Providing Integrated Care Is the Most Important Thing We Can Do for Behavioral Health

A Conversation with Dr. Gregory Miller, Chief Medical Officer, Unity Center for Behavioral Health

October 9, 2019

Planner/Healthcare Architect, NBBJ

Editor’s Note: The number of people reporting behavioral health issues is on the rise, a crisis often compounded by lower-than-average funding, a lack of psychiatric beds and high occupancy rates of behavioral health facilities. This week we are posting interviews with experts in behavioral health, following an NBBJ-hosted panel discussion, to learn how different parts of the country are addressing the crisis.

 

NBBJ: What is the most impactful change that could be made to how behavioral health is handled in the United States?

Dr. Gregory Miller: The development of a truly integrated system of care — not between behavioral health and physical health, but within behavioral health itself — is one change. Care for episodes of illness has become spread out between disparate providers, such as inpatient, partial hospitalization programs, outpatient, case management, etc. Often one team knows nothing about the real handoff information necessary to change the level of care smoothly. Delivering care from truly integrated systems would make a huge difference. In addition, community services need to be built out and invested in.

 

What is an innovative approach/treatment you — or another institution, city, state, country, etc. — are working on when it comes to behavioral health treatments?

The concept of Psychiatric Emergency Services, i.e. specialty mental health care that is immediately accessible, is an innovation that mostly benefits the severely mentally ill (SMI), a poorly-resourced population. It helps to rebalance the needs of the SMI population when community services are inadequate or poorly accessible. It should be seen as a temporary approach, providing access during a period of transition to more richly-resourced community services. When the community is adequately resourced, the need for such higher-end services will decrease.

 

Traditional behavioral health facilities are sometimes seen as socially isolating or unpleasant to the senses. How should the design of behavioral health facilities transform to better serve patients (and their families and visitors) and staff?

I like the design of progressively expanding “spheres of community.” For example, in an inpatient unit or subacute unit, the most intimate sphere of community is where one sleeps and tends to personal hygiene. Units where patient rooms are clustered internally with progressively expanding bands — such as an area for dining and group treatment, with activities that emerge into a larger sphere for consultation with providers, school service and family and visitation — tend to mimic life in the communities that we live in.

 

What makes you hopeful when it comes to combating the behavioral health crisis?

I am hopeful regarding the progression of knowledge and treatments. However, I am disappointed that care has become, over the course of my career, progressively more disintegrated and confusing. Systems do not converge to provide cohesive treatment. Patients are confused by the systems they are involved in. Providers, likewise, are confused. Hopefully this will be the next wave of progress.

 

Images courtesy Sean Airhart/NBBJ.

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Let’s Commit More Resources to Behavioral Health

A Conversation with Dr. Curtis Wittmann, Associate Director, Acute Psychiatry, Massachusetts General Hospital

October 8, 2019

Planner/Healthcare Architect, NBBJ

Editor’s Note: The number of people reporting behavioral health issues is on the rise, a crisis often compounded by lower-than-average funding, a lack of psychiatric beds and high occupancy rates of behavioral health facilities. This week we are posting interviews with experts in behavioral health, following an NBBJ-hosted panel discussion, to learn how different parts of the country are addressing the crisis.

 

NBBJ: What is the most impactful change that could be made to how behavioral health is handled in the United States?

Dr. Curtis Wittmann: The biggest issue currently is a lack of resources. This crosses many domains, ranging from a lack of true parity, which makes recruitment of providers more difficult; a lack of places to refer patients; inadequate inpatient and state hospital beds; and a lack of social resources and programs, which impedes our patients’ ability to engage in treatment.

An increased availability of resources, both within the mental health field and as social supports, would allow for meaningful and novel approaches to be implemented. Until then, even in relatively resource rich-environments, we don’t have enough to offer our patient
populations.

 

What is an innovative approach/treatment you — or another institution, city, state, country, etc. — are working on when it comes to behavioral health treatment?

At Massachusetts General Hospital we have been redesigning our dedicated emergency psychiatry space and increasing both our capacity and attention to patient comfort. We are moving to minimize the use of inappropriate clinical space and attempting to allow for a more open design to allow more patient interactions and increased programming while patients are boarding in the emergency department.

Concurrently, we are working to initiate treatment from the point at which patients arrive to the ED and are screened by emergency medicine. Both of these initiatives are designed to decrease the amount of boarding that takes place and the length of stay for patients who are boarding.

 

Traditional behavioral health facilities are sometimes seen as socially isolating or unpleasant to the senses. How should the design of behavioral health facilities transform to better serve patients (and their families and visitors) and staff?

There is always a balance between the need for safety on the one hand, and maximizing patient comfort, freedom and environments on the other. Increasing safe open spaces to allow for connection between patients, between patients and staff, and between patients and their families and visitors is critical.

Ideally these settings would make better use of natural light or, if possible, outdoor spaces — though this is very challenging in city environments. It may be possible to create a more natural space indoors through the use of plants and more creative design.

