When I joined a Denver community mental health center as a health coach serving 160 individuals with severe and persistent mental illness (SPMI), I landed on the frontlines of a radical experiment.
Our “health home” aimed to integrate behavioral and primary care services for SPMI individuals, the most medically complex users of our health care system.
Consider the grim picture for SPMI individuals in the current health care climate. They access the system at the outpatient level for psychiatric medications, counseling, case management and addiction services and are often hospitalized during mental or physical health crises.
A single case of schizophrenia costs more than $10 million over a patient’s lifetime. But for the amount of resources we spend on care – physical and financial – the outcomes are disappointing: SPMI patients die 20 to 25 years earlier than the rest of us.
Poor health outcomes are due in part to special health needs. More than 70 percent of SPMI patients have a chronic physical health problem; over 50 percent have two or more chronic conditions. They are triply at risk for diabetes, pre-diabetes, heart disease, lung cancer, obesity and metabolic syndrome. Lifestyle factors highly correlated with mental illness and low socioeconomic status such as smoking and substance abuse, inactivity, poor nutrition and risky sexual behavior contribute to the physical health problems.
Still, the prevailing issue is not the underlying health needs but how our current system fails to meet those needs. The separation of our behavioral and physical health provision systems makes them nearly impossible to navigate.
Each care site has its own culture. While the fee-for-service primary care model prioritizes improving quantitative outcomes like cholesterol numbers, most community mental health centers rely on capitation payments and emphasize qualitative and functional improvements. As a consequence, SPMI individuals often avoid contact with health care services until they face an acute illness or crisis.
Integration promises to simplify this confusing system into a one-stop shopping experience for SPMI patients. In our health home, each patient had a care team that included physicians, psychiatrists, psychologists, case managers and new direct service providers such as health coaches, substance abuse professionals, peer specialists and “navigators” that help patients access the right services within the building. Under a single roof, SPMI individuals could access physical and behavior health services as well as free services emphasizing prevention and wellness.
This structure helped empower SPMI patients to take ownership of their health. The patients I worked with started exercise programs, learned how to grocery shop, lost weight, quit smoking and dramatically lowered cholesterol or glucose numbers. One even completed a half-marathon. Integrated care proved more convenient for our patients, and we saw engagement and health outcomes improve across the board.
But even though health outcomes improved overall, our health home also failed a large number of patients. In our rush to fuse behavioral and physical health systems, we forgot about mindful practice.
Mindful practice is about applying skills that improve our relationships with patients. It requires self-awareness, active listening and responding to the patient’s emotions. When we ask patients about their values, expectations and competencies and see them in the context of their current lives, we do better at treating the whole person and avoiding medical errors. Better alliances with patients lead to more engagement in prevention and wellness, less attrition, fewer hospitalizations and lower overall care costs.
Our health home’s cutting-edge program was plagued by frequent complaints about negative interactions with providers and front office staff. Clients said they had been chided and felt that medical providers were condescending or rude. I often heard more negative feedback about providers than I did about the caustic side effects of psychotropic drugs. And even though they were receiving more “complete” care, the majority of SPMI patients I worked with didn’t know their prescriber’s goals or what their treatment plan said.
The institutional growing pains of integrating two distinct systems also affected the patients’ experience. Physicians sometimes grimaced at having to care for SPMI patients. And our staff failed to model healthy behavior. One of our nurses smoked and the lead psychiatrist was morbidly obese. Collectively, these factors made an unpleasant experience for some patients who dropped out of integrated care and opted back into the chaos of separate systems.
My experience shows that while integration is necessary, it is not enough. The truly essential – and perhaps more radical – ingredient is mindful practice.
Making mindful practice part of our integrated care system means taking steps to improve patient-provider relationships at the institutional and team levels. Our organizational culture must evolve to support collaborative treatment planning. Motivational interviewing, cultural competency and trauma-informed care courses should be part of new-hire orientation for all direct service providers.
Additionally, we can incentivize providers who ask patients about their goals, include patients in health planning and empower patients to leave our offices knowing how they can contribute to their own recovery and care. At the team-level, mindful practice requires restructuring our workflow. Weekly collaborative care meetings or daily “huddles” can help keep our teams better informed, more consistent in our messaging and more connected to teammates who are already mindfulness champions.
Monthly team meetings should include patient voices in the form of patient ambassadors or even a patient advisory board. Patient representatives can help transform our traditional workflows into inclusive sessions where providers get live, constructive feedback.
To fully realize the promise of integrated care for SPMI health outcomes, we need to advance mindful practice. Together with integration, mindful practice has the potential to turn our sick-care system into a well-care one.
Alexandra Reed is a Tufts graduate, SPMI health coach and a research assistant with the Center for Schizophrenia Research at University of Colorado’s School of Medicine. She is currently applying to Ph.D. programs in clinical psychology. Her email is: firstname.lastname@example.org.