Mental health in progress
Sitting in an office at the Mental Health Association of Jefferson County in Watertown, Tammy C. Gould bounces her knee up and down frenetically. She fiddles with the name tag on her tidy Subway uniform. Her eyes are striking — one hazel, the other a clear blue.
Mrs. Gould’s movements scream one word, which describes how most people feel when talking about mental health: uneasy. She jokes that her family has always been “off the rocker.”
With 130 ER visits per 10,000 people, mental disorders are one of the leading causes of disability in the United States.
Through the Delivery System Reform Incentive Payment program, which began in 2015, the state is in the process of distributing $7.3 billion among 25 performing provider systems statewide.
The north country provider system is the Samaritan Medical Center PPS and includes Carthage Area Hospital, River Hospital of Alexandria Bay, Clifton-Fine Hospital of Star Lake, Claxton-Hepburn Medical Center of Ogdensburg and Massena Memorial Hospital. The seven hospitals are united by the North Country Initiative, LLC.
These hospitals and partnered community programs are expected to receive more than $78 million in state funding to help overhaul the delivery of care and cut unneeded hospital visits over a five-year span.
All funding that flows through the Samaritan PPS is directed by the North Country Initiative in partnership with the Fort Drum Regional Health Planning Organization.
Deficient mental and behavioral health services lead the approval of the North Country Initiative’s application for funding. Benchmarks to be met include the integration of behavioral care services into the primary care setting, growing the region’s workforce of mental health professionals and community outreach.
At the time of the application, FDRHPO identified mental health and substance abuse problems as one of the three most pressing healthcare needs in Jefferson, St. Lawrence and Lewis counties with 20.1 percent of all tri-county residents living with a mental illness.
“We’ve always had the idea and the heart. We knew that this made sense, but to actually have the resources to make it happen is another thing entirely,” FDRHPO Executive Director Erika F. Flint said. “Now we have the dollars to allow us to focus on standardization and access to care.”
The north country’s milestones, according to DSRIP, have been met on time for the last two years, and in some cases ahead of schedule, earning the provider system stellar reviews at its mid-point assessment and state review in early February.
“Behavioral health has been one of the earliest commitments of our organization, years before DSRIP,” Mrs. Flint said. “This work wouldn’t happen without a willingness to change.”
Changes to healthcare, however, come slowly. Patients may not yet feel progress made at the high levels of government and administration trickling down.
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Mrs. Gould has been treated on and off for anxiety, major depression and post-traumatic stress disorder.
Six years ago she got involved with the Mental Health Association of Jefferson County, both volunteering and taking part in its peer program.
“I’ve always loved to help others, but I could never help myself,” Mrs. Gould said.
The more she speaks, the more her posture settles from anxiety into energy, into purpose.
“Helping others here has taught me to help myself,” she said.
Mrs. Gould has been homeless many times in her life, bouncing from place to place. Now, for the first time in years, she has signed a second year’s lease on her apartment.
“When I get sick, doctors always put me on disability. I hate not working, being idle, being broke,” Mrs. Gould said.
The last time she was placed on disability, she took herself off by getting a job at Subway, where she is now a supervisor.
Mrs. Gould isn’t currently receiving any mental health services, like seeing a psychiatrist, but she’s trying.
“I’ve been on the waiting list for pretty much a year now, trying to get into counseling,” Mrs. Gould said. “Some of us get put on hold. Some of us get put in a crack and that’s where they keep us.”
As the executive director of the Mental Health Association of Jefferson County, Korin Scheible has a view into both worlds — that of agencies, red tape and providers, and that of the patients.
“With DSRIP we’ve brought more providers into the area, which is half the battle, and there are more different options for mental health care. In that sense it’s definitely improving,” Ms. Scheible said. “Some of our people have had persistent mental illness and maybe struggle to keep appointments, get to their appointments, and then get discharged. It can still be a challenge.”
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Phil and Margaret Reed’s son Austin, 23, has Prader–Willi syndrome, a genetic developmental disorder affecting appetite, growth, metabolism, cognitive function and behavior.
Two years ago, Austin began struggling with behavioral health issues, including obsessive-compulsive disorder. Young adulthood is often made more difficult by mental illnesses presenting themselves for the first time.
“We spent three months making call after call once we realized we needed to get Austin help,” Mrs. Reed said. “Thankfully we got some help from Austin’s Medicare manager, but really we were flying blind.”
The parents recalled transfers, unanswered phones, and unreturned calls and voicemails plagued their efforts seeking treatment for their son.
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One of the North Country Initiative’s top priorities is a massive plan to fully integrate mental health and primary care services.
