December 2019, Volume XXXIII, No 9
Minnesota’s leading edge
Creativity and collaboration
ur nation is amidst a mental health crisis. For the last decade we have seen an increase in the prevalence of psychiatric conditions, deaths from opioid overdoses, and suicide rates, coupled with a drastic increase in people with mental illness who are homeless or incarcerated. All too often, barriers to accessing care result in individuals and families enduring crisis and experiencing traumatic events that could have been prevented. We are also facing a substantial shortage of psychiatrists as well as access to inpatient beds and specialized psychiatric care. Studies demonstrate a public perception that mental illnesses are linked to dangerousness or violence. Funding strategies are constantly shifting at the federal and state levels, and the insurance reimbursement for psychiatrists is, on average, 21% less than for primary care physicians.
The grim reality is that our current approach to mental health care, shaped in the late 20th century, will not continue be effective today. Effective models for mental health care require radical change and transformation. Bruce Schwartz, MD, president of the American Psychiatric Association, stated recently that, “We have to marshal the entire workforce who cares for people with mental illness. That includes social workers, advanced practice nurses, psychologists, mental health counselors, and peer counselors. It comes down to collaboration and putting aside some of the guild issues about which we all have valid concerns.”
The local angle
Minnesota, on the other hand, has led the way with creative and collaborative new care models. Since the early 2000s, the state has consistently ranked among the top 10 states in health care, education, quality of life, cost of living, social welfare, entertainment—and in mental health. Even before the passage of the Affordable Care Act (ACA) in 2010, nearly 95% of Minnesotans had insurance coverage, and mental health parity was noticeably salient for residents. Today, more Minnesotans than ever have greater access to care, and more children and families are proactively seeking health care through annual check-ups and wellness visits.
Our current approach to mental health care … will not continue be effective today.
Creativity and collaboration have been key factors as Minnesota addresses our mental health crisis in various settings, including hospitals, schools, advocacy groups, and nonprofits. Initiatives to meaningfully manage mental health needs span the continuum of care: resiliency coaching, crisis prevention, trauma response, integrated care, and acute care. This includes service providers and new screening and diagnostic tools.
Prevention and wellness
Examples of Minnesota’s initiatives include Allina Health’s Penny George Institute—the largest integrative health center in a health system in the country—which focuses on holistic health and wellness. The University of Minnesota offers a bachelor’s degree program in Health and Wellbeing Sciences, as well as a graduate degree in Professional Studies of Integrated Behavioral Health. These educational programs, along with the investment into services and infrastructure, help Minnesotans prepare for the future; they are an invitation to change the way we currently react to mental illnesses and crisis, preparing us to prevent and better understand mental health.
Many more schools and community-based organizations have started programs that focus on mental well-being, resiliency, and peer support. Seventy percent of mental illnesses have an onset of symptoms before age 14. Programs that can help kids and parents identify these symptoms earlier can help prevent or lessen the potentially devastating impact that untreated mental illnesses can have on the academic and social development of youth. This can be done through screening, conversations with school staff, and breaking down the stigma that often prevents individuals from reaching out for help. Many local charities and non-profit organizations have supported schools in these endeavors through grants and in-kind access to professional mental health resources.
Employers have brought mental health resources, education, and support into the workplace. Studies show that nearly 63% of individuals with a diagnosed mental illness have not disclosed it to their employer. Ryan Companies’ Support without Stigma program allows for open conversation and sharing about mental health issues. Similarly, one large local retailer now hosts monthly educational events and has established a mental health ally program that allows employees to connect with peers who have gone through special training.
The Minnesota chapter of the National Alliance on Mental Illness has helped support funding for countless mental health programs, along with the ongoing development of new programs, such as school-linked mental health. When the state did face cuts and setbacks to mental health programs, NAMI Minnesota’s persistent and staunch advocacy remained intact. And in 2014, Healthpartners launched an award-winning anti-stigma campaign called MakeItOK that is supported by 11 local health systems, mental health providers, and media.
Integrated behavioral health
Many individuals in need of treatment for mental health and substance abuse disorders will never be identified in primary care—and, even if they are identified, will then have to rely on referrals to outside agencies. Less than 50% of these patients follow through on their referrals. In response, many health systems now offer onsite, integrated behavioral health services. This can reduce expenditures, since treating a medical condition can cost upwards of 200% more when an untreated mental health condition also exists.
South Lake Pediatrics, an independently operated and physician-owned medical group, has nourished a culture of listening closely to parents and kids to understand and identify signs of mental illnesses. They have partnered with behavioral health providers to integrate psychotherapy and psychiatry at their sites, allowing for easy referrals, increased communication, and optimized coordination of care. This model delivered a 28% increase in follow-through for initial referrals and a 10% decrease in no-show rates. Clinicians and patients have praised the ease of referrals and resulting quality of care.
