Halting the Cycle

Mayo Clinic is re-engineering mental health care delivery

By Mayo Clinic Staff

To help patients receive timely care, Kalyan S. Pasupathy, Ph.D., Ronna L. Campbell, M.D., Ph.D., and Thomas R. Hellmich, M.D., are looking at the problem through an engineering lens.

Imagine a 55-year-old man living with undiagnosed depression. Simply getting up and going to work in the morning takes all of his strength. When he comes home from work, he retreats from family, seeking isolation and anything that will numb the persistent hopelessness that weighs on him like strands of rusty chains. Like many Americans suffering similarly, he refuses to acknowledge this crushing burden — not with his wife, not his friends, not his doctor. No one.

It's a situation all too common. According to the Substance Abuse and Mental Health Services Administration, an estimated 1 in 5 adults in the U.S. lived with a mental health condition in 2013. More than 24 million of them failed to receive treatment.

Even for those who do seek treatment, they find a U.S. health care system that is unwieldy and complex. For many patients who churn through its gears, calling it a "system" is a misnomer, with order, reliability and efficiency difficult to find.

On a societal level, mental health issues carry a $444 billion price tag, with health care expenses accounting for one-third of the cost and the majority of lost wages, according to the National Institute of Mental Health.

It's a vicious downward cycle — depression resulting in lost income, which results in increased stress and hopelessness, which makes it harder to function, which results in more lost income. And on and on.

To help these patients, researchers in the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery and the Division of Integrated Behavioral Health are looking at the system holistically. They apply systems science, operations research, engineering principles and computer modeling to fix some of the most pressing issues in health care, including how the nation cares, or doesn't care, for its mentally ill.

Nowhere to go

Overcoming the social stigma of mental illness is one of the biggest barriers to care and prevents many people from seeking help in the primary care setting. When untreated symptoms spiral out of control — depression turning into suicidal thoughts or self-inflicted harm, for example — these patients may visit the emergency department until their condition is stabilized or, in the most serious cases, until they can transfer to an inpatient treatment facility.

This is where they hit another wall. Over the past half-century, inpatient treatment facilities have disappeared from the health care landscape, as attitudes shifted from state institutionalization to community-based care at local hospitals — and full investment in community-based care has never been fully realized. Without adequate funding or staffing, these hospitals reduced their number of psychiatric beds to dangerously low proportions.

With nowhere for patients to go, the hospital emergency department becomes the de facto safety net. A patient with a mental health crisis may stay for days or even weeks until a transfer can be made, which chokes the system and makes it harder for others to access emergency care.

Kalyan S. Pasupathy, Ph.D., wants to find a way for all patients to receive timely care. A health sciences researcher and scientific director for the clinical engineering learning laboratory at Mayo Clinic, Dr. Pasupathy and a team he co-leads with medical director Thomas R. Hellmich, M.D., are looking at the problem through an engineer's lens.

"Many of the problems we face in health care are systemic problems," Dr. Pasupathy observes. "With mental health care, we face issues around coordination of primary care and the availability of inpatient care facilities. At the end of the day, these factors affect the emergency department. If we study them in silos, we risk shifting the problem from one area to another."

The clinical engineering learning laboratory is just one way the Mayo Clinic Kern Center for the Science of Health Care Delivery plans to dismantle those silos. Embedded in the emergency department at Mayo Clinic Hospital — Rochester, Saint Marys Campus, it's the first of its kind in the nation to study the delivery of care in a live patient environment rather than a simulated research suite.

The lab tracks patients, caregivers and medical equipment in real time using technology such as radiofrequency. Data readers built into the walls capture this information round-the-clock, so researchers can map the collective emergency department experience from start to finish.

Using this computer model, they can then answer key questions: How does extended boarding of patients with mental illness impact overall patient access? What prevents these patients from inpatient placement? How can resources both in the emergency department and beyond be reallocated to address gaps in care?

