“Even though it’s across the street, it might as well be across the country,” Rogan said.
Now if mental health workers suspect high blood pressure or diabetes, FSI staff members escort patients from the psychiatrists’ offices straight to Thomas-Mohamed, who leaves open plenty of walk-in appointments to accommodate them. Therapists are taught to be more aware of somatic concerns, asking patients about blood pressure and smoking cessation. They’ve also put therapists at the medical clinic across the street for patients who still see doctors there.
Other low-income clinics across the region have been moving in the same direction. In Fairfax County, the Community Services Board will soon begin operating a health center staffed by three medical workers out of the Gartlan Center, a site serving people with mental health and substance abuse issues.
In Baltimore, Mosaic Community Services, which operates clinics that provide mental health and substance abuse services, has also recently brought in primary care doctors and nurses to work in some of its 100 locations and sent its mental health workers to other primary care facilities.
Even though its medical services are FSI’s newest advancement, the center also provides housing services, counseling for battered women and drug users, group therapy and other treatments.
“They’ve been helping me for years,” said one patient who has schizophrenia and spoke on the condition of anonymity. “You get to meet people through the lunch programs and groups. I try to participate every day.”
If it sounds as if providing such comprehensive services to such an impoverished population would be almost prohibitively expensive, that’s because it is. FSI said that, while they are funded through grants and other mechanisms, they are grappling with how to pay for some of their services in coming years.
FSI’s $2 million grant covers nursing salaries, some contractors, diabetes education and wellness programs, and it lasts for four years. When the grant runs out, they aren’t entirely sure what’s next.
In Maryland, for example, mental health clinics can’t bill for nursing services, Rogan said, and “we’re still trying to figure out how to fund the nurses after the grant runs out.”
Fairfax County’s Community Services Board has also felt the crunch, letting several vacant staff positions go unfilled.“Our staff is so stretched right now and working so hard to keep services going,” said Laura Yager, the board’s partnership and resource development director.
Then there are the challenges doctors face when treating a profoundly mentally ill population. Appointments take longer, past visits are forgotten, changes in habits or new ailments go unmentioned.
“People could be walking around with high blood pressure and thyroid problems, but they don’t think about them as problems because they have had them for so long,” Thomas-Mohamed said. “They have too much else to deal with, and everything can overshadow the primary health-care interest.”
SAMHSA’s program started three years ago with 13 grantees, and there are now 93 around the country — mostly community mental health centers that want to bring on medical services. As the psychiatrists started trying to incorporate somatic concerns, the learning curve was steep.
“We had folks who didn’t even understand how they would start weighing people [on scales] — that was so far outside the scope of their organization,” said Trina Dutta, the lead for primary and behavioral health-care integration at SAMHSA.
But there have been signs of progress. Of the 592 people who have been enrolled in FSI’s three-year integration effort, many have seen blood pressure decline, weight stabilize and cholesterol levels drop. Fewer patients report being depressed, but the number of smokers has remained the same.
One 29-year-old man, an obese smoker with hypertension and hypothyroidism, lost 27 pounds through diet and exercise after a year with FSI. A 33-year-old woman who had schizoaffective disorder weighed 372 pounds, but with diet advice from an FSI nurse, she lost 31 pounds in a year.
In addition to nudging the numbers closer to the healthy range, experts say health integration represents an important step in making health care prioritize patients’ needs.
“There’s a difference between a system of care that’s provider centered, rather than patient-
centered,” McGovern said. “We have a back that might ache, but we also might be sad about a loss, and that affects how our feet and backs feel.”