It was the weirdest timing. Just when a medical team got to a name during its weekly briefing, the client called the office.
Social worker Shannon Flynn answered and waved, hushing the room.
“(He) just called and said, ‘I’m hurt. I’m hurt. Help me, I’m hurt,’ ” Flynn said.
The University of Oklahoma-Integrated Multidisciplinary Program of Assertive Community Treatment (OU-IMPACT) team — composed of doctors, nurses, social workers and a peer provider — jumped into action. EMSA was called, and two members were out the door within one minute.
Flynn stayed on the phone to monitor what was happening and kept talking to the client.
“He’s not hurt physically, but he’s symptomatic,” Flynn told the room.
“We’re heading out now,” she said into the phone. “I’m coming by to see you. Can I talk to you when I get there? Thanks.”
Then, she was out the door.
This was my introduction to the inner workings of a Program of Assertive Community Treatment, called PACT, team. For more than a decade in Tulsa, these intensive, wrap-around support teams have been helping people in the city who face the most significant mental health diseases.
Often, these are the people whose families are at their wit’s end or have simply given up. Traditional treatments and hospitalizations haven’t worked. They go in and out of homelessness. They bump up against law enforcement. They live in poverty, can’t stay employed and struggle with hazy thoughts or delusions.
This is the last step before long-term institutionalization or even incarceration. Clients can be referred into a PACT team by anyone, but it usually comes from psychiatric centers.
The OU IMPACT team finds them, whether in their own homes, under a bridge, in a homeless shelter or crashing on a friend’s sofa.
Dr. Erik Vanderlip, both a psychiatrist and a family medicine physician, manages the team as part of his role as an assistant professor at the University of Oklahoma-Tulsa School of Community Medicine in the departments of psychiatry and medical informatics.
“We are creating a psychiatric hospital, but in their homes,” Vanderlip said. “You can’t just discharge someone from the team for missing an appointment or not following all the rules. Once they are part of the team, we are responsible for them. We find them wherever they may be.”
Tulsa’s three PACT teams — one based at OU-Tulsa School of Community Medicine and two at the nonprofit Family & Children’s Services — together serve about 275 people. A study by OU-Tulsa a few years ago estimated another 700 Tulsa residents could be eligible for services, but not enough slots are available.
Vanderlip said a significant portion of the clients may forever need a PACT team, while the others may progress to a stepped down level of treatment. There are no timelines.
“By the time they get to us, it’s pretty serious, and they have few social supports and are showing a lot of symptoms of psychotic episodes,” Vanderlip said. “Often, they do not like the health-care system. The health-care system has failed them. It takes a long time to build the relationship, at least six months to a year.”
For the first time, I was allowed to sit in on the team’s conference and ride along to a client visit. It sheds light on what these workers do and how their approach has expanded in the past six months with the addition of primary care.
The morning began with a rundown of the clients, called team members.
Vanderlip takes notes and checks their prescriptions as the others describe the actions and appearances observed among the clients. He and another psychiatrist split their time seeing each of the 75 clients at least once a month. The nurses and social workers make at least three visits a week, sometimes shopping with them or hanging out on a porch.
“In this, the you-come-to-us mentality is overcome,” Vanderlip said.
Among this week’s reports:
- A woman is resistant to following rules in her apartment building. She has no money and just finished the last of a bag of rice she seasons with artificial sweetener. She was going to pawn some items but had no money for bus fare. The social worker took her to a food pantry and is working on a budget. Vanderlip is concerned about how nutrition is affecting her diabetes.
- A man was on his porch in a confused and disoriented state. He was irritable and refusing to take his anti-psychotic medication. He refused to let team members into his home. The team discussed possible changes in treatment, including a short hospitalization to change his medication.
- A woman was acting “appropriately” on a recent visit, but was frustrated and tired after spending four hours on a city bus getting to a food pantry.
- A man had been temporarily suspended from going to a homeless shelter. He was found at a home with possibly dangerous people. The team agreed to meet with the client at other locations. His family is working with the team to coax him into other housing.
- A man had changes in some heart and diabetes medications. The team came up with a walking routine and discussed with him how to make better food choices.
- A client had the television on loudly while all the water faucets were running. His speech was slurred, and his appearance unkempt.
