar barriers to the medical home, including finding funding streams and educating physicians on how it should work, and reimbursement for mental health services can be more challenging. In addition, mental illness tends to be more stigmatized than physical health issues, and many experts believe this will prove to be a significant stumbling block to improving coordination of care.