Solutions
Renewing access to psychiatric care
Marvin Swartz and T. Scott Stroup
There is much to be encouraged about in the renewed focus on recharting mental health reform in North Carolina. All concerned have acknowledged the myriad and complex problems with the reorganization and financing of care in the redesigned system. It is critical however, that as we move forward we offer simple, common-sense ideas to encourage stakeholders that new funding in our system will be well-spent.
In this spirit, we suggest a renewed focus on a basic principle of mental health treatment -- access to psychiatrists as part of a multidisciplinary treatment team.
The overwhelming share of patients in our public mental health system are treated with psychiatric medications, often in complex combinations and often entailing increasingly recognized serious side effect risks. All our patients require a thorough psychiatric and physical examination and continuing review of treatment, even if not in need of medication.
Yet we have a severe shortage of psychiatrists for publicly funded patients -- a situation not created, but badly exacerbated, by the privatization of the public mental health work-force under mental health reform.
A recent report from UNC's Sheps Center for Health Services Research detailed these shortages: It found that public mental health provider groups, and especially rural provider groups, will likely face stiff competition in recruiting and retaining psychiatrists in their practices, that a third of counties in North Carolina have a shortage of general psychiatrists, nearly one-half of counties have no child psychiatrists and roughly one-half of all counties are losing psychiatrists relative to population or have had no psychiatrists in the past five years.
Daily we hear stories about patients with no regular "clinical home," where a psychiatrist and multidisciplinary team provide care. Daily we hear stories of our patients lacking access to adequate medical care as well.
As a result, far too many patients resort to hospital emergency rooms to receive stopgap psychiatric and medical care.
To be clear: The psychiatrist work forces shortages pre-dated mental health reform, but reform exacerbated the problem by removing salary support and benefits from the public psychiatry work-force.
We suggest as a first principle that all our publicly funded patients should have a clinical home to anchor their care. Each local management entity should be funded for such a basic one-stop safety-net mental health clinic. These core clinical homes should receive stable support for a core team of psychiatrists, case managers and other mental health professionals. In these clinical homes patients would be assessed and treated, with referral for other specialized and privatized services only as needed.
Such a model could provide clinically informed oversight of community services and avoid further problems with unmonitored community support services. These clinical homes would also be the focus for developing, sustaining, recruiting and retaining a revitalized public psychiatrist work-force, while adding a cadre of stable clinical co-workers. The clinical homes would also be centers for innovation: finding new methods to optimize team-based care, integrating evidence-based care, providing or linking patients to medical care and intensively focusing on effective and safe care.
We now need to assure access to high-quality psychiatric care and rebuild the public mental health work-force. We know of many superb clinicians displaced by reform who are eager to return to public service. There is no better way to start rebuilding the work force than to nest it in new and innovative care settings.
How do we get there? We have no precise estimate of the startup or ongoing costs of a clinical home. Careful evaluation of the costs and cost-savings of the clinical home are needed; we are not suggesting disseminating an untested model. We do suggest rapid development of several pilot clinical homes to test, to refine the model and to put simple clinical care first.
Marvin Swartz, M.D., is a professor and head of the Division of Social and Community Psychiatry Division in the Duke Department of Psychiatry and Behavioral Sciences. T. Scott Stroup, M.D., is a professor in the UNC-Chapel Hill Department of Psychiatry.
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