Early this year, 65-year-old Peggy Huff of Springfield felt like she was falling apart.
"I've had a lot of injuries over the years," she said, including a shattered knee, a broken wrist and arthritis setting in now.
Huff was in chronic pain and taking a combination of acetaminophen and ibuprofen every six hours around the clock, every day.
Her mood sank, too.
"It was, man, I'm not getting any better here, and I was really quite depressed, quite unhappy."
Her doctor at Springfield Family Physicians suggested she talk with Carrie Suiter, a therapist with the Eugene-based Center for Family Development who works right there at Springfield Family Physicians. Suiter directed Huff to a weekly yoga class for people with chronic pain. After just four months, Huff said, the class has made a huge difference in her life.
"When I first started there, I could barely get up and down to the mat," she said. "Sometimes I would have to stay in the chair. I've just gradually gotten better all the time."
The class offers more than physical exercise. "It's like rethinking my life," Huff said. "I can't do the things I used to do. I'm finding acceptance in that. It's like I've been turning my life around -- the breathing exercises, the relaxation, the real emphasis on taking care of ourselves."
There's also a camaraderie, almost a "spiritual connection," to others in the class, she said.
Now, Huff said if she needs any pain medication, it's just one pill to be able to sleep through the night.
Since early May 2012, Springfield Family Physicians has referred about 1,200 patients to the Center for Family Development, a behavioral health clinic that has partnered with the physicians group on an innovative project to offer physical and mental health services in the same office. The center started out providing services one day a week at the Springfield clinic, and gradually increased that to five days a week.
About 85 percent of patients who want behavioral health services at the Springfield clinic receive follow-up services after their first meeting, said Suiter, health services coordinator for the family development center.
The idea is to get patients who are struggling with such issues as anxiety, depression, or substance abuse to a therapist early on, before problems escalate into crises, to help patients stay happier and healthier and to save health care dollars.
Backing from Trillium
Springfield Family Physicians and the Center for Family Development were among the first clinics in Lane County to team up to offer physical and mental health services in one place. Now after trying to make the program fly on their own, they're getting backing from Trillium Community Health Plan, the Coordinated Care Organization that manages the health care of 89,131 Lane County members of the Oregon Health Plan, the state's version of Medicaid.
Trillium has given $535,200 in one-year grants to eight projects that are integrating mental and physical health services for local Trillium members, said Lynnea Lindsey-Pengelly, Trillium's behavioral health medical services director.
Lane County also contributed $250,000 to help with startup costs and oversight of the projects, Lindsey-Pengelly said.
The offices undertaking the projects range from small private medical practices to the largest medical groups in Lane County: Oregon Medical Group and PeaceHealth Medical Group.
Some of the projects station behavioral health specialists in primary care practices. Others go in the opposite direction, placing primary care providers in behavioral health clinics.
Being able to refer a patient to someone across the hall, instead of across town, eases the way for patients, said Dr. Dan Paulson, a doctor with Springfield Family Physicians.
"They already have established a relationship and trust someone here, and 'I'm bringing in someone who I trust to work with you,'?" Paulson tells his patients. "They feel better because we've endorsed it, basically."
The immediacy is especially important when a patient is in crisis or has identified a substance abuse problem, Paulson said
"Sometimes you have to strike when the time is right," he said. "If they can meet someone that day they're ready for it."
No official study has been made to see if this experiment is working. But "we've got lots of anecdotes," Paulson said. "Many patients have been very pleased about the good this did. It's been striking to me how many got better by their reports in three to five visits."
The Center for Family Development soon will add another therapist at Springfield Family Physicians, responding to steady demand. The center also plans this fall to put a primary care provider in its behavioral health clinic in downtown Eugene.
'A second choice'
Health professionals caring for people with severe mental illness are hoping that easy access to both mental and physical health services will help change this statistic: People with severe persistent mental illness tend to die 25 years earlier than the general population.
That's not because of suicides, Lindsey-Pengelly said. It's because of health complications. Psychotropic medications can lead to metabolic conditions, such as weight gain.
"The treatment sometimes compromises folks' health," she said. "Having a physical health provider right there allows things to be caught much earlier."
Before Suiter became a fixture at Springfield Family Physicians, doctors there referred patients to therapists outside the clinic and had no way of knowing whether the patient ever followed through.
Did they make the appointment? "We didn't know," Paulson said. "Some of them got services -- we didn't know who. Others never got help."
"There were some people for whom my only choice was medication," Paulson said. "Now I have a second choice, which is great to have."
The chances that a patient actually will follow through on a doctor's recommendation to see a therapist increases substantially when a referral is made to someone in the same office, said Mary Peterson, who chairs the graduate department of clinical psychology at George Fox University in Newberg and is training behavioral health consultants being placed in primary care clinics in Yamhill County.
If a primary care doctor refers a patient outside the office, the rate of follow-up is 8 percent, Peterson said. That rate shoots up to 80 percent, if the doctor refers the patient to someone in the same office.
Trillium's "integration incubation" project is high on the CCO's priority list because it's focused on the goals of the federal Affordable Care Act -- better care for patients, better overall health and at a lower cost, Lindsey-Pengelly said.
The cost of health care is driven up by "gaps in care, delays in care and fragmented care," she said.
