With the addition of primary care to the behavioral health practice at Hempstead, South Nassau’s behavioral health program has expanded to provide synergistic care that addresses mental and physical health concerns in a compassionate, multidisciplinary fashion.
Long known for excellence in behavioral health, South Nassau maintains two mental health counseling centers, one at Baldwin and the other at Hempstead. At the centers, patients can benefit from the services of more than 45 behavioral health experts, including psychiatrists, psychologists, art therapists and social workers. Patients can receive treatment for behavioral issues, from depression to schizophrenia and substance abuse. Adults and children alike can find help at South Nassau, ranging in acuity from counseling sessions to intensive outpatient treatment, partial hospitalization or inpatient care. Now, with the evolution of the Hempstead location into a Center for Behavioral and Primary Health Care in spring 2018, patients with behavioral health needs can find medical and psychiatric care housed under the same roof.
The Center for Behavioral and Primary Health Care is accepting new primary care patients, too. In fact, patients may come into the practice from one of three avenues: they may be existing behavioral health patients, they may be new behavioral health patients referred through an emergency department or other acute care setting, or they may be new primary care patients who discovered the practice through word-of-mouth. New patients who arrive through the hospital complete a behavioral health screening as part of their intake paperwork and may be directed to a counselor if needed.
“In traditional health care, we think we know what’s best. We give patients a prescription and ask them to call someone. There’s no follow-up until the next visit. But in integrated care, the idea is that while the patient is with you and raises an issue, that is the best time to get the patient involved in his or her own care. Their motivation for change tends to be higher if you have a relationship with them in the moment. That’s the idea: Get them in the moment and get them the care they need, now, in an accessible manner. We find many things can be treated successfully in a short-term, 15-minute consultation. It need not be a lengthy intervention, but it needs to be then.”
— Janet Kahn-Scolaro, PhD, LCSWR, Administrative Director of South Nassau Communities Hospital’s Behavioral Health and Family Medicine Integrated Service Line
A New, Innovative Model of Collaboration
Karen Isaacs-Charles, DO, MS, became the Assistant Medical Director of the center in April. A career with the Veterans Affairs — first as a volunteer, then as a contract physician — showed her the advantages of an integrated care model.
Karen Isaacs-Charles, DO, MS, Assistant Medical Director at the Center for Behavioral and Primary Health Care, visits with a patient prior to examination.
“South Nassau had an outpatient behavioral health component already in place when I interviewed in December 2017,” Dr. Isaacs-Charles says. “They were going to add a medical component in order to offer more integrated care. I was very excited. There’s often resistance among behavioral health patients to seek medical care, especially for chronic illnesses. These patients can feel they are not understood.”
Now, when behavioral health patients report that they haven’t seen a primary care physician in a long time, they can be walked directly to an office in the same building. If they’re afraid of communication difficulties with the family medicine provider — for instance, if they feel shy or afraid that the medical physician will attribute their health difficulties to their mental or emotional status — a behavioral medicine provider can sit in the appointment with them to facilitate communication.
Mulchand Chugh, MD, psychiatrist at South Nassau Communities Hospital, has been working in behavioral medicine with a focus on child psychiatry since he came to South Nassau a decade ago. He describes a synergy between the family and behavioral medicine sides of the new practice.
Mulchand Chugh, MD, psychiatrist at South Nassau Communities Hospital, visits with a patient in the calm office surroundings.
“When patients present with a medical problem, we in behavioral health can refer them to a family care provider,” he says. “If they have a mental or behavioral problem, they can refer them back to psychiatry.”
Further coordination takes place in a daily staff huddle, involving both medical and behavioral sides. Jennifer Kurko, LCSWR, Manager for the Center for Behavioral and Primary Health Care, leads a review of high-risk patients expected that day and a management plan is devised for each. More broadly, providers including Henry Conde, LCSW, Behavioral Health Integrated Care Specialist, Amber Vitale, MSN, FNP-C, and Shari Karp, LCSW-R, Behavioral Health Supervisor, all give input into patient care and assist in coordination at levels ranging from the institutional to patient-by-patient. In weekly case discussions, providers examine particularly challenging cases to see how to better manage each patient and achieve healthy outcomes for the whole person. As a result, each patient’s care plan stems from a conversation between providers involved in the care of the body as well as those with expertise in feelings, thoughts and behavior. The synergy is truly unique.
A Network of Related Concerns
A unique, powerful approach is needed because South Nassau’s patients face a variety of tough, interlocked challenges. Poverty, chronic disease and ongoing stress can place seemingly insurmountable obstacles before them.