On Jan. 2, Claxton-Hepburn Medical Center opened its new Wellness Center, an outpatient mental health clinic in Ogdensburg.
The new clinic offers individual and group therapy, psychoeducation, psychiatric diagnostic assessment, psychiatric medication management, genetic testing, integration with primary care and coping skills training. It now provides 24/7 access to mental health specialists, emergency care, inpatient care, electroconvulsive therapy and on-site ancillary medical services.
“With the addition of our outpatient center, mental health needs are being better met, but there is still a need for more,” Claxton-Hepburn Executive Director of Community Relations and Planning Laura Shea wrote in an email. “Services for children are a real need. Currently, our services are only available to individuals 18 years and older.”
In February 2013, River Hospital started the River Community Wellness Program, a partial hospitalization program for active duty service members with PTSD, which has since been extended to veterans as well.
In January 2016, the program began offering outpatient behavioral health services to children, thanks to an arrangement with SUNY Upstate Medical University, which provides child and adolescent psychiatric services to Alexandria Bay patients through telemedicine.
River Hospital began its “Hope + Healing” capital campaign in spring 2016 to raise $7.5 million for overdue renovations to both its emergency department and its primary care service buildings. The proposed project integrates primary care, preventive and behavioral health services, and administration into a single, three-story, 26,000 square-foot building.
“Due to state and federal restrictions under our current operating license, reimbursement for services to our adult clients is not where it should be.” River Community Wellness Program Director Bradley D. Frey wrote in an email, explaining that the hospital still struggles with the financial burden of providing such services.
Educating primary care providers in behavioral health screenings and connecting them with tools to treat and refer is another priority of FDRHPO.
“The bottom line is that some people don’t pursue behavioral health care because of stigma. So going to primary care instead of sitting in a psychiatrist’s office makes it easier,” said Patrick A. Fontana, FDRHPO’s health IT workforce program director. “We’re seeing a culture shift as well. Doctors are more open to treating mental illness.”
Providers are also pursuing expanded telemedicine capabilities as a way to connect patients to treatment as a way to circumvent the regional shortage of mental health professionals.
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Too few health providers is a problem that shadows all healthcare in the north country.
Since 2015, FDRHPO has allocated approximately $3 million to North Country Initiative partners to recruit eight new primary care providers, six family nurse practitioners, two psychiatric nurse practitioners, five physician assistants, two psychiatrists and two dentists. DSRIP dollars have also been deployed to grow the education and certification of providers already in the region.
The agency is also investing long-term in the future by recruiting young. The Medical Academy of Science and Health camp for grades 8 to 12, job skills trainings and job shadow programs have been created in the hopes of fostering a “pipeline” of medical professionals to the north country.
In her time at the MHA, Ms. Scheible has recognized that the north country has both unique challenges and unique strengths.
For one thing, people are very spread out and clinics are much less so. Clients, like those at the MHA who often who can’t afford a car or gas money, aren’t likely to be able to afford a taxi to and from weekly appointments, at times over long, rural distances.
The few transportation services in Jefferson County that bus people to their appointments don’t leave Watertown city limits. The MHA does its best to shuttle clients without transportation, but the nonprofit doesn’t have the means to pick up clients outside the city either.
“It doesn’t matter if the services are there if people can’t access them, if patients miss their appointments and get discharged,” Ms. Scheible said.
Another step in breaking down the barriers to care is destigmatization of mental illness and creation of a well-linked provider community with easily accessible resources.
“In a small community, maybe we don’t have as many resources, but I find that the resources that are here work better together. We’re trying to net those providers together, and I think that’s the ultimate goal of DSRIP. I think also in this region, partners have always worked very well together.” Ms. Scheible said. “I don’t know that we’re quite at that peak yet, but were working on building that foundation. In the north country, those players are already at the table.”
“I see that they’re trying. I do see Jefferson County trying,” Mrs. Gould said. “There’s a lot of different things that are changing and changing and changing, but it’s really not there yet. I don’t think they are where they need to be.”
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Now it has been over a year since Austin was prescribed medication and he and his family started counseling, and the Reeds can’t imagine going back.
Mrs. Reed says as they learning coping skills, they’re learning to function as a family again.
“If we hadn’t (gotten help) ... someone would have had to go,” Mrs. Reed said shaking her head.
Phil remembers asking one of the mental health providers they eventually contacted what happens to a person if they can’t get treatment, if they’re alone or a single parent with no one to help them.
“If people don’t have help, where do they end up? In emergency rooms and jails. When we found that out, that was troubling. Disheartening,” Phil said. “How do we work together as a community to get everybody the help that they need?”