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L&M: 'Decentralization' of outpatient mental health services to improve care

By Judy Benson

Publication: The Day

Published 12/28/2012 12:00 AM
Updated 12/28/2012 12:18 AM
But former outpatient psychiatry director says relocating services from main hospital is financially motivated

New London - The center at Lawrence & Memorial Hospital that provides outpatient mental health services for about 800 patients is being moved from the main hospital into five primary-care offices from North Stonington to Niantic.

Dr. Bertrand Duval-Arnould, chairman of the L&M psychiatry department, said the Counseling Center on the fifth and sixth floors of the hospital's Pond House building on Ocean Avenue is being decentralized to enable closer coordination between primary-care physicians and the counselors and doctors who provide psychiatric services.

Starting Jan. 21, the services will be offered at primary-care offices that are part of L&M Physicians Associates in Niantic, New London, Groton, Ledyard and North Stonington. An L&M-affiliated primary care office in Old Lyme will add mental health services once a new, larger building opens.

"We're trying to bring psychiatry back into medicine by imbedding mental health staff in the primary-care setting," Duval-Arnould said, adding that he believes the new model will help reduce the reluctance some people have about accessing services in the "relatively isolated" Pond House setting because of the stigma associated with mental health treatment.

But Dr. Julia Chase-Brand, who was medical director of outpatient psychiatry from 2008 until her resignation in March, said she believes the decentralized services will shortchange the many low-income, chronically mentally ill patients covered by Medicare or Medicaid, most of whom live in New London and have relatively easy access to the main hospital.

"The majority of chronic patients are being geographically separated from their care," she said in an interview last week. "Private practice in general will not take Medicare and Medicaid, and financially these patients cannot afford private services. What is left but for these patients to destabilize?"

Duval-Arnould is retiring Jan. 1, but he said his retirement is not related to the restructuring. He said that it was at his urging that hospital administrators first considered and ultimately approved the decentralization of services. No changes are contemplated for the 17-bed inpatient psychiatric unit at L&M, or for the Intensive Outpatient Program, which serves patients after hospitalization at the main hospital, he said.

L&M informed Counseling Center patients about the pending plan in a Nov. 23 letter, which describes the change as "expansion and enhancements of services that will improve quality of care," and assures patients that they will be able to continue seeing their therapists and psychiatrists in the primary-care offices. The letter does not provide specific contact information.

Pamela Kane, vice president of physician practice management, said Wednesday that the work schedules of the clinical and medical staff at the five offices are still being finalized, and that patient appointments at the new offices will be made after that process is complete.

"We'll make sure none of our patients fall through the cracks," she said.

Kane added that in addition to the Counseling Center changes, L&M is looking to enhance psychiatric crisis services in its Emergency Department.

Chase-Brand faulted L&M for not organizing the required "transition of care" to the new offices before announcing the change.

Resigned 'in protest'

Chase-Brand, who also briefly served as interim chairwoman of psychiatry in 2010 and 2011, sent a letter on Dec. 19 to the commissioner of the state Department of Public Health outlining her concerns.

Her letter to Dr. Jewel Mullen, state public health commissioner, is being reviewed, Diana Lejardi, department spokeswoman, said Wednesday, adding that she had no additional comment.

James Siemianowski, spokesman for the state Department of Mental Health and Addiction Services, said L&M receives no DMHAS funding for the Counseling Center, but the hospital did inform the department about the pending change.

"We are appreciative that they shared their plan with us," he said. "But they are free to restructure in any way that they want."

In her letter, Chase-Brand said restructuring is the latest of several steps the hospital has taken since 2010 to pare back its outpatient mental health services. This has included the closing of a clinic in Mystic in 2010, the layoffs of four advance practice nurse practitioners, five social workers, a caseworker and office staff, and a push to "get rid of the long-term patients and move to a model of 'brief care (12-session) psychiatry,'" Chase-Brand wrote.

"Like most people in behavioral health, I see much of mental illness as an array of chronic conditions, not amenable to a 'quick fix,'" she wrote. "Finally in March 2012, I resigned in protest."

Financial motives, she believes, are behind the hospital's decision as it seeks to reduce the rolls of lower-reimbursed Medicare and Medicaid psychiatric patients and increase the numbers of those with private insurance.

"I don't see where the poor, chronic mentally ill patients are going to receive their care," she said.

No financial motive

Kane denied that L&M is looking to reduce Medicare and Medicaid patients served by the Counseling Center.

"This didn't originate because of a financial motivation," she said. "It started because of the patient-centered medical home model that incorporates behavioral health into primary care."

She expects, however, that a wider range of patients will access the services in the new locations, including more of those with private insurance. Under the new model, she said, the center will be able to serve the same or more patients.

Duval-Arnould, the retiring psychiatry department chairman, said group therapy as well as one-on-one sessions will be available at the primary care offices. Once renovations to the Howard Street office building recently purchased by L&M are complete, some group therapy sessions will be offered there, he added.

Counseling Center patients will be able to receive services at the primary-care offices regardless of whether they are patients of the primary-care doctors there, he added.

Staffing will consist of four full-time counselors who will rotate among the various sites, three psychiatrists and one advance practice registered nurse who would be assigned one or more days each week to each site to prescribe, check and administer medications, consult with the primary-care doctors and handle the more complex cases, he said.

"Closer collaboration and integration of primary care and psychiatry is absolutely needed," he said in an email message. "The model proposed here has been tested and validated in many different settings; the current evidence supports better outcomes for patients ... following integrated delivery of care."

j.benson@theday.com

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