Working with the County of San Diego to Provide Mental Health Services Family Health Centers of San Diego October 31, 2007

Family Health Centers of San Diego 10 Primary Care clinic sites 3 Mobile Medical Units 3 Dental Clinics 3 Mental Health clinics  Children’s mental health services in numerous school sites  Mental Health Services offered at 4 additional primary care clinic sites One of the largest community health center systems in the country; FHCSD assisted 106,691 patients in 2006 with over 368,800 patient visits

Mental Health Services -Individually contracted with San Diego County since 1998 for adult mental health services (Logan Heights Family Counseling Center) -Individually contracted since 2000 for children’s mental health services (Logan Heights Family Counseling Center, East County Family Counseling Center, numerous schools and homes) -Joined Federal Health Disparities Collaborative movement for the treatment of depression in 2004; genesis of FHCSD’s integrated primary care services (North Park Family Health Center) -Subcontracted with San Diego’s Council of Community Clinics in early 2007 to expand the integrated model (City Heights Family Health Center, North Park Family Health Center, Grossmont Spring Valley Family Health Center) In CY ,765 mental health visits, of which 1,093 were integrated visits in the primary care setting.

The Case for Providing Mental Health Care in the Primary Care Setting  28% of Americans have a diagnosable mental health and/or addictive disorder; less than one third ever seek treatment.  Some 60-70% of primary care visits have a psychosocial basis.  Majority of Americans receive their care for behavioral health conditions from a primary care physician.  People who report persistent depression have annual adjusted medical costs that are 70% higher than those who do not report having depression.  THE MEDICAL UNDERSERVED ARE AT HIGHER RISK FOR POOR HEALTH STATUS; HAVE MORE UNMET MENTAL HEALTH NEEDS THAN THE POPULATION AT LARGE.

PREVALENCE OF PSYCHIATRIC DISORDERS IN LOW-INCOME PRIMARY CARE PATIENTS Psychiatric DisorderLow-Income Patients General PC Population At least one psychiatric Dx Mood Disorder Anxiety Disorder Alcohol Abuse Eating Disorder 51% 33% 36% 17% 10% 28% 16% 11% 7% - 35% of low-income patients with a psychiatric diagnosis saw their PCP in the past 3 months -90% of patients preferred integrated care Source: Mauksch LB, et. Al. Mental Illness, Functional Impairment, and Patient Preferences for Collaborative Care in an Uninsured, Primary Care Population. The Journal of Family Practice, 50(1): 41-47, 2001.

Unmet Mental Health needs in our Populations  Percentage of African-Americans receiving needed care is only half that of non-Hispanic whites.  Nearly one out of two Asian-Americans/Pacific Islanders experience trouble getting mental health treatment due to language barriers (only some 17% seek treatment).  Among Hispanic/Latino Americans with a mental disorder, fewer than one in eleven contact a mental health specialist (fewer than one in five contact their general health care provider regarding mental health concerns). For immigrants, the numbers are fewer than one in twenty for a specialist, one in ten for primary care provider.  Additional factors are poverty, lack of insurance coverage, stigma, etc. - United States Public Health Service Office of the Surgeon General (2001). Mental Health Culture, Race and Ethnicity: A Supplement to Mental Health: A Report of the Surgeon General. Rockville, MD. Dept. of Health and Human Services, U.S. Public Health Service.

Integrated Service Process Screening - PHQ-9 directed by primary care provider (PCP) Treatment - Offered by PCP if PHQ-9 score is 10 or higher - “Warm hand-off” to therapist/care coordinator for brief therapy and/or care management services - Referral to FHCSD’s on site psychiatrist if needed (consultation available on all cases, referred or not) Frequent re-screening with PHQ-9 is done; medications are adjusted as necessary.

Why is the Integrated Model a Good ‘Fit”? -Patients like it -Potential for early identification and treatment of illness especially depression -Stigma reduction (acceptance of treatment) -Impact on treatment compliance for other health conditions -Leveraging of scarce psychiatry resources -Comfort level of the population -Co-location of treatment staff; team approach -Better compliance with psychotropics -Working as part of a team -New funding streams allow more people to be served

Patient Point of View (focus group) “It is a great relief to have my doctor care about how I feel” “Having a doctor talk to me about mental health tells me that this is as important as my physical health” “For many years, I wasn’t aware that I suffered from depression until my doctor helped me to identify it and treat it” “Receiving treatment for my depression through my doctor has helped me to move forward in life” “I think that having my doctor ask me about my feelings is an excellent idea; most of the time that’s what I want them to ask me about” “If it wasn’t for my doctor asking me about my emotional state I would have never understood that feeling depressed needs treatment” “Discussing my emotional needs with my doctor has provided a sense of relief and makes me believe that he cares about my well being”

Challenges - Chaos that comes with new monies and the strings that come with them -Service number expectations for partial year contract -Changing documentation requirements -Complex and protracted contract negotiations; followed by very short start-up period inadequate for full implementation -Burden of audit details -Short term nature of contracted services -Documentation issue

How to reach me: Nora Cole, MEd, MFT Assistant Director, Family Counseling Services Family Health Centers of San Diego 823 Gateway Center Way San Diego, CA (619)