Once for Migrants, Clinic Melds Medicine and Mental Health
A report by Health Policy Solutions.
By Katie Kerwin McCrimmon
FORT LUPTON – A clinic with roots caring for migrant farm workers in an old onion shed offers one of the most sophisticated models in Colorado for integrating mental health with primary care.
“If you come to my health center, your chances of also seeing a mental health counselor are great,” said Dr. Tillman Farley, medical services director for Salud Family Health Centers. “Wall Street bankers don’t get the care that we give our patients.”
The mental health counselors don’t wait for a doctor or other health provider to invite them into a patient’s room. They see all new patients, all pregnant women and anyone with a physical complaint — like a stomachache or a headache — that could indicate mental health stress.
The behavioral health experts also operate by instinct. They scan their laptops to see who has come for help that day. Sometimes a hunch leads them to a person desperately in need of help, but hesitant to ask. A woman might be afraid to confide that she is experiencing domestic violence or a teen boy may be considering suicide because he thinks he’s gay and his traditional Mexican parents disapprove.
“We don’t ask for permission to go in,” Farley said. “Our mental health people are like primary care providers.”
Salud started serving patients in Northern Colorado in 1970. At first, migrant farm workers would run if they saw the mobile clinic coming. Many were undocumented immigrants who feared deportation. Over time, Salud’s providers built a high level of trust. They now see 80,000 patients a year in 300,000 visits. In 2010, about 10,000 of those visits were specifically for mental health care.
From its humble roots, Salud now offers fully integrated medical, dental and mental health care in 14 clinics throughout nine communities from Estes Park to Sterling and Frederick to Fort Collins.
Farley and the other Salud providers speak both Spanish and English, and they see patients of all ages regardless of race, ethnicity or ability to pay. Salud’s clinics are Federally Qualified Health Centers. These types of safety-net clinics will anchor many of the expansions in health care under reforms in the Affordable Care Act.
“We cover about 10,000 square miles from Commerce City to Wyoming and from the mountains to the eastern plains,” Farley said. “About 60 percent of our patients have no insurance.”
Salud’s annual budget is about $44 million, of which about $1 million is spent specifically on mental health care. About 5 percent of patients have private insurance. Another 30 percent qualify for Medicaid and 5 percent have Medicare.
Patients without insurance pay for care on a sliding scale based on income. The average co-pay is about $20 while the average visit costs about $130. Salud has to do considerable fund-raising to fill that gap.
Farley says some traditional doctors think integrated care will take them too much time. In fact, he finds that the behavioral health specialists usually save doctors time by u ncovering core concerns that are leading to physical complaints.
Take the example of a pregnant woman who came in concerned that she was not feeling her baby move. The mental health expert visited the patient first and learned that the woman’s husband had just been deported. The visit was really about stress. Instead of spending 45 minutes probing what was wrong, Farley could listen for the baby’s heartbeat, assure the mother that the baby was OK and let the behavioral health expert teach the woman how to cope with her justified fears and depression.
Patients who are severely mentally ill need care from specialists. But, primary care doctors routinely see patients with basic mental health needs including depression, anxiety, grief and job stresses.
Farley said that there’s a strong correlation between lower income people and higher incidence of mental health problems. At Salud, about four out of 10 patients report behavioral health problems. At the Marillac Clinic in Grand Junction, which serves low-income patients, studies have found as many as 59 percent of patients have mental health ailments.
“We all need at least preventive mental health care,’’ Farley said. “Doctors are not good at picking this up. Studies suggest that physicians miss about half of these (mental health diagnoses).”
In some medical models, where a clinic might be “co-located” with a mental health facility, doctors will sometimes give what’s called a “warm handoff.” If they suspect a patient is struggling with mental health issues, they will leave the exam room and go get a mental health worker. That’s better than referring patients to specialists they might never see. But because doctors can miss behavioral health symptoms, Salud’s experts find it works much better to give behavioral health workers the autonomy to find people who need help and give them good results.
“It’s an outcome-based system,” Farley said.
That means that Susana Gonzalez, a psychotherapist and licensed counselor at Salud’s Fort Lupton clinic, does what works. She has one patient who was in a bad automobile accident and suffers from panic attacks while she’s driving. So, Gonzalez and the woman conduct their therapy sessions while driving around town.
Gonzalez sees a number of women who report domestic violence. And she always keeps a close eye on her prenatal patients and new mothers. In a throwback to old-fashioned medicine, she sometimes makes house calls.
“Many feel very isolated. They are here in the middle of nowhere. Some are living on ranches. They don’t speak the language. They don’t know the culture,” Gonzalez said.
With one woman, building a relationship over time was key. Gonzalez saw the woman during her pregnancy. She was a first-time single mother. The woman had a good pregnancy and was confident that she would do well once the baby was born. Before the birth, Gonzalez reminded her about post-partum depression.
Sure enough, after the birth, Gonzalez visited the young mother and found her feeling desperate and alone.
“I don’t’ know what to do,’’ the mother said as the baby cried inconsolably.
Gonzalez was able to calm the baby down and link the new mother with a program where a nurse will visit her regularly for the baby’s first two years.
“She did well. It was just overwhelming.”
In another case, a woman came in telling the doctors that she was having headaches and couldn’t sleep. Gonzalez knows how to ask the right questions. She found that the woman had a 14-month-old boy and that she feared she was going to hurt herself and the baby.
“She was mortified that she was having these thoughts,” Gonzalez said.
The mother feared that if she sought help, police would take her baby away. Instead, Gonzalez was able to get the woman’s permission to tell family members that she was struggling and depressed.
“We developed a safety plan and let her know that this can happen.”
The woman improved dramatically and both she and the toddler are doing well.
While Salud leads the way on integrated behavioral health care, Farley would like to continue to expand so every patient gets a mental health screening.
Many have come from such chaotic backgrounds that Farley includes drawings called genograms in his charts to help him remember all that his patients have endured. The pictures look like stick-person family trees. They provide Farley with a shorthand method to remember how many partners and children a patient has had.
Circles represent women. A squiggly line represents abuse. In one case, a woman struggling with chronic pain and narcotic use has a picture that reveals utter chaos. She has had multiple children by four different partners, three of whom have died. A squiggly line connecting her to her mother indicates that she was physically abused as a child.
Given this type of complexity, medicine alone cannot provide adequate cures. Mental health care is critical too.
Says Farley: “We’ve got a long way to go.”