The depression started after Maria Antunez was diagnosed with breast cancer.
Without warning, tears would fall and not stop.
Antunez, 43, had moved to Fresno to live with her mother and didn't know where to go for mental health services. Desperate, she confided in her primary care doctor at the Deran Koligian Ambulatory Care Center.
Her doctor made an appointment for Antunez with Marcelia Black, a mental health care manager available to patients at the downtown Fresno health center. After three counseling sessions, she sensed things were improving.
"The last time I was here, I was just crying and crying," Antunez said after a recent meeting with Black. "I feel so much better now. I'm so glad they have this help here."
Across the central San Joaquin Valley, health centers have been adding psychiatric care to their list of services in anticipation of thousands of new patients enrolling in health plans under the Affordable Care Act.
Their goal is to manage many mental health concerns within the confines of primary care, helping patients find service in the same care setting as well as reducing costs.
Much of it will be provided by primary care doctors. To help them provide services in a timely and cost-efficient way, centers have added teams of mental health workers — but not without challenges. Finding behavioral health workers to staff the clinics can be as difficult as securing the funds to pay for them.
The county's program at the Deran Koligian health center places primary care doctors alongside psychiatrists and clinical social workers. The program, which is less than a year old, is based on one in Washington state that is considered a model for providing mental health care in the primary care setting.
With more than 300,000 Medi-Cal beneficiaries in Fresno County, "one of our big challenges is, how do we provide access to all the people we have to provide access for," said Dr. Robert Oldham, the county's medical director for behavioral health.
Under the new federal health-care law, Medi-Cal patients with mild to moderate mental health conditions, such as depression and anxiety, are to be treated by providers in the community. County behavioral health departments will continue to provide psychiatric services for the seriously mentally ill who have conditions such as schizophrenia or bipolar disorder. Medi-Cal is the state-federal insurance for low-income residents.
Last year, 23,816 people received mental health care from the Fresno County Department of Behavioral Health.
The Valley doesn't have enough psychiatrists to meet the need for mental health services. According to a 2013 report by the California Healthcare Foundation, the San Joaquin Valley has eight psychiatrists per 100,000 patients — the lowest rate in the state. The statewide average is 19 per 100,000.
Doctors manage care
Primary care doctors always have been on the front lines of psychiatric care — many patients prefer to go to a family doctor to avoid what they perceive as the stigma of being seen by a psychiatrist — but family doctors often lack time, training and the back-up needed to provide the help. Too often, the best that they can do is refer patients to mental health specialists and hope they will follow through and make appointments.
The integrated primary care mental health program at the Deran Koligian center was designed to connect patients with care. Oldham brought the program to the center last August, basing it on the University of Washington program known as AIMS (Advancing Integrated Mental Health Solutions).
Under the program, primary care providers still run the show — they manage patients' health care, including screening for mental health issues — but have a direct access to mental health professionals. At the Deran Koligian center, one full-time and two part-time psychiatrists and four care managers are available to provide help and resources to primary care doctors.
Fresno's program also allots time for psychiatrist Shawn Hersevoort, the program's director and a UCSF-Fresno faculty member, to teach primary care doctors working at the center. They receive lectures and written materials in psychiatric care alongside their primary care training through UCSF-Fresno.
The program is good for patient care and for teaching, said Dr. Dominic Dizon, medical director at Deran Koligian, which is operated by Community Medical Centers. "It's provided a better quality of care for our patients," he said, and "so far as I can see, it's catered to our needs."
For patients who need urgent psychiatric care, doctors can talk to a psychiatrist immediately, Dizon said.
Doctors also can get consultations on medications. Patients may be taking four or more psychiatric drugs that need adjusting or changing, he said. "In the past ... it would be months down the road to get the patient into county mental health."
The program also allows resources to be better allocated.
With primary care doctors handling care for patients with mild and moderate mental illnesses, "it frees up the psychiatrist and other specialty mental health workers to focus on patients who aren't getting better," Oldham said.
And by receiving timely and appropriate treatment for mild to moderate illnesses, fewer patients require more intensive county behavioral health services, Hersevoort said.
He estimates the mental health team this year will see more than 5,500 patients, or almost 10% of the center's total patients, which has doctors for internal medicine, family practice, pediatrics and obstetrics/gynecology.
The program at Deran Koligian is a collaboration of the county's Department of Behavioral Health, UCSF-Fresno Medical Education Program and Community Medical Centers.
The county provides psychiatric social workers who are called care managers. The county also pays for the psychiatrists who are placed there by the UCSF-Fresno faculty medical group, and Community Medical Centers provides the space and electronic medical record system.
