When Brenda Reiss-Brennan was completing her clinical rotations as a nursing student, she recalls having to address both the physical and the emotional components of each patient's case as she wrote her nursing care plans. She remembers realizing that the "emotional" factors played a critical role in her patients' outcomes and that mental health was driving many of their health issues.
| Brenda Reiss-Brennan, PhD, APRN. Photo courtesy of Brenda Reiss-Brennan.|
"The emotional and the physical were really entwined for me," she said, noting that this was true no matter what disease the patients had-be it cancer or diabetes.
When she left school she took a job as a staff nurse on a five-bed inpatient child psychiatric unit at the University of North Carolina, Chapel Hill, working with children with a history of abuse and neglect and serious psychiatric disorders (psychosis, neurological deficits, and disruptive behaviors, to name a few). There she worked with a psychiatrist who embraced the concept of interdisciplinary care, making sure to include the nurses in team meetings, which eventually led to Reiss-Brennan working one-on-one with the children and sitting in on family meetings.
"Our responsibilities included what we now call patient rounds with the chief psychiatrist, group interventions, individual and family therapy with the social workers, and of course basic monitoring of safety and the therapeutic milieu," said Reiss-Brennan. "We would hold conferences about difficult cases with the team, monitor progress, and watch for relapses in symptoms."
When she left this job and started looking for another, she could not find a place with a team process in which all team members were considered equal. So she created her own.
THE MHI MODEL IS BORN
Now a psychiatric NP, Reiss-Brennan started her independent nursing family therapy practice in 1978. It wasn't long after that she began to receive referrals from primary care providers who were unsure how to handle their patients' mental health needs. She soon realized that working with one patient at a time limited her ability to reach more people, so in 1984 she developed a model to train other nurses, primary care providers, and clinics in treating patients with mental illness.
This mental health care model eventually caught the attention of Intermountain Healthcare, a nonprofit health care system located in Salt Lake City, Utah. In 1998, Intermountain initiated a pilot program in which Reiss-Brennan's model, together with a model on chronic medical diseases, was instituted in Intermountain primary care settings. As part of this new care model, which became known as Mental Health Integration (MHI), the treatment of mental health conditions such as anxiety, depression, and substance abuse was integrated into the primary care system. Several years later, following positive outcomes of the pilot program, Reiss-Brennan was asked to join Intermountain Healthcare and establish the MHI model throughout its entire system. She has been MHI director at Intermountain for 15 years.
HOW IS THE MHI MODEL DIFFERENT?
In many primary care practices, patients are referred elsewhere for mental health treatment. But with MHI, instead of handing out a referral to an external provider or a prescription and losing patients to follow-up, mental health conditions are treated in the same primary care practice. Patients receive education materials, are screened for suicide, and are provided a safe environment in which to start the conversation about their mental health needs.
In the MHI model, "patients and families are treated with respect and confidence as mental health is normalized in their health care experience," Reiss-Brennan said. "This increases early detection, prevention, and education, as well as intervention with the appropriate level of team care and effective management of chronic disease."
The MHI model is a team-based model. At Intermountain Healthcare, a transparent data system is shared with all team members for ease of communication and care coordination. All providers-nurses and physicians alike-are trained to assess the patient for early recognition of mental illness. If any member of the care team feels that a patient isn't getting better, they are trained to take the next step. "Mental health is everyone's job," Reiss-Brennan said.
Patients are also motivated to take an active role in their own care. "One of the goals is to involve patients and families in their care and to help their self-management skills," she added.
It has been well established that patients are happier when they are treated as a whole person. According to Reiss-Brennan, patients with depression who are treated in MHI clinics are 54% less likely to visit the ED than patients in non-MHI clinics. Recent data suggest that MHI is cost-effective as well-in 2010, patients with depression who were treated in an MHI clinic saw a $667 decrease in insurance claims the year following their diagnosis. And in a recent retrospective longitudinal cohort study by Reiss-Brennan and colleagues published in the August 23-30 JAMA, adults enrolled in an integrated health care delivery system who received team-based care integrating mental and physical health had higher rates of depression screenings, better adherence to diabetes care, and a lower number of ED visits and hospital admissions than adults in a traditional practice.
The model has spread to other facilities throughout the country that have heard about it through word of mouth and want to implement it. Over the last seven years, Intermountain Healthcare has collaborated with over 45 outside clinics in New Hampshire, Oregon, Maine, Ohio, Arizona, Utah, Minnesota, Mississippi, and California to support implementation of MHI through a team-based care model. Collaboration includes standardized training, routine team consultations, and yearly continuing medical education and evaluation conferences, where diverse team stakeholders share lessons learned and design innovative solutions to barriers to quality care.
"Our team-based model works so well and is such a good solution to how to navigate the complexities of health care today," said Reiss-Brennan. "We're focused on how fast we can get our clinics up and running and on encouraging other systems to adopt this model so we can reach and help as many families as possible."-Amy M. Collins, managing editor