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Adventures in Integrated Care

NOW THEY CAN’T


PRACTICE WITHOUT HIM
Just two years after integrating a psychologist into its
staff, this family medicine practice is reducing emergency
room visits and improving overall patient care
BY AMY NOVOTNEY

A
sign at the nurses’ sta- patients to outpatient coun-
tion at South Nassau seling. In 2016, Cavera’s first
Family Medicine Cen- full year on staff, he referred 99
ter reads “Go Get Dr. Cavera!” patients for outpatient coun-
It’s an enthusiastic reminder for seling, with 60 percent of them
the medical staff to tap the exper- following through, according
tise of clinical health psychologist to Janet Kahn-Scolaro, LCSW,
Robert Cavera, PsyD. Though he PhD, administrative director of
joined the practice only two years integrated behavioral health and
ago, patient data from the center family medicine at South Nassau Dr. Robert Cavera
have shown that his expertise is Communities Hospital, the spends his days
in what he terms
improving care and outcomes, Oceanside center’s institutional “all-day on-call
whether it’s by his working with partner. That’s a more than 420 mode,” pulled
a patient in a mental health crisis, percent increase in referrals and into appointments
on an as-needed
advising one who needs behav- a clear sign that more patients basis by physicians
ioral insights for complying with are getting needed s­ ervices from and residents
a medication regimen or referring their physician rather than the to provide brief class and relatively healthy,
mental health
another to the nearby counseling emergency room, Kahn-­Scolaro assessments and but many are low-income and
center for longer-term mental says. consultations to ethnic-minority patients, includ-
health treatment. “Our goal is to make sure patients. ing a high percentage of Latino
“Rob has been such a great that patients get what they need adults who are uninsured or
asset to our team here,” says Joyce in the community, rather than underinsured and dealing with
Robert, MD, an attending physi- at the hospital,” she says. “The chronic medical diseases and
cian in the practice and director integration of services plays a co-morbidities, including diabe-
of performance improvement at significant role in this, as the tes and heart disease as well as
the center, located in Oceanside, patients seen in family medi- anxiety, depression and trauma.
New York. “When we have 20 cine and behavioral health have Several years ago, the South
patients in the waiting room, it’s coordinated care that helps them Nassau Communities Hospital
nice to have an expert in behav- avoid emergencies.” noticed that many patients were
ioral health on-site who can take coming to both the family med-
additional time with patients who MEETING icine center and the hospital’s
might need more mental health COMMUNITY NEEDS mental health counseling center
support than I can provide.” Located on Long Island, the for treatment, but coordinating
Patient data show how much center accommodates about care between the two facilities
of a difference Cavera has made. 21,000 visits each year from a to ensure patients weren’t falling
In 2015, the year Cavera joined socioeconomic mix of patients. through the cracks proved diffi-
the center, physicians referred 19 Some patients are upper middle cult, Kahn-Scolaro says.

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Cavera, whose training in basis by physicians and medical who might be right at the border
school and community psychol- residents to provide brief mental or needing services due to the
ogy had provided him with an health assessments and con- screenings,” Robert says.
expertise in mental health consul- sultations to patients. “It took Cavera will consult with
tations, jumped at Kahn-Scolaro’s our physicians a little while to patients who screen positive for
idea to establish a pilot program understand how best to utilize these symptoms, or any patient
in which a psychologist would Rob’s expertise, but now that who a physician feels might
work right onsite in the Ocean- he’s been here a few years, when need mental health treat-
side family medicine practice, he’s not here one day, everyone ment, then facilitate a referral
both to increase the referral around the office goes around to the hospital’s mental health
stream and improve patient care. saying, ‘I wish Dr. Cavera was center for longer-term coun-
He’d already spent several years here today because I really have seling for conditions such as
on the staff at the hospital’s men- a case I could use his help with,’” anxiety, depression or schizo-
tal health counseling center, so Kahn-Scolaro says. phrenia. He then provides an
he was familiar with the patient Perhaps one of his most in-person handoff to help boost
base and the issues many of far-reaching interventions since follow-through with referrals.
them face. joining the center is ensuring “I’ll often walk over and meet
Cavera spends his days at that all patients are screened for with patients I refer when they
ROBERT ADAM MAYER

