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Missouri pioneers community-based mental and medical health services

This article first appeared in the St. Louis Beacon, March 20, 2012 - If Hopewell Center decides to add a slogan to its name, the words would probably be a variation of those made famous by Harry Truman: The revolving door stops here.

For years, poor people suffering from a combination of mental and physical health conditions have had few options beyond walking through the door at an emergency room or finding a bed in a nursing home until the crisis eases.

Now come unique services through Hopewell and People's Health Centers. Both are among Missouri pioneers in integrating mental and physical health services to help people remain in the community rather than in institutions.

"We're very excited about this because for years we've been moving in this direction," says Wendy Orson, vice president of clinical services at Hopewell, 1504 South Grand Boulevard. The center merged about two years ago with People's Health Centers. Following the merger of the two programs, Dwayne Butler was appointed CEO of both.

Orson says the trend is for health-care providers to pay more attention to the relationship between physical and mental health in a patient's well-being.

"Someone comes into a behavioral mental health organization, and we'd just look at their mental health," Orson says. "Or the individual might have gone to a primary medical care organization, like People's to get medical treatment, but nobody recognized the signs that this individual had a mental illness that also needed to be addressed."

One of the worst nightmares in the old approach, she says, was that patients being treated for mental and physical disorders might be taking prescription drugs "that might not go well together, and nobody was paying attention."

Hopewell and People's are pioneers in what's known as the health-care home model of integrated care. "Before, we were treating just part of the client," Orson says. "But now with health-care homes, we can make sure that nothing in the medical is interfering with the behavioral and nothing in the behavioral is interfering with medical."

The upshot, she says, is that various practitioners treating the same patient in different parts of the region "can work as a team to wrap around (services for) each individual and make sure that their needs are met and that their quality of life is improved."

Missouri isn't known for innovative medical approaches to care for its needy, having set its Medicaid threshold so low that people have to be dirt poor to qualify. Yet the state stands out on the health-care home front by developing a program that allows more people to remain in their homes and get a continuum of care. These residents used to rely heavily on emergency rooms or end up in nursing homes because they lacked convenient transportation, help with taking medications, transportation to a dialysis center and other support services. 

Savings sought and found

Missouri's motive isn't purely altruistic. It worries about the bottom line. The state has had to cut health-care expenses to balance its budget. Missouri initially identified about 18,000 Medicaid recipients who were imposing high cost on the system, each consuming an average of $20,000 in medical services annually. In other words, this relatively small number of patients was taking a $360 million bite out of the Missouri Medicaid system each year, consuming services for conditions that might have been preventable or certainly would have been cheaper to treat in community facilities, such as Hopewell or People's.

Last fall, two state agencies -- the Department of Mental Health and he Department of Social Services -- persuaded the federal Centers for Medicare and Medicaid Services to fund a two-year pilot program for better coordination of services to these individuals, with mental-health facilities like Hopewell taking the lead. Orson says Hopewell is handling about 600 of the state's clients. About 1,100 are targeted for services through People's, she says.

The clients served by People's are part of about 17,000 chronically ill residents that the state wants to serve through federally qualified health centers, such as People's, as well as rural health clinics, and hospital-affiliate primary care clinics.

State officials say the health care home project is feasible because the federal government underwrites 90 percent of the Medicaid cost to run it. Normally, the federal government picks up 64 percent of Missouri's Medicaid cost, with the state covering the remaining 36 percent.

Orson notes that individuals in the program at Hopewell have both a serious mental illness, such as bipolar disorder, schizophrenia or serious depression, along with a chronic medical condition, which might range from diabetes, to high blood pressure to heart disease.

Treating the whole person

Typical of the basic care is that provided recently to Marie H. Smith, an elderly woman who dropped by Hopewell for metabolic screening that's crucial to keeping people out of emergency rooms. Providing the screening was Maile Jarrette, a nurse care manager who moved to St. Louis a few years ago after graduating from UCLA. Her office on an upper floor of the Hopewell building is airy and brightened by lots of sunshine from windows looking down into South Grand and the St. Louis University Medical School complex.

Smith's screening session involved a few quick procedures, including a tiny pin prick on a finger to draw blood. The procedures help Jarrette make an early detection of diabetes, increased cholesterol and elevated blood pressure. In a matter of minutes, Jarrette read the results and explained them to Smith, who was soon on her way.

Orson says the program marks an innovation in health-care delivery, providing patients with nurse care managers,  such as Jarrette, who not only help monitor a patient's medical condition, but help coordinate the patient's services with hospitals and primary-care providers.

Beyond nurse care managers are Hopewell internists who review each case and might provide "doctor to doctor communication" to coordinate the care, Orson says.

"We want to make sure the left hand knows what the right hand is doing."

Beyond Jarrette are home visitors or community support workers who make sure the clients are taking their medications, and that their food, shelter and other needs are being met.

"The idea is to create a climate so that people don't have to go to the emergency room and they don't have to go to nursing homes," Orson says.

"We just really try to enhance the quality of their lives. A lot of times behavioral health is masking physical needs. We want to treat the whole person."

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