Think about this: When it comes to mental health treatment in America, more than 50 percent of that care is delivered in a primary care setting. Couple that with findings suggesting more than 50 percent of patients who visit a primary care physician also need behavioral health services. Add to that the mounds of research confirming that patients' mental wellbeing affects their physical wellbeing. Doesn't it make you wonder why the integration of physical and behavioral healthcare has taken so long?

 

"I think all would agree that how one thinks affects one's physical health, and one's physical health certainly has an impact on how one thinks," said Ben Middleton, senior vice president for core services at Centerstone, the nation's largest not-for-profit provider of community-based behavioral healthcare.

 

Middleton said medicine's penchant for specialization, while important, compartmentalizes a patient's care and thus discourages treatment coordination. With more than 60 facilities in 20 Middle Tennessee counties, Centerstone is working to bridge that gap and making notable strides, particularly in pediatrics.

 

Middleton said Centerstone's push for integrated care began when "it was clear to us that individuals we were seeing needed a medical home, and I'm talking here physical health, as much as they needed a place where they could come and receive mental health treatment. In fact, we became their medical home, and I think you can quickly see the challenge there for us." That challenge prompted Centerstone's integrated care initiative.

 

Integrated care "puts behavioral healthcare providers in the medical setting, actually placing on the ground licensed, clinical social workers or master's-prepared individuals who have the abilities and expertise to diagnose and to work alongside the physician or nurse practitioner," Middleton explained. About four years ago, Centerstone launched just such a model, partnering with Columbia Pediatric Clinic and Patricia Davis, MD. Centerstone had a facility just 100 yards from Davis' practice, yet many times patients she referred to Centerstone never made an appointment. Once Centerstone placed a mental health professional within the walls of the doctor's office, the number of referrals quickly shot up to 40 per month. "That made all the difference in the world," Middleton said.

 

On the national mental health scene, "integrated care" has been the buzz phrase for two decades, but changes have been excruciatingly slow. In short, it's the proverbial paradigm shift, with both physical and behavioral healthcare providers working to reconcile their preconceived notions of delivery.

 

"We have as much to learn about their environment and how they operate as they do about our services," Middleton said. Then he added, "That's a wonderful match."

 

Since the establishment of a Centerstone employee in the pediatric practice in Columbia, the organization has forged a similar partnership with Centennial Pediatrics at its location in Clarksville and in Nashville at the Centennial Park and Southern Hills locations. Last month, Centerstone hired a behavioral health professional who speaks both English and Spanish at the Southern Hills office. At all the locations, the behavioral health professionals are Centerstone employees, and Centerstone leases space from the practice.

 

Yet, the goal is for the Centerstone representatives "to be part of the team," Middleton explained. "They now see the behavioral health provider who actually works for Centerstone as their provider, and that's exactly what we want. ... We knew we'd arrived when one of our providers was invited to the company Christmas party. It may not sound like much, but for us, it was, 'Oh my goodness! We're there.'"

 

Middleton described the Centerstone providers' job within the primary care setting as one of triage — diagnosing a problem and then establishing treatment in concert with the physician. Picture this scenario: A parent brings a child to see the doctor for a physical ailment. During the course of the exam, the parent says the child is having trouble focusing in school and problems sleeping. That's the opportune time for the physician to call in the behavioral health specialist to meet the parent and child. The mental health expert provides information to engage the parent and help him or her realize that what's being offered might benefit the child and the family. Then together they decide whether the child should be clinically assessed.

 

"We have to be Johnny-on-the-spot. We've got to be right there," said Middleton, adding it's "a different kind of animal" than the conventional approach of behavioral practitioners. "It requires enthusiastic, high-energy, fast-paced clinicians, and those aren't easy to find," he said.

 

Following ... and perhaps during ... treatment, the behavioral health practitioner reports findings to the physician. Other offerings by Centerstone employees in these primary care settings include traditional social work activities such as directing patients to appropriate legal or financial resources or even offering case management services, where the professional visits the patient in his or her home. Such in-home treatment allows the mental health expert to see the patient in the "natural environment" and to serve "as a link between home and school and the medical provider," Middleton said.

 

Centerstone's next step is to set up the same model for the assistance of adults; and according to Middleton, there are already successful models to duplicate in East Tennessee.

 

"What integrated care is all about is providers working together ... in this instance, in the medical setting ... but it could be the other way around, as well," Middleton concluded. "I would love to see the day when you have medical providers actually working out of mental health centers."