Oceanside in what he terms “all- depression and trauma through a come for their first visit, to intro-
day on-call mode,” pulled into simple intake form. “We are defi- duce them to their counselor.
appointments on an as-needed nitely all catching more patients This way we’re providing not just

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Adventures in Integrated Care

a warm handoff, but more like a two to three months. “This has
warm hug, to help patients feel shown us how connected one
more comfortable,” Cavera says. ailment is to the other, and how
Cavera also works directly working on both is likely to
with patients who have co-­ improve the overall health of the
morbid psychiatric and medical patient,” Cavera says.
illnesses and those with solely Cavera’s presence also helps
medical ailments, such as the medical residents gain a
uncontrolled diabetes and hyper- better understanding of the psy-
tension. A lot of this work is chiatric and psychosocial aspects
cognitive-behavior focused, help- of their patients’ illnesses.
ing patients set realistic goals for “Rob provides real-time,
themselves in terms of nutrition, on-the-spot education in dif-
exercise, stress reduction and ferential diagnosis, motivational
smoking cessation. interviewing and information
“I listen to their concerns and on who needs to be referred
then give them really concrete to also see the patient to check in. and who really shouldn’t be
things they can do—baby steps, The team also works together referred—patients he can handle
so to speak,” he says. In the to address the needs of patients right there,” Kahn-Scolaro says.
case of very sedentary patients with depression and uncon- Cavera’s influence seems
with uncontrolled diabetes, for trolled diabetes. Several studies Dr. Cavera meets to stick with the new doctors,
example, Cavera encourages have found that people with daily with medical he says. Last year, for example,
staff to discuss
them to walk around the block diabetes have a greater risk of high-risk patients. he was treating a patient with
once a week, then twice a week. depression than those without hypertension and intense anx-
He also coaches them on how to the disease (Diabetes Care, Vol. iety alongside a resident. After
prepare their foods in healthier 31, No. 1, 2008). Depression can speaking with the patient, he
ways or asks them if there is one also make it harder to practice had both the patient and the
small unhealthy habit they could good diabetes self-care, so treat- resident do a brief mindfulness/
change in their diets. “That’s ing the depression with cognitive deep-breathing exercise. “The
something they might not get in behavioral therapy can make a patient reported feeling much
a 15-minute appointment with big difference in these patients’ better afterwards, and it has
their physician, who has told health outcomes and overall made a huge difference in terms
them they simply need to lose treatment costs. of helping to manage her anxiety
weight,” Cavera says. Last year, the practice ran- and her hypertension,” he says.
domly enrolled 25 patients The resident also told Cavera
COORDINATED CARE with both conditions into a how relaxed and less stressed she
Cavera also participates in trial program that provided felt after the exercise as well.
the morning huddles held ongoing team-based medical “My work on this team is
by the center’s medical treat- treatment, nutrition education helping challenge the way phy-
ment team to discuss the day’s and mental health support from sicians and other medical staff
most high-risk patients, for Cavera, as well as any specialty think, and increasing their will-
whom consultation or quick care that might be warranted, ingness and confidence to think
­follow-ups—from Cavera or any including podiatry and endocri- outside of the box,” he says. ■
of the other specialists—might be nology. After six months, these
needed. If a patient he’s provided patients reported reduced levels
● The Monitor’s “Adventures in
mental health support to in the of depression, and blood work
ROBERT ADAM MAYER

Integrated Care” series explores


past is scheduled to come in for showed improved hemoglobin the work psychologists are doing as
members of interdisciplinary teams.
a medical follow-up, for example, A1C, a measure of a patient’s If you have a story to share, contact
Cavera makes a concerted effort average blood sugar level over editor Sara Martin at smartin@apa.org.

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