A patient arrives at the reception area for primary care. There are two separate waiting and reception areas, one for primary care and one for behavioral health.
Janet Kahn-Scolaro, PhD, LCSWR, Administrative Director of South Nassau Communities Hospital’s Behavioral Health and Family Medicine Integrated Service Line, identifies poverty and lack of access to specialists in the community as two of the most pressing problems facing patients at the Center for Behavioral and Primary Health Care.
“Poverty impacts more than just material things,” she says. “On the behavioral health side, we must understand that people who are struggling to maintain their families’ existence face stress that is very real. There’s a difference in stress that’s controllable versus the stress of living in an impoverished community — that is outside patients’ control. We can address and treat it sometimes but not in total.”
Access can also be partly ameliorated by the Center’s efforts. Providers known as behavioral health integrated specialists, whose function is similar to that of nurse navigators, take the lead in tasks such as finding an accessible provider, making an appointment for the patient and arranging transportation to the specialist.
Patients’ health concerns frequently meld the social, mental and physical, often in the form of a vicious cycle. Lack of access to healthy food can lead to or exacerbate weight problems and related illnesses, causing stress and depression, for instance. The same economic problems that adversely affect weight are also stressful. In another typical cycle, antipsychotic medications can lead to diabetes. Sleep apnea and depression also commonly co-occur, Dr. Chugh says.
“Frequently, patients will tell me they’re tired and unmotivated,” he says. “They’re feeling down, especially in the morning. Then I’ll ask about their sleep history. I offer to refer them to a pulmonologist to rule out sleep apnea, and it turns out they need to be treated for apnea rather than depression.”
Improved Health Outcomes
The integrated care model is likely to improve health outcomes among patients, Kahn-Scolaro says. A South Nassau provider for more than two decades, she points out that the Center for Behavioral and Primary Health Care, while innovative, is not unlike the South Nassau’s Oceanside practice, where family medicine and psychiatric care are co-located.
With both primary care and behavioral health housed in the same location, physicians are able to readily consult with each other regarding the patients and their plans of care.
“We gathered a lot of data from that endeavor,” she says. “It is fascinating. We looked at the levels of depression among patients being treated at the family medicine and behavioral health practices. We found that patients presenting with comorbid conditions, such as diabetes, had high rates of depression — as high as those of behavioral health patients. We felt that we were doing the right thing in colocating care. Before that, we had not known that this group of patients was truly suffering.”
The colocation of the two practices, family medicine and psychiatric care, allowed South Nassau to provide referrals and warm hand-offs, that is, a provider walking them to an appointment personally or meeting them at the new provider’s office to address heretofore unrecognized, untreated depression. Kahn-Scolaro also notes that patients adhered to their appointments more frequently with warm hand-offs.
“In the past, 30 to 40 percent of patients came to behavioral health after a referral from family medicine,” she says. “But it went up to 68 percent because the family medicine provider would hurry over to behavioral medicine and do the initial assessment together with the patient. ‘I’ll meet you over there and get you started,’ they’d say. It was extraordinarily helpful.”
Though the new practice at Hempstead has not yet had time to accumulate this kind of data, Kahn-Scolaro predicts results will be the same with the collaborative care model. Already, individual patients are seeing specific health problems addressed by the collaborative behavioral/mental health model, Dr. Chugh observes.
Dr. Chugh provides behavioral health services at the combined facility.
“When our patients visit a family medicine provider, we are able to identify problems such as high blood pressure, diabetes and hypothyroidism,” he says. “Now we can get those health concerns taken care of promptly.”
For improved outcomes, it’s often the simple step of actually getting a needed screening or treatment, such as a blood draw or injection that can make all the difference. In many cases, Dr. Chugh says patients at the Center for Behavioral and Primary Health Care can receive injectable medications on the spot. Before, patients would receive a prescription and then would have to get the injection done elsewhere, which lessened the likelihood of compliance. Also, patients can have blood tests to check medication levels, blood sugar and other health metrics, both to insure they are following their medication regimen properly and to identify potential health issues.
“We provide competent, compassionate care in the primary care and behavioral care settings.”
— Karen Isaacs-Charles, DO, MS, Assistant Medical Director of the Center for Behavioral and Primary Healthcare
Directing Patients to Appropriate Care
The new Center for Behavioral and Primary Health Care has reduced Emergency Department (ED) visits and unnecessary hospitalizations and specialist referrals among some patients, while increasing needed ED visits and specialist consultations for others, Dr. Isaacs-Charles says. In effect, the Center for Behavioral and Primary Health Care serves as a traffic controller to direct patients to the appropriate level of acuity, allowing South Nassau and other hospitals in the area to use their resources in an effective fashion.
