Integrating Mental and Behavioral Health into a Student Run Free Medical Clinic Nate Ewigman, M.S. Department of Clinical & Health Psychology Department of Health Services Research, Management & Policy University of Florida

The Equal Access Clinic is a student-run free healthcare clinic Provides free care and other services to the medically underserved in the Gainesville community Health professional students from the University of Florida disciplines – Medicine – Pharmacy – Dentistry – Physical Therapy – Physician Assistant – Pre-Med – Clinical Psychology – Public Health Doors open since 1992 – Current sister clinics: Follow-up primary care clinic, weekly Free Psychotherapy Night, weekly Physical Therapy Night, weekly Once per month women’s night clinic

Thursday: pm First come, first serve, arrive at 4:00 & WAIT Premeds perform patient intake Cases reviewed and assigned History and Physical performed by 1st year and a 2nd-4th year medical student Case is presented to a resident/attending Resident/attending and students see the patient together

What are mental and behavioral health services in a SRFMC setting? – Identification of comorbid mental disorders/mental suffering and behavioral risk factors – Referral or Treatment – Mental/behavioral professionals (e.g. psychiatrist, psychologist, LCSW, psychiatric nurse practitioner, etc.) What is integration? – Coordination of mental/behavioral health services with medical care – Most typically, mental/behavioral health services are provided as a specialty service (i.e. cardiology) – There are different levels (e.g. co-location, collaboration – we do both) of integration – Take home of integration: incorporation of mental/behavioral health provider occurs at the point of medical care Which is rare

Why do we care about this? – Primary care is the 1 st point of access for most mental health problems – Our patients often have no where else to go – 28% detection rate of depression among PCPs – When recognized, treatment typically not guideline concordant – Risk Suicide Nonadherence Self-medicating behaviors Functional impairments

Evolution EAC Mental & Behavioral Health Services prior to current integration – Faculty social workers, mostly experienced LCSWs Rotate one week per month among four social workers No UF students – What attending and students provide – No screening system, based on referral from docs and med students All referrals based on identifying needy patients and making decision to refer without support – Heavily social services and “out-of-network” referral focused – Psychiatry Night Once per month “fizzled out” Key lesson: lack of integration

Began with interested clinical psychology students supervised by LCSW or used as consultants Volunteering August 2008 How we integrated and evolved into a systematic screening, referral and treatment clinic for mental/behavioral health services – Built professional relationships – Established value – Developed successful screening and referral system

First Steps to Integrating Mental/Behavioral Health Services into your SRFMC – Understanding your patient needs and community resources – Implementing an effective screening system

Understanding your patient need and community resources – Where to begin? The patient. – What is the need? Morbidity – EAC data » 1 psychological condition per patient – Why it’s important… » Little green men example – Need to understand the extant mental health system in your community Psychiatry Free counseling resources Social services, rehabilitation, support groups

Implementing the Screening System – Still utilize shoulder-rubbing consult model Strong professional relationships necessary Education about services offered necessary – Screening System Pre-meds PHQ-2, GAD/PD PRIME MD and internally created measure of appropriateness of referral All in charts Officers, the “ big board” for patient tracking – Speaks to our commitment to mental and behavioral health Integration at the EAC – We see or consult on ½ the patients every week, range of reasons/conditions – What we do when we see them Assessment Psychoeducation Brief interventions Referral plan

– Case study Presenting Problem: – Telekinesis Rapport and Trust – Listen, “speak the language” Med adherence – Don’t like the demons, but I won’t give up Alice Care Plan: – Clinical psychology: determined what HE wanted in terms of meds, and why he didn’t want to take other meds – Pharmacy/medicine: found the right meds – Social work: prescription assistance program, disability Importance of screening system Importance of high level of integration Importance of specialty follow-up, partnerships in different disciplines

Main Lessons If you build it, they will come, Presenting Problems over the time of our involvement… – All strictly medical presenting complaints, 2-3 referrals by medical students or pre-meds – SSRI refill – Comorbid medical and anxiety/depression – Need psych eval – Psych student Word of mouth Start grass-roots. How we have achieved sustainability of primary care mental/behavioral services – Mental health officer model – Advanced Practicum for clinical psych students Sustainability matters Regular presence matters Collaboration matters – Versus uncoordinated care – Challenges – Benefits Patient trust, respect and listening matter

Acknowledgements – Julius Gylys, PhD – Callie Tyner – Matt Cohen, MS – Zoe Swaine, MS – Shannon Driscoll – Kari Mader – Sean Timpane – Adam Mecca – Rhondda Waddell, PhD LCSW – Mary Ann Burg, PhD LCSW – Greg McCann, LCSW – Chris Clark, LCSW – Tom Ward, MSW

Open Discussion/Reciprocal Learning – Reactions? Is this valuable work? What do you do to integrate mental/behavioral health services? How can we improve? What is the place of mental/behavioral health services in this population?