By Katie Kerwin McCrimmon

COLORADO SPRINGS — The relationship is on the rocks.

Long divided into opposing cultures, doctors, who focus on the body, are trying to work side-by-side with behavioral health experts who try to heal patients’ minds. In a grand Colorado experiment called Advancing Care Together, 11 pilot sites are participating in a $4 million four-year experiment to bring these disparate worlds together.

And some are pining for a divorce.

Or at least they want a proper wedding that includes electronic medical records that actually talk to each other.

“If we want it, we’ve got a put a ring on it,” said Dr. James Meyer, with Miramont Family Medicine’s Parker office.  Meyer drew loud laughter from a room full of ACT participants who gathered recently in Colorado Springs.

Their struggles after a year in the trenches show just how complex real health reform will be.

Among the lessons learned so far:

• Physical space matters. A relatively small clinic in remote Cortez that was designed for integrated care is making the most progress. In fact, the Cortez Integrated Healthcare Clinic is now struggling with too many patients. Read more.
• At various sites, integration works better when behavioral and physical health experts trip over each other and are forced to share work areas. The behavioral health experts can “stalk docs” to make sure they are tapping their skills. And doctors, who are perpetually short of time, can give quick patient updates on the fly.  Patients benefit when they receive seamless care. Said Dr. C.J. Peek, an expert from the University of Minnesota Medical School: “You can’t put the therapist in a nice unused office with a couch and a fern. That person has to be in the traffic pattern, in the most cluttered place so you are tripping over each other. Out of sight. Out of mind.”
• The biggest health systems are struggling the most. In one that is supposed to be a national model for integration, it took a behavioral health expert two years to get an office at a medical clinic where she had been assigned. The rest of the time, she was supposed to float. With limited personnel and pressure for each provider to be more productive in less time, the counselor is supposed to spend just 20 minutes with each patient, a marked departure from the typical 50-minute or hour-long counseling session.
• Low-tech can work well. At Salud Family Health Centers, which has long had behavioral health experts in its clinics, counselors use white boards in common areas with doctors and simply mark a BH next to patients they want to see. They don’t wait for doctors to come get them since providers often miss signs of mental distress. Behavioral health experts see all new mothers and anyone who complains of pain, such as a headache or a stomachache that might be associated with a mental illness. Read more about integration at Salud. 
• Another innovator, Westminster Medical Clinic, has already gone through two therapists in a year and is hunting for a third. But even with unemployment high, it can’t find a qualified behavioral health expert who wants the part-time job. The first was great, but was hired away. The second only wanted to do limited work, never meshed with the rest of the staff and could make significantly more money doing crisis care at a hospital emergency room. Now Westminster has created a detailed contract it is calling a health compact that will govern how a future relationship will work. Central to its success will be housing the behavioral health expert in a room full of desks where the behavioral health experts will work “shoulder-to-shoulder” with the medical staff. Read more about Westminster’s initial efforts. 
• None of the sites can figure out how to pay for integrated care over the long term. For now, some ACT innovators feel they must “be creative” with health insurance billing codes in order to make ends meet. Others fear they will be dependent on grants forever. A separate experiment that will soon begin in Grand Junction aims to determine if a nonprofit health insurance company, Rocky Mountain Health Plans, which is not an ACT participant, can cover behavioral health in primary care settings through monthly “per member” fees instead of typical fee-for-service models. Read more: Insurance company bets on benefits of integration.
• Distrust between behavioral health experts and doctors is rampant. Some counselors think doctors simply prescribe unproven medications, then send patients packing without considering the potential value of therapy. Meanwhile some medical experts think behavioral health experts are slow, unresponsive and never keep them posted about patient progress. What’s more, some doctors hate the way mentally ill patients who should be seen through Colorado’s network of mental health facilities “get fired” if they fail to show up for appointments and ricochet right back to overwhelmed doctors.
• Electronic health records for medical and behavioral health care don’t interface even when that care is located in the same clinic.
• Some providers said they have “change fatigue.” They’re exhausted from the perpetual reforms in medicine.
• A solo medical practitioner in Basalt in the Roaring Fork River Valley near Aspen, Dr. Glenn Kotz, is making great progress at integrating by creating partnerships with nonprofits in the area. But because he’s so busy seeing patients each day and financial pressures are paramount in private practice, Kotz pours his energy into creating partnerships and innovating his practice from 4 to 6 a.m., then sees patients as fast as he can the rest of the day.