Lessening those gaps and delays by better coordinating mental and physical health services was one of the main drivers for creating Coordinated Care Organizations in Oregon.
Trillium's effort is among the most sweeping being rolled out by Oregon's 16 CCOs.
Trillium serves a little over 89,000 members -- about a quarter of Lane County's population, Lindsey-Pengelly said. "This project can serve almost 17,000 of those members, which is huge," she said.
"Trillium should feel really proud of the effort they're putting into this project," said Cathy Kaufmann, director of the Oregon Health Authority's transformation center. "It is a great project, and we're really excited to see what they learn from it."
Trillium didn't set out to be so ambitious with this, Lindsey-Pengelly said.
"When we got the eight projects and they were so stellar, we just knew we couldn't not do it," she said.
She credits the local health care community for their vision and commitment to find new, better ways to help their patients while keeping a lid on health care costs.
"These are incredible human beings and visionary people who really see where things are going," Lindsey-Pengelly said. "We're trying to work as a partner with them to make sure it will happen, but they're the ones who are making it happen."
She said, "this is an opportunity to take eight different sites and have some variability in the site based on what they proposed, and do it all simultaneously and see what rises to the top."
After the yearlong trial, Trillium wants to pick the best practices or the best models to roll out on a broader scale, Lindsey-Pengelly said.
In addition to the grants, Trillium is paying for the services delivered to Trillium members, plus it is giving each project a set amount per member per month "for enhanced services that go beyond what's billable," she said.
Examples include the peer support specialist at PeaceHealth's new Youth Hub program in downtown Eugene, who works with young adults with mental health issues, or the case manager at Eugene Pediatric Associates who can help families with a range of needs, from arranging for transportation to their appointments to making home visits to assess what social services might help families.
Like Springfield Family Physicians, Eugene Pediatric already was working on an integration project before Trillium put out the call for grant proposals.
Over the past year, pediatrician Dr. Pilar Bradshaw has been planning with local child psychologist Jenny Mauro to launch Thrive Behavioral Health.
The clinic, owned by Bradshaw, opened last month at Eugene Pediatric's offices near Valley River Center. The clinic has a child psychologist, a developmental pediatrician, a consulting child psychiatrist and a case manager. It is available to all children in the community, not just Eugene Pediatric's patients, Bradshaw said.
She said she is excited about the opportunities this presents for patients and for clinicians.
"I've wished I could do this project for 15 years," when she began her career, Bradshaw said.
"I feel like the response from patients has been overwhelming," she said. "People literally are amazed that I can give them something I couldn't do before."
"I think the previous stigma attached with seeking mental health care kept a lot of patients from going," Bradshaw said. "I could say why don't you see so-and-so across town, and I never knew if they went, and sometimes they didn't."
Now, "if we have a kid coming in whose mom is crying because she's struggling with a social issue or because her child is struggling with medical issues, I can take the mom down the hall" to the behavioral health clinic, Bradshaw said.
"A kid involved with drugs or alcohol -- I can take that child (immediately) to someone who is effective in cessation of use of drugs and alcohol," Bradshaw said.
The clinic also hired a case manager "with a long and storied career at DHS (Oregon's Department of Human Services) who wanted to work on preventive side of disaster," Bradshaw said.
She helps provide extra support to children whose families are dealing with high social risk factors, such as drug use, family violence or a family member who is incarcerated, and to families with children who are medically fragile.
But Thrive Behavioral Clinic is available to all families, Bradshaw said.
"I don't think there's a single parent who at some point couldn't benefit from additional support," she said. "This is for parents with strong, spirited kids, for moms who are postpartum. The goal is not just to address the needs of sort of the most wrecked family units, but to help support those that are actually working pretty well, but they could use a tweak."
Bradshaw said she also welcomes the chance to collaborate more closely with her colleagues in mental health.
"For me one of the most wonderful things is the ease of access to these professionals," she said. "I think because all of us are very busy, when you try to connect with another professional by phone or send a fax you can't pass along the nuances of a child's care."
The challenge now for all of these projects is to figure out how to track whether offering physical and mental health care in the same place really keeps patients healthier and saves money.
"That's a huge challenge that all of us are trying to tackle together," Bradshaw said.
She said Eugene Pediatric and Thrive will use industry-recognized questionnaires every three months to measure patient satisfaction -- how well parents and children are doing. The clinic also will track its interactions with families.
"We're trying to do a little experiment in our clinic to see which interventions help the most: more phone calls, having a case manager out at your house, more frequent office visits with the doctor, more frequent office visits with psychologists," Bradshaw said.
Trillium's Lindsey-Pengelly said that Oregon already requires CCOs to report on 17 measurements, such as adolescent well-care checks and screenings for substance abuse, so it will compare the clinics that are integrating medical and physical health services with nonintegrated clinics.
Trillium also wants to make sure clinics find a way to track patients' quality of life at the start of treatment and at various points during treatment, she said.
And Trillium wants to see where the integrated clinics spent health care dollars: office visits, hospitals, emergency departments and so on.
In addition to the grant money, Trillium is providing the projects with other support, Lindsey-Pengelly said.
"It's not just that we gave them money and walked away and measured them," she said. "We're giving them rich learning opportunities. Once a month we have a learning collaborative, and we also have some trainers coming in to teach (on such topics as) new models of care and team-based care."
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