A sign at the nurses’ station at South Nassau Family Medicine Center reads "Go Get Dr. Cavera!" It’s an enthusiastic reminder for the medical staff to tap the expertise of clinical health psychologist Robert Cavera, PsyD. Though he joined the practice only two years ago, patient data from the center have shown that his expertise is improving care and outcomes, whether it’s by his working with a patient in a mental health crisis, advising one who needs behavioral insights for complying with a medication regimen or referring another to the nearby counseling center for longer-term mental health treatment.
"Rob has been such a great asset to our team here," says Joyce Robert, MD, an attending physician in the practice and director of performance improvement at the center, located in Oceanside, New York. "When we have 20 patients in the waiting room, it’s nice to have an expert in behavioral health on-site who can take additional time with patients who might need more mental health support than I can provide."
Patient data show how much of a difference Cavera has made. In 2015, the year Cavera joined the center, physicians referred 19 patients to outpatient counseling. In 2016, Cavera’s first full year on staff, he referred 99 patients for outpatient counseling, with 60 percent of them following through, according to Janet Kahn-Scolaro, LCSW, PhD, administrative director of integrated behavioral health and family medicine at South Nassau Communities Hospital, the Oceanside center’s institutional partner. That’s a more than 420 percent increase in referrals and a clear sign that more patients are getting needed services from their physician rather than the emergency room, Kahn-Scolaro says.
"Our goal is to make sure that patients get what they need in the community, rather than at the hospital," she says. "The integration of services plays a significant role in this, as the patients seen in family medicine and behavioral health have coordinated care that helps them avoid emergencies."
Meeting community needs
Located on Long Island, the center accommodates about 21,000 visits each year from a socioeconomic mix of patients. Some patients are upper middle class and relatively healthy, but many are low-income and ethnic-minority patients, including a high percentage of Latino adults who are uninsured or underinsured and dealing with chronic medical diseases and co-morbidities, including diabetes and heart disease as well as anxiety, depression and trauma.
Several years ago, the South Nassau Communities Hospital noticed that many patients were coming to both the family medicine center and the hospital’s mental health counseling center for treatment, but coordinating care between the two facilities to ensure patients weren’t falling through the cracks proved difficult, Kahn-Scolaro says.
Dr. Robert Cavera spends his days in what he terms "all-day on-call mode," pulled into appointments on an as-needed basis by physicians and residents to provide brief mental health assessments and consultations to patients.
Cavera, whose training in school and community psychology had provided him with an expertise in mental health consultations, jumped at Kahn-Scolaro’s idea to establish a pilot program in which a psychologist would work right onsite in the Ocean-side family medicine practice, both to increase the referral stream and improve patient care. He’d already spent several years on the staff at the hospital’s mental health counseling center, so he was familiar with the patient base and the issues many of them face.
Cavera spends his days at Oceanside in what he terms "all-day on-call mode," pulled into appointments on an as-needed basis by physicians and medical residents to provide brief mental health assessments and consultations to patients. "It took our physicians a little while to understand how best to utilize Rob’s expertise, but now that he’s been here a few years, when he’s not here one day, everyone around the office goes around saying, ‘I wish Dr. Cavera was here today because I really have a case I could use his help with,’" Kahn-Scolaro says.
Perhaps one of his most far-reaching interventions since joining the center is ensuring that all patients are screened for depression and trauma through a simple intake form. "We are definitely all catching more patients who might be right at the border or needing services due to the screenings," Robert says.
Cavera will consult with patients who screen positive for these symptoms, or any patient who a physician feels might need mental health treatment, then facilitate a referral to the hospital’s mental health center for longer-term counseling for conditions such as anxiety, depression or schizophrenia. He then provides an in-person handoff to help boost follow-through with referrals.
"I’ll often walk over and meet with patients I refer when they come for their first visit, to introduce them to their counselor. This way we’re providing not just a warm handoff, but more like a warm hug, to help patients feel more comfortable," Cavera says.
Cavera also works directly with patients who have co-morbid psychiatric and medical illnesses and those with solely medical ailments, such as uncontrolled diabetes and hypertension. A lot of this work is cognitive-behavior focused, helping patients set realistic goals for themselves in terms of nutrition, exercise, stress reduction and smoking cessation.
"I listen to their concerns and then give them really concrete things they can do—baby steps, so to speak," he says. In the case of very sedentary patients with uncontrolled diabetes, for example, Cavera encourages them to walk around the block once a week, then twice a week. He also coaches them on how to prepare their foods in healthier ways or asks them if there is one small unhealthy habit they could change in their diets. "That’s something they might not get in a 15-minute appointment with their physician, who has told them they simply need to lose weight," Cavera says.
Coordinated care
Cavera also participates in the morning huddles held by the center’s medical treatment team to discuss the day’s most high-risk patients, for whom consultation or quick follow-ups—from Cavera or any of the other specialists—might be needed. If a patient he’s provided mental health support to in the past is scheduled to come in for a medical follow-up, for example, Cavera makes a concerted effort to also see the patient to check in.
The team also works together to address the needs of patients with depression and uncontrolled diabetes. Several studies have found that people with diabetes have a greater risk of depression than those without the disease (Diabetes Careopens in new window, Vol. 31, No. 1, 2008). Depression can also make it harder to practice good diabetes self-care, so treating the depression with cognitive behavioral therapy can make a big difference in these patients’ health outcomes and overall treatment costs.
Last year, the practice randomly enrolled 25 patients with both conditions into a trial program that provided ongoing team-based medical treatment, nutrition education and mental health support from Cavera, as well as any specialty care that might be warranted, including podiatry and endocrinology. After six months, these patients reported reduced levels of depression, and blood work showed improved hemoglobin A1C, a measure of a patient’s average blood sugar level over two to three months. "This has shown us how connected one ailment is to the other, and how working on both is likely to improve the overall health of the patient," Cavera says.
Cavera’s presence also helps the medical residents gain a better understanding of the psychiatric and psychosocial aspects of their patients’ illnesses.
"Rob provides real-time, on-the-spot education in differential diagnosis, motivational interviewing and information on who needs to be referred and who really shouldn’t be referred—patients he can handle right there," Kahn-Scolaro says.
Cavera’s influence seems to stick with the new doctors, he says. Last year, for example, he was treating a patient with hypertension and intense anxiety alongside a resident. After speaking with the patient, he had both the patient and the resident do a brief mindfulness/deep-breathing exercise. "The patient reported feeling much better afterwards, and it has made a huge difference in terms of helping to manage her anxiety and her hypertension," he says.
The resident also told Cavera how relaxed and less stressed she felt after the exercise as well.
"My work on this team is helping challenge the way physicians and other medical staff think, and increasing their willingness and confidence to think outside of the box," he says.
The Monitor’s "Adventures in Integrated Care" series explores the work psychologists are doing as members of interdisciplinary teams. If you have a story to share, contact editor Sara Martin at smartin@apa.org.