A staff nurse discusses the patient’s chart with Dr. Isaacs-Charles.
Some patients who would not otherwise have sought acute or urgent care have received lifesaving treatment because they felt safe going to the Center for Behavioral and Primary Health Care with their concerns. For example, Dr. Isaacs-Charles had one patient present with atrial fibrillation and two others arrived while having heart attacks. Each time, EMS teams were called and transferred the patients promptly to the hospital for immediate treatment. These patients might not have felt confident calling 911, she notes.
Addressing the Whole Person for Greater Patient Satisfaction
As physicians take the time to collaborate around care, patients perceive a level of compassion and individual attention that is particularly gratifying. As a result, patients trust their providers and feel increasingly satisfied with their care, not just from each provider, but also from the practice as a whole.
“In social work, we describe positive feelings for the institution based on feelings for the provider as institutional transference,” Kahn-Scolaro says. “You develop a relationship not with just one provider but with the group. You have the positive feeling: ‘This is my place. These are my people. They will be there for me.’”
Kahn-Scolaro recalls former patients who now bring their children to see her.
“If I wasn’t here, another provider at the center would care for them in the same way,” she adds. “And they know that.”
Holistic patient care includes the community, too, especially at South Nassau where so many patient health concerns have socioeconomic roots. Dr. Isaacs-Charles says her fellowship in health policy informs her work at South Nassau. She asks about her patients’ work and finds that many of them, even those with significant psychiatric conditions, hold regular jobs. Learning about patients and their lives helps Dr. Isaacs-Charles and her colleagues understand the social determinants of their health, which researchers are finding contribute significantly to physical and mental well-being.
Not only do South Nassau’s providers investigate their patients’ socioeconomic conditions, they actively work to engage with them at the community level, whether through direct outreach or research and interaction with colleagues in related disciplines. Dr. Isaacs-Charles and Kahn-Scolaro regularly attend conferences to share findings and best practices in collaborative health care. And South Nassau held a health fair in October to help members of the community learn about healthy behaviors, as well as services available to them.
“Behavioral health providers at South Nassau see patients as a whole, not just their mental health. Patients may miss their primary care appointments, but they don’t miss their appointments with us. So we ask them, ‘When was the last time you saw your primary care physician?’ ‘Oh, doc, maybe three years ago,’ they’ll answer. So we send them right away to their primary care provider.”
— Mulchand Chugh, MD, psychiatrist at South Nassau Communities Hospital
The staff and practice management of South Nassau’s Center for Behavioral and Primary Health Care
Just as providers at the Center for Behavioral and Primary Healthcare look to create a continuum of care across disciplines or areas of life, they also look to create continuity across time, from cradle to senescence. This is especially important given that children in the community, often faced with high levels of stress, may develop both physical and behavioral problems. The Center provides coordinated behavioral and medical pediatric care, a relatively rare offering. Dr. Chugh, for example, specializes in child psychiatry. Geriatric patients also frequent the center. Providers aim to cultivate lifelong relationships as a background context for episodic, on-the-spot care.
“Family medicine is wonderful and unique in that providers look to have long-term relationships with patients and treat them over the course of their lives,” Kahn-Scolaro says. “Pediatrics and geriatrics fit nicely into that perspective. Though treatments are short-term, they can be episodes in a larger trajectory. A patient may come in with a behavioral health crisis or life change, receive help, and go on. We would like the behavioral side to be like family medicine: to be the place where patients can come back for a tune-up if another episode arises. We want to be there for patients just as family medicine wants to be there.”
From the individual to the institutional level, patients at the Center for Behavioral and Primary Health Care often express an unexpected emotion for the healthcare setting: joy. The providers, too, seem to glow as they speak about their patients.
“Patients are so happy here. They’re so trusting, also. With the patient-physician relationship, there’s always a level of trust. And it helps that the behavioral piece is right here. They feel safer. They quickly give their medical history because we have access to a lot of their story already,” Dr. Isaacs-Charles says. “Here’s the hidden secret: some people don’t like to tell you about their behavioral health diagnoses. But we know about that already! So they can move on to medical history, family history, without the anxiety of disclosure.”
“We’d like referring providers to know we see each patient as a whole person,” Dr. Chugh says. “This is literally the best way to treat them. We don’t just provide psychiatric care — we’re a medical, psychological and counseling center.”
For more information, visit southnassau.org.
In accordance with HIPAA restrictions prohibiting the photography of behavioral health patients, photographic portrayal of patient interactions were made using models, not actual patients.