This team of systems engineers, informaticians and social scientists works with providers such as Ronna L. Campbell, M.D., Ph.D., an emergency medicine consultant who also chairs the Behavioral Health Workgroup in the Department of Emergency Medicine.

"We're collaborating with the center to model mental health care delivery from a much larger perspective, larger than what we see as providers on a day-to-day basis in our own emergency department," Dr. Campbell says. "We can see what's changing and what's happening using our data, but the center can look further out and see how we connect to the health system and how the system connects to statewide resources."

Getting ahead of the problem

Mark D. Williams, M.D., and David J. Katzelnick, M.D., are developing a more patient-centric approach to care.

Clearing the pathway to emergency mental health services is just one way physicians and researchers aim to get patients the care they need at the right place and time. Another is preventing those emergencies in the first place.

Mental health crises can result from a snowballing of obstacles. Ashamed, many patients deny they have a problem, says David J. Katzelnick, M.D., a psychiatrist and chair of the Division of Integrated Behavioral Health at Mayo Clinic. Even when they do acknowledge symptoms, their family doctor might not feel confident or have enough resources to provide care beyond prescribing medication or referring the patient to a psychiatrist — and the wait for a psychiatry appointment could be months. Meanwhile, the patient's condition declines.

Mark D. Williams, M.D., a psychiatrist and population health scholar with the Mayo Clinic Kern Center for the Science of Health Care Delivery, believes the remedy is a more proactive, patient-centered approach. He leads implementation of Mayo Clinic's Depression Improvement Across Minnesota, Offering a New Direction (DIAMOND) program. The model, initially implemented at 80 practices in Minnesota, including Mayo Clinic, is part of a statewide effort led by the Institute for Clinical Systems Improvement to better coordinate community-based mental health care.

The first step in DIAMOND is earlier identification of who needs help. When patients visit their primary care providers for a regular checkup, they fill out a questionnaire that assesses depressive symptoms. If they score in a certain range, their doctors will invite them to participate in DIAMOND. Patients who sign up for the program are matched with a nurse care coordinator, and together they spend around an hour creating a thorough history of the patient's condition. The nurse care coordinator works with the primary care provider and a psychiatrist to translate this history into a care plan. As a result, the patient has access to personalized mental health resources within a week, rather than months.

"Now that nurse is involved in the patient's life, aiming to get them into remission," Dr. Williams says. "The nurse may call the patient weekly or monthly depending on the case and will challenge them to set goals: What are you willing to do to change? Cut down on alcohol? Try to exercise? Try a different medication? Did you make it to therapy? The patient can also call the nurse anytime, typically once a week in the beginning, but once a day if in crisis. The nurse becomes the patient's advocate."

From Dr. Katzelnick's perspective, DIAMOND has significantly streamlined the delivery of mental health care so people encounter fewer roadblocks.

"With a relatively small investment of resources, DIAMOND allows many patients to get much better care. As a psychiatrist working with the care team, I can provide input on 100 to 120 patients in one morning. The scale and reach is dramatically wider, and the people I'm seeing in person are not random, but the ones who are most in need of the highest level of care."

To prove whether those benefits can be replicated broadly, Dr. Williams is collecting data to demonstrate DIAMOND's impact on long-term health care spending, patient outcomes, patient satisfaction, reduction in emergency department visits and other indicators of value.

"How should you design your interventions to make the best impact and do the best for all your patients? It's not something we're always taught in our medical education," Dr. Williams reflects. "We're more taught to look at the individual, but after seeing 100 patients, you wonder if there was a pattern in the people you saw, and if you changed one element in the delivery of their care, to what degree do they get better?

"We need rigorous ways to assess these changes so that we make the right investments in better care for our patients. That's what the center offers: tools to understand and improve upon models like DIAMOND so that more patients get evidence-based care."

For those feeling lost amid a broken health care system, that evidence may be the thread that mends.

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