Similarly, Ridgeview Medical Center has partnered with PrairieCare Medical Group to establish a jointly managed behavioral health division offering integrated outpatient care and inpatient consultations to their hospital. This partnership will offer expedited access to mental health care to thousands of individuals in the community, through coordination with primary care providers.
Minnesota school systems—long revered as leaders—have often been the “canary in the coal mine,” the first ones to observe and experience changes in youth behavior and engagement. Starting in 2006, the Minnesota Department of Human Services (DHS) supported legislation to help fund school-linked mental health services aimed at reducing barriers to care and to promote early identification and intervention. Newer state-sponsored innovation grants continue to help identify new ideas and creative ways in which school districts can better support students whose academics and futures are jeopardized by unidentified or untreated mental illnesses.
Creativity and collaboration have made Minnesota a leader [in mental health care].
Minnesota has three metro-based Intermediate School Districts with special designations that support integrated services in vocational education, special education, and, increasingly, in the area of mental health. Since summer 2018, five Intermediate School Innovation Grants were awarded with the goal of improving clinical outcomes for students, helping them return to their home school district, reversing the disproportionate impact on students of color, and providing support and training for school staff and parents. Intermediate School District #287 has prioritized funding strategies to have board-certified child and adolescent psychiatrists onsite to integrate care with the families and learning teams. The shortage of these specialists, along with the barriers in accessing care, would otherwise mean that many of these youth in need would likely never receive the care required.
Some schools have even built health clinics on-campus. Brooklyn Center schools offer wellness visits, vaccinations, and mental health counseling. Minnesota Community Care operates clinics in nine St. Paul public high schools, providing mental health case management as well as trauma-focused cognitive behavioral therapy (TF-CBT) therapists. A new grant extension of these programs now includes federal funding to pilot onsite psychiatry.
Statewide psychiatric consultation
In 2010, the Minnesota Legislature directed DHS to make psychiatric consultation available statewide to primary care providers. The goal was to create rapid access to psychiatrists for consultation on cases, triage, and referral, and to provide ongoing education to primary care providers. Nearly half of the states in the nation have some form of a psychiatric consultation service, ranging from telephonic consults to brick-and-mortar clinics based in academic medical centers. Minnesota’s Psychiatric Assistance Line (PAL) has provided thousands of consultations to primary care providers across the state, and has trained hundreds of pediatricians and nurse practitioners. PAL can be accessed weekdays via a toll-free number or online. This service is supported by DHS, PrairieCare Medical Group, and the Minnesota Community Mental Health Foundation. In addition to the core clinical team members at PAL, clinicians at Pregnancy & Postpartum Support Minnesota are available for mothers who have specific needs requiring their expertise.
Most of the consultations are with youth, who otherwise would endure delays in getting specialized treatment and suffer from the adverse developmental impact that mental illnesses can have during childhood. A six-month follow-up study confirmed PAL’s efficacy and the overall positive experience of the providers, individuals, and families that utilized it. The psychiatric consultation service was recently honored by the American Psychiatric Association (APA) and the Association of Medicine and Psychiatry (AMP). Several other states and outstate health systems continue to express interest in partnering with PAL.
In addition to psychiatric consultation and education, an online tool called the Fast-Tracker was developed to link people to mental health and substance use disorder services and resources with real time availability. This online tool, which is free to the public, uses sophisticated search tools and algorithms to help identify niche services for individuals seeking care.
Future considerations and improvements
While creativity and collaboration have made Minnesota a leader, there are still critical needs that require attention. It has been said that our mental health system is not broken, because it has yet to be built. The aforementioned innovations have helped many patients, but are just a part of the necessary transformation, which still needs to grow and adapt to future needs.
While the ACA and mental health parity have moved us forward in some ways, concerning trends in the behavior of many health insurance companies suggest that adequate coverage for services is still in our distant future. High-deductible plans have become more popular, and large employers have elected to carve out mental and chemical health coverage to lower premiums, perpetuating both barriers in accessing care and the stigma surrounding mental illnesses. Many individuals and families are simply finding themselves under-insured.
Communication between health providers continues to lag, especially with regard to mental health. While electronic health records allow for the possibly of a seamless community, expensive integrations between systems often prohibit this from happening, and release of information and consent laws create confusion around what information is released. Some patients may bounce between several providers, and the refusal to disclose past mental health information can be common and detrimental to care.
Minnesota is indeed a leader in mental health care, as we have continued to demonstrate through our creativity and collaboration. However, we have a long journey ahead of us, and we must have the perseverance and gumption required to move our local communities and the rest of the nation forward.
© Minnesota Physician Publishing · All Rights Reserved. 2019