At the conference that brought representatives from the 11 sites together with a high-powered advisory board full of national experts on integration, there were moments when it felt like a fistfight might break out. But, these are health experts with advanced degrees. They duked it out through impeccably-cited dueling PowerPoint presentations instead.

Sounds chaotic. Right?

Yes, and that’s just what the unflappable leader of ACT, Dr. Larry Green, was hoping would happen at this stage of the game.

“It’s going better than I expected,” said Green, with the imperturbable air of an elementary school principal serene amid a group of naughty knee-high charges.  “It’s important to recall what our aim is. Our aim is to change practice. It’s hard.”

Even if opposing experts sometimes wanted to smack each other at their annual gathering on the flanks of Pikes Peak, at least they were in the same room, sharing results from real-life on-the-ground experiments. At each of their sites, they were testing unique methods that Green and others hope will someday amount to the “secret formulas” providing a playbook for integration around the country.

“Our name says we’re advancing care together, not apart. The institutional impediments to taking proper care of people are now out in plain sight. Pretty much anything is now discussable,” said Green.

Dr. Mary Jane England, chair of the ACT steering committee, a professor at the Boston University School of Public Health and one of the top mental health experts in the country, was downright rosy in her assessment of how the Colorado pilots are doing.

“You are leading the nation. We in Massachusetts have now covered 98 percent of people. We have a cap on expenditures and bundled payments … But you’re doing the really important work out here.

“You really are grass roots. This isn’t easy. This is change. It’s very exciting. You are now very much in the national forefront,” said England who chaired a watershed 2005 report for the National Academies’ Institute of Medicine on improving care for people with mental health and substance abuse problems.

Forefront, shmorefront. On the ground, reform is exhausting as are challenges that cut right to the core of patients’ lives.

Dr. Kotz, the solo doctor at MidValley Family Practice in Basalt, says the mental health system in his area that is supposed to help his neediest patients isn’t working. He is dealing with one family that has experienced severe trauma, abuse and domestic violence. He believes that both the mother and children should be getting care from the mental health facility. But, Kotz said his patients are not getting adequate care, so they keep coming back to him.

“I don’t want to paint this just as a negative picture. I think they try to do their best, but they are overwhelmed,” Kotz said.

To provide behavioral health to his patients, Kotz has partnered with the Aspen Hope Center, which is funded by the Aspen Valley Medical Center.  He now has a therapist employed by the Hope Center who works in his office part ime. Together they see the patients who have the toughest behavioral health challenges.

“They are high-need both from the medical and mental health standpoint,” Kotz said.

Some are bipolar or suicidal. One patient has been hospitalized 15 times.  Another is just 21, suffers from schizophrenia and has been hospitalized for the third time in three months.

Kotz said some mental health providers have expectations that patients can’t achieve.

“If you don’t show up, you’re fired.”

Then they wind up back at his practice.

To fill the gap, Amy Gensch, the Hope Center therapist in Kotz’ office, has simply taken on the family that suffered trauma and abuse so they won’t fall through the cracks.

“It’s the worst trauma I’ve ever seen,” Gensch said. “They had two therapists within two months. It didn’t work for them.”

Gensch and Kotz work together seamlessly, flagging each other down casually when they need to consult.

“It works really well,” said Gensch.

Their primary desire would be to expand their capacity.

“The statistics showing the number of mental health patients that come to primary care seeking help proves to me that it’s an absolute need to have primary care and behavioral health integrated,” said Kotz.

So, the goal is worthy. The path to get there remains difficult to find.

“Nobody has this figured out yet,” said Green, director of ACT. “We are comfortable enough to show all the warts now. We’ve got miles to go before we sleep.”