The idea for the program began taking shape a couple of years ago when Oldham began doing psychiatric consultations at Community Regional Medical Center in downtown Fresno.
There was no outpatient program to follow mental health patients once they were discharged from the hospital, he said. Oldham said he and staff from the county Department of Behavioral Health met with Community to find a solution.
It took more than a year for Mental Health Services Act money to be appropriated and for staff to be placed at the center. "It was slow going in the beginning — but things have taken off now," Oldham said.
The health center is not the first in Fresno County to provide mental health services, but it's the only one with county workers on staff. Other local health centers have integrated mental health programs that employ their own psychiatrists and supporting mental health staffs.
Placing county social workers at a community health center is unusual, Oldham said, but it's proven to be beneficial. The workers have become ambassadors for patients weaving between the county system and the health center.
Patricia Coronel, one of the care managers, recently counseled an elderly health center patient and then helped connect her to a county-run support program for seniors struggling with depression. "We can streamline them straight into services at the county," she said.
Oldham, in addition to helping start the program at the Deran Koligian center, has done the same for two federally qualified health centers in the Valley.
United Health Centers of the San Joaquin Valley has hired a psychiatrist and a team of social workers and case managers to provide services in Parlier, Sanger, Orange Cove and Mendota.
Valley Health Team has a psychologist, a social worker and two case managers for patients in Kerman, San Joaquin and Firebaugh, Oldham said.
Starting programs not easy or cheap
United Health Centers got lucky when it came time to hire a psychiatrist, Oldham said. The clinic is in a health provider shortage area and was able to recruit a doctor through the National Health Services Corps, which offers loan repayments to physicians who are willing to work in underserved areas.
The affiliation with UCSF-Fresno made it easier to get a psychiatrist for the Deran Koligian center, Oldham said. "For a lot of psychiatrists, it's more desirable to work for a university."
But health centers in the Valley have struggled to staff mental health programs. Clinica Sierra Vista, which operates in Fresno and Bakersfield, has built a behavioral health program over the past several years — but finding providers has been difficult, and the lack of staff has limited the number of patients who can be helped.
Clinica has behavioral health staff at seven of its 26 community clinics — but has been able to hire only one psychiatrist in Kern County who is available through video conference. Another part-time psychiatrist works in Fresno. Psychiatric nurse practitioners and family nurse practitioners see most of the patients.
Last year, Clinica saw 7,000 patients for mental health reasons. The centers saw a total of 160,000 patients.
"It's simply not enough" staff for the mental health needs, said Christopher Reilly, Clinica's director of behavioral health based in Kern County. "The Affordable Care Act would expect me to serve a lot more people, but how am I going to do that? How's anybody going to do that?"
Money needed to start programs
Finding funds to start — and then maintain — mental health programs is another problem.
Integrated mental health care often starts with grant funds, said Ashley Heald, senior project coordinator for the University of Washington AIMS Center. "They're fine until that money runs out," she said.
Fresno County used more than $1 million in funds from the Mental Health Services Act, a 1% tax on millionaires, to open programs at the Deran Koligian center, United and Valley Health Team.
The county allocates $471,418 annually to United's program and $301,398 to Valley Health Team.
The budget for the Deran Koligian center is $301,871 a year, which covers the cost for the psychiatrists. The county transferred care managers from other programs to the health center instead of creating new positions.
Oldham said eventually a method for billing Medi-Cal will be developed. Now, services are not billed because the program is so new and the state has yet to create a streamlined billing process, he said. For now, the county is covering costs with the Mental Health Service Act allocation.
With Medi-Cal payments, the program should be self-sustaining, Oldham said. And by integrating primary care and mental health, there could be cost savings. Over the long run, medical problems are more apt to be controlled and less costly when mental health issues are addressed, he said.
Studies show patients with chronic illnesses, such as heart disease and diabetes, are more likely to suffer from anxiety and depression than the general population.
And according to a 2002 AIMS study that looked at health-care costs over a four-year period, older adults with depression who were treated in an integrated mental health program had annual medical costs that were about $3,300 lower on average than for other patients. And diabetic patients in the program also had lower total health-care costs over a two-year period.
So far, the integrated programs in the Valley have been well received by patients.
Antunez, the Deran Koligian patient, said having primary care and mental health appointments at the health center "is easy for me. I thought I would have to go somewhere else for help." She doesn't have her own transportation.
Integrating mental health care and primary care makes sense on several fronts, Hersevoort said. "It's better care. It costs less. Patients are happier. Doctors are happier. So there's no down side — except it's hard to set up."
The reporter can be reached at (559) 441-6310, firstname.lastname@example.org or @beehealthwriter on Twitter.