Editor’s note: This is the second of a two-part series examining the shortage of mental health care in Hawaii. It’s part of an ongoing initiative to look more closely at problems faced by those suffering from mental illness here and possible solutions. Read Part 1 here.

For months the woman had been sleepless and aggravated. There were intruders in her home — she was sure of it.

But during a routine phone call with a social worker, the woman refused to modify her prescription drug treatment.

“All you guys want to do is mess with my life and adjust my medication,” she said.

The phone call abruptly ended.

A day later, psychiatrist Stephen Kemble sat across the table from the woman’s social worker, who recounted the details of the phone call and the woman’s gradual slip into a mania.

Kemble rendered his verdict: “Well, she’s correct that we would like to adjust her medication — but not if it’s going to be at the expense of her stopping contact with all of us,” he said, logging his advice to the woman’s primary care doctor in her electronic record.

“So I think we just need to keep being gentle and maintain the relationship.”

For people in Hawaii with mental illness, it can be difficult — sometimes impossible — to secure a timely appointment with a psychiatrist. 

Nearly 57 percent of American adults with mental health disorders receive no treatment. In Hawaii, the situation is even worse. A 2017 access-to-care study ranks the islands second-to-last in the nation, with 66 percent of adults with mental health disorders failing to receive treatment.

Barriers to patient access to psychiatric care include Hawaii’s rural geography, a statewide shortage of psychiatrists and the stigma of mental illness.

So last year the Queen’s Clinically Integrated Physician Network launched a new, integrated style of health care. The first of its kind in Hawaii, Queen’s collaborative care model multiplies tenfold a psychiatrist’s capacity to consult with patients. 

With collaborative care, the patient gets expert psychiatric care without ever having to step inside the office of a psychiatrist. Primary care doctors get the support they need to confidently treat their patient’s mental illness. And the psychiatrist gains satisfaction by working a model that allows them to reach more patients.

Holding it all together are social workers, who act as go-betweens for the psychiatrist, primary care doctor and patient. 

On a recent morning, the manager of Queen’s new coordinated care model allowed a reporter and photographer in the room for a regular meeting between Kemble and a pair of social workers during which they discuss patients’ progress, examine treatment options and make recommendations to primary care physicians. Civil Beat is withholding identifying details to protect patient privacy.

The woman described at the beginning of this story does not acknowledge her bipolar disorder. She won’t see a psychiatrist. But her primary care doctor, under Kemble’s guidance, prescribes medication for her anxiety and depression. She agrees to take it.

When she’s having a depressive episode, the drugs fend off sluggishness and feelings of sadness.

But when she’s manic, the treatment has an opposite effect, intensifying her symptoms of paranoia, irritability, impulsivity and restlessness.

It’s the latter scenario that the woman’s doctor, working in tandem with Kemble and a social worker, is currently trying to manage.

Bipolar disorder that is not well-controlled is beyond the intended scope of collaborative care. But when there is no other treatment option, the program takes on the patient.

“At least she’s taking something, and maybe this episode will soon pass,” Kemble said. “Manic episodes don’t last forever and if we can get through it without burning bridges, hopefully in the long run we’ll be able to get a little more effective in getting her to take adequate medicine.”

Expansion Plans

The collaborative care model was developed at the Advancing Integrated Mental Health Solutions Center at the University of Washington.

Queen’s adopted the model in July 2017, launching a pilot program with 19 patients.

The goal is to boost patient access to quality care by assisting primary care physicians in treating mild to moderate mental health disorders, including depression, ADHD, anxiety, post-traumatic stress disorder and stable bipolar or schizophrenia.

It works like this: Queen’s contracts with Kemble and another psychiatrist to assist primary care doctors in treating patients with mental illness. A pair of social workers interact by phone or in person with the doctors and their patients who’ve been accepted into the program. During a weekly two-hour meeting, the social workers present the patient cases to the psychiatrists.

It takes the psychiatrists 10 minutes or less to execute a patient consult. The psychiatrists log their treatment recommendations in the patient’s electronic file, giving the primary care doctor the confidence to carry out the treatment.

The psychiatrists and social workers are immediately available to take phone calls from the patient or primary care physician in response to a crisis.

As people stabilize, they fall off the active case list. If they later develop a side effect or new symptom, their case becomes active again.

The model is available to Queen’s interisland network of about 300 primary care physicians. Plans are already in the works to expand outside the network.

“Treating the patient right in the family physician’s office is better than giving the patient a piece of paper and sending them across town to the psychiatrist’s office, where maybe they are worried about someone they know seeing them walk into the office,” said Jeffery Akaka, an executive member of the Hawaii Psychiatric Medical Association who helped bring the collaborative care model to Queen’s.

“For one, you don’t have to tell your painful story all over again to a stranger who you’re worried might think you’re a kook.”

The program has about 45 active patients. About 56 percent of them are insured by Medicaid or Medicare.

Dan Morgann, an internal medicine doctor in Honolulu, described the program as “incredibly effective,” for its ability to provide fast support to doctors and patients.

“What I think we’re starting to understand fundamentally in medicine is, in the end, we want the patient to be part of the team and engaged,” Morgann said.

Cost Effective — And The Right Thing To Do

Queen’s considers its fledgling collaborative care model a success. Now it’s Mia Taylor’s job to figure out how to keep paying for it. 

Since the psychiatrist doesn’t see the patient face-to-face, they aren’t eligible for payment by most insurance companies, said Taylor, Queen’s manager of clinical programs.

Medicare offers a unique billing mechanism for collaborative care, and it works well in some larger practices on the mainland, Taylor said. But in Hawaii, where solo practitioners make up a huge chunk of the physician network, it’s just not viable.

The cost — the equivalent of one full-time social worker and two contracted psychiatrists — is about $150,000, Taylor said. For now, Queen’s is committed to funding and growing the initiative.

For one, the model is “the right thing to do,” in that it expands patient access to quality care, Taylor said. But it’s also cost-effective. The collaborative care model saves up to $6 for every $1 spent, according to a University of Washington study on the long-term cost effects of collaborative care for late-life depression.

Working with Hawaii Medicaid Director Judy Mohr Peterson, Taylor said she is exploring whether it’s feasible to include collaborative care as a business model in the next Med-QUEST contract.

“It’s a model that we all want to see work,” Peterson said. “But it’s also not a model that the health care system knows how to provide good financial incentives for. We really divvy up the body — we chop the head off from the rest of the body in how we think about our health. That’s really not useful because we know there are profound connections between our mental health and the rest of our physical health.”

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