Two years after the death of her husband, 88-year-old Jean* was still struggling with depression. Suzette Santos, a behavioral health nurse at the Visiting Nurse Service of New York, where I work, had cared for the Long Island, NY resident previously, and when she was reassigned to Jean's case last summer, immediately saw that Jean's mental and physical state had gone downhill. "She had lost 20 pounds, wasn't sleeping well, and had no interest in eating," Suzette recalls.
This decline was also making Jean's underlying diabetes and cardiac conditions worse because her depression impaired her ability to manage her diet and take medications as prescribed. As a result, Jean's blood glucose levels had begun fluctuating wildly. At the time Suzette and Jean reconnected, hospitalization seemed to be the most likely option. But VNSNY had recently implemented a robust new protocol for behavioral health nurses encouraging them to reach out directly to their patients' doctors to give feedback and make recommendations--fortunately, this opened the door for a much better scenario.
In this new model, Suzette was empowered to take a proactive approach in reviewing Jean's medications. "Jean was on several psychoactive medications, and their combined side effects were upsetting her more," Suzette recalls. Realizing that a single medication would address all of Jean's symptoms, Suzette suggested to Jean's primary care physician that this medication be substituted, and the doctor readily agreed.
Following the new care model, Suzette explained to Jean about the new medication and the importance of taking it daily; Suzette earned Jean's buy-in. After this change in medication, Jean's condition quickly began to improve. "Within three weeks she was doing much better," reports Suzette. "Today, Jean's medication compliance is one hundred percent and she is a different person. Her blood glucose is stable, she's regained her weight, is talking and socializing more, and has started cooking again. Now, during my weekly visits, she asks what she can make for me!"
This story illustrates a major shift taking place over the past few years in how medicine is practiced in America. Today, the major health care players--including home care companies like VNSNY, medical systems like the Veterans Administration, managed care organizations, Medicare, Medicaid, and government health agencies--are all moving toward an integrated view of physical and behavioral health, in which mental disorders are being screened for early and treated aggressively.
This shift is being driven in part by economics. Today, we have a much clearer understanding of how untreated behavioral health conditions contribute to physical illness and impact the cost of care. Depressed individuals with chronic illness are almost twice as likely to be non-adherent when it comes to taking prescribed medications, and among lower-income adults, anxiety and depression have been shown to cause higher rates of binge drinking, smoking and illegal drug use. People with behavioral health problems are also more likely to become acutely ill. Anxiety and depression have both been linked to increased stroke risk, for example. A recent study in New York State found that people with mental illness and/or a substance abuse disorder accounted for over one-quarter of all hospitalizations in New York State, and that two-thirds of this group had two or more other chronic diseases.
At the same time, people with mental illness are much more likely to access the medical system for a physical complaint than to seek out mental health treatment directly. This is why health care providers are focusing more than ever on integrating behavioral health screening and treatment into their standard medical care. The Veterans Administration formally adopted this approach in 2007, and has continued to expand the number of mental health professionals it employs. In another important development, Medicare instituted a new coverage policy for mental health services in 2014, agreeing to cover them at the same 80 percent rate as other medical services. Previously, patients had to pay for up to half the cost of mental health care either out of pocket or through supplemental insurance.
There has also been a push among managed care practices and home care providers to identify and treat mental health issues sooner rather than later. At VNSNY, our home care nurses and other clinicians now screen new patients routinely for mental health disorders, and also have a list of trigger behaviors they are on the lookout for. If a new patient exhibits signs of mental illness, we promptly connect them with additional behavioral health services.
In our home state of New York and elsewhere, there has also been an increased emphasis on psychiatric outreach programs. For example, New York City just awarded $6 million in grants to fund a three-year program that will identify and treat depression in area seniors, using an innovative, short-term cognitive behavioral approach. The city also supports mobile crisis teams, reachable through a toll-free hotline, that provide immediate intervention when an adult or child is experiencing a psychological crisis. New York's Medicaid program is also leading the way in establishing "health homes"--community based networks where people with behavioral health disorders and other co-morbidities have access to integrated physical and mental health care in their community, all overseen and coordinated by a health home staff member.
These programs, which are affiliated with VNSNY's Community Mental Health Services division, demonstrate that when it comes to building healthy communities and supporting the well-being of patients like Jean, physical and mental health can't be separated. My colleague Neil Pessin, who directs our CMHS program, says, "Developing a medical system that integrates care for the mind and the body been a goal of mine for 30 years." Neil thinks we're on the verge of making that goal a reality today. I agree, and it's clear that health care founded on that reality makes good sense for the future.
*Name changed to respect privacy