- One man had been depending on pain medication to handle dental problems. It was going to cost more than $1,000 for dentures, so the social worker was trying to find lower-cost dental services.
- At least half the clients visited during the week live in apartments with bed-bug problems.
Though half the clients reported stable mental health, this is clearly a more chaotic week with the several exhibiting symptoms of psychotic episodes or physical health problems.
When it came to a client who had passed out at a store, then was taken to a hospital only to discover lung cancer, Vanderlip was almost speechless.
“What? Lung cancer?” he shook his head. “What has happened this week? It’s not normally like this.”
Tying things together
PACT teams were developed more than 30 years ago for a more team-based approach to health care for vulnerable populations. The teams have always struggled to provide holistic care — mind and body. Traditionally, different doctors handle different health issues with not a lot of crossover. It’s up to the patient to coordinate the care.
The PACT team psychiatrists faced treating physical ailments along with mental health diseases, but funding didn’t cover the primary care portion or they felt ill-equipped to manage physical health conditions. They had to depend on making referrals. Or, primary care physicians didn’t communicate with the team.
This led to PACT team clients getting well mentally but not physically.
“They are dying at 55 from strokes, heart attacks and other cardiovascular events,” Vanderlip said. “The real things that are killing them are cardiovascular reasons. Many smoke like chimneys. But there is high blood pressure, diabetes and cholesterol.”
Change came with the passage of the Affordable Care Act, which enhanced traditional community mental-health services to allow for better primary care coordination. These government-defined services are called “health homes.” PACT teams are included in those programs.
Oklahoma turned down Medicaid expansion for individuals. However, Medicaid dollars were made available for health home programs, which served to strengthen the existing PACT teams. The teams are able to incorporate primary care for an integrated approach to health and wellness.
The Oklahoma Department of Mental Health and Substance Abuse was approved to provide funding for qualifying teams, and OU-IMPACT started adding the primary care aspect in March 2015. The funding is provided on a per-member, per-month rate (about $450) for eligible clients opting into the health home program.
Results from the first six months of the program will be presented by Vanderlip and colleagues at the Zarrow Mental Health Symposium on Sept. 17-18 in Tulsa. In general, the findings show improved physical health factors such as cholesterol screenings, blood pressure and diabetes maintenance.
Vanderlip and other members of the American Psychiatric Association recently completed a position statement calling on psychiatrists to do a better job of managing the physical health conditions of their patients, not just their mental health conditions.
What this complex system of integrated care and coordinated funding streams looks like in reality is quite simple.
It’s Vanderlip and nurse Elizabeth Bouch sitting with 43-year-old Raquel Acosta in the community room of the Altamont Apartments, which is a Mental Health Association Oklahoma property.
This is the opposite of the white coat, form-dependent routine used in nearly every doctor’s office. The trio jokes with a comfortable banter without a worry for time.
Acosta has schizophrenia, but she really wants a neutral ear to sort through frustrations with a friend and family member. She’s concerned about her efforts to cut down on her four- to five-can-a-day soda habit and never-satiated sweet tooth.
Vanderlip discreetly checks his smartphone for information and looks at her medicine bottles. He asks how long she’s had diabetes.
“As a kid, I used to get these head rushes, so I think I had it then. But I really don’t know,” she said.
Acosta is talkative, often getting off track and sometimes getting emotional when speaking of her childhood or relationships. Vanderlip subtly brings her back to the topic with encouraging words.
“That’s a lot to keep up with,” “I’m impressed how much you are able to do,” and “You’re doing a good job,” are among his encouragements.
By the end of the visit, Vanderlip decided to order blood tests to possibly adjust her diabetes medication, and he and Bouch established a plan to have the team communicate with Acosta’s provider who manages her diabetes. He said the mental health medications seem to be working fine.
Acosta asked twice for reassurance the team will continue the visits. She has been with the OU Impact team since it began 11 years ago. She was referred by a psychiatric hospital after a series of failed admissions.
“I love you all so much,” she said. “What you do for us is so special. For any reason, when one of us is not doing something right or having a psychotic episode, they are there to care for us. I think it was God’s plan for me to be here. Before this, I was involved with a lot of bad people. If I wasn’t here, I’d be in jail. I’ve made a lot of changes.”
Ginnie Graham 918-581-8376