"Everything is connected"
Treating the cause, not just the symptom. That’s the approach behind a combined grant of $1 million from Cedars-Sinai and $500,000 from the California Community Foundation and a doctor-driven effort to make MLKCH patients not only better, but well.
Together, Dr. Yulsi Fernandez Montero, a primary care provider and addiction medicine specialist at the MLK Community Medical Group, and Dr. PK Fonsworth, an addiction psychiatrist who works at both the hospital and medical group, are leading an effort to make mental health and substance abuse treatment part of routine patient care.
They sat down together recently to discuss the mental health connection to physical healing, how the patient experience will change as the result of integrating the two, and why South LA’s history makes a comprehensive approach to healthcare so necessary.
Why is mental health important to physical recovery?
Dr. Fonsworth: There is no health without mental health. There is no physical health without emotional health. It takes far more than just a psychiatrist to work on the often complex medical, mental and psychosocial issues or traumas that patients walk in the door with. We need an integrated care team that can help patients from every angle.
Dr. Fernandez Montero: Fortunately we are now riding this wave that sees mental health and physical health not as separate, but as one continuum. Everything is connected. There are studies that show that people with serious mental illnesses have a life expectancy that is 10-25 years less than people who do not. Clearly what happens to the mind affects the body, and vice-versa.
What did you see in your day to day practice that gave you the idea that physical and behavioral health should be integrated?
Dr. Fernandez Montero: I’m a family medicine doctor. Oftentimes I’m there to treat a physical symptom or a chronic illness, like diabetes. But often as I’m closing the visit with a patient they say, by the way, I feel really sad. Next thing I know, the patient is tearfully confiding all the trauma they have suffered.
Somehow, as a primary care doctor, I have to say, “OK, but you have to give yourself your insulin,” while making sure I address the patient’s mental health. And how do you make the time to address everything in one visit?
When care is integrated, I can tell Dr. Fonsworth, hey I have this patient with depression and anxiety, could you see them in your clinic? And then the patient is heard, their needs are addressed and Dr. Fonsworth and I can share notes and discuss the case to come up with a more complete care plan.
Dr. Fonsworth: We’re overdue for this. Not only are we in medicine overdue for this, this particular community is overdue for this. There is so much need and until recently, so few providers and so little integration of care. People were getting treated piecemeal for different conditions but nobody was considering the whole patient. Patients are more likely to stay in treatment if they maintain a connection with treatment providers through a continuum of care.
Do you see more behavioral health problems in South LA than in other places?
Dr. Fernandez Montero: Not necessarily, but I do think we see more untreated patients. In other places, some of these diagnoses might be picked up earlier. But here in South LA, diagnosis and early treatment happens less for many reasons. So people just sit and suffer with their problems, whether they be physical or mental or both. And by the time Dr. Fonsworth and I see them, their conditions have advanced, and we’re playing catch-up with their care.
Dr. Fonsworth: Which makes the need for an integrated care team even more important, because complex health conditions also impact other problems, such as substance abuse and vice versa. So we need a comprehensive response to the multiple issues we might see.
What will “complete care” look like at the hospital and clinic?
Dr. Fernandez Montero: This is a multi-specialty medical group, so to a certain extent we already provide integrated care because we work side by side. But we knew we had to take it to the next level because the need is so great. Now a patient, regardless of their symptom, is going to be screened for depression, anxiety, and substance use disorders.
Dr. Fonsworth: Behavioral health will be considered at every level—the emergency room, the hospital, the clinic. When someone is admitted, I will be consulted if there is a concomitant psychiatric issue. A substance abuse counselor may see someone in the emergency room or the hospital and refer them instantly to the clinic, or to a rehabilitation center. A therapist could provide daily supportive psychotherapy to someone admitted to the hospital. It won’t be an afterthought. It will be part of the standard treatment.
Dr. Fernandez Montero: We’re going to be adding ancillary staff to our care team and implementing different workflows. For example, we will do routine screening, but does this have to be done by the doctor? Not necessarily. A well-trained medical assistant, social worker, or care coordinator can do it. So by the time that I’m entering the room as a doctor I already have this data. My job is to interpret it, figure out what the next steps are and make sure patients are plugged into the right specialty, resources and care.
For example, if it’s depression, anxiety, bipolar disorder or schizophrenia, we have psychiatry. If we have addiction issues, then in addition to Dr. Fonsworth and me, we have a substance abuse counselor, and a social worker and care coordinator can come in. And with them will come support groups for patients and their loved ones on mental illness, recovery, and individual psychotherapy. This all can contribute to long-term wellness outside the doctor’s office.
Dr. Fonsworth: One advantage of the team approach is our ability to consult each other for patient care. I love talking to Dr. Fernandez Montero about challenging cases involving substance use. Also, seeing a psychiatrist for the first time can be a difficult experience for some people. But if Dr. Fernandez Montero is working next door and informally introduces me to one of her patients, or asks me to come over and say hi, it can help patients feel more comfortable to take the next step and make an appointment with me.
Dr. Fernandez Montero: Part of this is normalizing and removing the stigma from seeking mental health care. If a patient walks in and knows that a mental health screening is standard no matter why they’re coming in, then it normalizes this idea of mental health being part of physical health.
What do you hope will come out of this initiative?
Dr. Fonsworth: We want to grow the synchronous treatment of physical health and mental health and substance abuse disorders because it is the future of care. What Dr. Fernandez Montero and I and our colleagues do together as an integrated system of care will be powerful for a community that may have never had that level of care before.