Finally, there is increasing attention to the role of physical activity and exercise in mental well-being, and even suggestions that exercise may be an effective treatment for several mental health conditions — a creative design would work to implement increased walking space and/or a semi-dedicated space for exercise with associated programming to implement positive habits or continue them while patients are hospitalized.

 

What makes you hopeful when it comes to combating the behavioral health crisis?

I’m made hopeful when I see the response to the opioid use disorder epidemic. Although it was delayed, across the country there has been a dramatic increase in the commitment of resources to treatment and to novel programs within hospitals and communities. These resources have been a blend of government resources along with hospital and private resources.

The mental health epidemic does not have the same dramatic statistics regarding increasing death rates, but arguably it extracts an even larger price from a larger number of people. Should we be able to learn from some of the lessons of the opioid crisis — rapid access to treatment, de-stigmatization, increased recovery supports — we could have a similar impact on improving our country’s approach to behavioral health.

 

Banner image courtesy of Anton Grassl/Esto/NBBJ.

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Behavioral Health Needs Spaces Where Patients Can “Pass Storms and Glimpse a New Horizon”

A Conversation with Dr. Susan Swick, Physician in Chief and Medical Director, Ohana Montage Health

October 7, 2019

Planner/Healthcare Architect, NBBJ

Editor’s Note: The number of people reporting behavioral health issues is on the rise, a crisis often compounded by lower-than-average funding, a lack of psychiatric beds and high occupancy rates of behavioral health facilities. This week we are posting interviews with experts in behavioral health, following an NBBJ-hosted panel discussion, to learn how different parts of the country are addressing the crisis.

 

NBBJ: What is the most impactful change that could be made to how behavioral health is handled in the United States?

Dr. Susan Swick: Psychiatric illnesses are common and treatable, often curable, but access to effective treatment remains maddeningly difficult in the United States. Yet even with effective treatments, being disease-free is not the same as being healthy. Building mental health can protect against disease and contribute to a life of meaning, with happier relationships, satisfying work and better physical health. Helping people to understand that good mental health is something each individual must develop will not only improve public health, but also diminish the stigma that remains around mental illnesses.

Finally, by helping parents to understand that mental health is something we help our children develop, rather than simply protecting them from mental illness, we contribute greater resilience in children and well-being in families. I have seen the power of these ideas at work in my patients and in my own family and am passionate about contributing to a health care system that builds health.

 

What is an innovative approach/treatment you — or another institution, city, state, country, etc. — are working on when it comes to behavioral health treatment?

The physical environment in which care occurs contributes profoundly to the well-being of patients and caregivers, just as classrooms affect students. Environments create our sense of what is possible, while raising or lowering the volume of what we are hearing in the moment. Environments — including the materials, presence of natural light, fresh air and sounds — have the power to be soothing and quieting or highly stimulating and activating.

In a windowless, crowded psychiatric emergency department in NYC, I experienced the power of music to quiet agitation and comfort the lonely: a cozy office filled with art, books and overstuffed furniture created the personal, warm and reliable setting that allowed effective psychotherapy to take place. In addition, an escalating child was able to go on a walk outside with a trusted adult and was able to naturally re-regulate themselves and not require medications or restraints to do so. The setting never does all the therapeutic work, but the right setting makes it possible for the clinician and patient to do the work together.

 

Traditional behavioral health facilities are sometimes seen as socially isolating or unpleasant to the senses. How should the design of behavioral health facilities transform to better serve patients (and their families and visitors) and staff?

Behavioral health facilities are still healthcare facilities, and they must ensure safety, including infection control, prevention of suicide and everyone’s safety around agitated or aggressive patients. But they must support quality care, also. I think design for highest-quality behavioral health care should create an environment which is soothing — with, for example, lower noise levels, natural materials, neutral colors, predictability and options for retreat or privacy. At the same time, they should be inspiriting or support a sense of possibility with higher ceilings, dynamic views, fresh air and ample, diffuse, natural light.

It is critical that these spaces include the potential for agency or choice, more so when patients spend more time in them. We hope that the skills which our patients build in these spaces will remain when they return to their homes, offices and schools. Therapeutic spaces should echo the spaces our patients inhabit. But they can still be special — spaces in which to pass storms and glimpse a new horizon.

 

What makes you hopeful when it comes to combating the behavioral health crisis?

If design can serve both the passing of a storm and the promise of an open horizon, all while promoting agency, it will be an extraordinary space. When we provide care and offer education about mental fitness in spaces that everyone is delighted to be in, it destigmatizes mental illness in ways that words and statistics cannot. When we provide care in humane spaces that promote autonomy and individualism, alongside nurturing connections between patient and clinician, between family members, among colleagues, between friends, and across a community, we support mental fitness in our patients, ourselves, our colleagues and our guests.

 

Banner image courtesy D Ramey Logan/Wikipedia.

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