By LISA EISENHAUER
ST. LOUIS — When it became clear that the same population coming to Casa de Salud for medical care also needed better access to mental health care, the nonprofit's operators tried to stick with the care model that had made the clinic a success.
Sr. Michelle Salois, RSM, left, a clinical social worker, supervises therapists-in-training Katie Killeen and David Chism, as part of her work at the Mental Health Collaborative in midtown St. Louis. Sr. Salois and other therapists in the collaborative get free office space courtesy of the Casa de Salud medical clinic in return for providing care pro bono to immigrants in the St. Louis metro area.
Sid Hastings/©CHA
Under that model, clinicians volunteer their services and patients pay a flat fee that helps cover the cost of running the primary care clinic seven days a week. While the clinic accepts anyone as a patient, it was established in 2010 with a mission of providing health care to foreign-born residents of the St. Louis region.
Kate Koch, the clinic's vice president and chief operating officer, later sought out mental health therapists and counselors willing to volunteer at the clinic. That effort came up short and Koch suspects it was largely because the clinicians she contacted weren't making enough through their practices or salaries to slice off a chunk of time to donate.
Koch
So, Koch set up a new program called the Mental Health Collaborative that tapped the existing clinic's resources and added incentives for mental health providers — carrots that weren't needed on the medical side. Like the medical clinic, the collaborative provides back-office support, translators and case management for clients. Unlike the medical clinic, it offers therapists and counselors free office space for use with all their clients. In return, the care providers agree to reserve at least 25% of their caseload for referrals from Casa de Salud. Those clients pay on a sliding-fee scale of up to $20 per session.
The collaborative launched in February 2018. It now has partnerships with 17 mental health clinicians. In fiscal year 2019, those partners delivered 3,207 hours of therapy to clients referred by Casa de Salud. The average wait time for appointments for Casa de Salud clients, who had previously been referred to outside providers, was reduced from 18 months to 18 days.
"It's still a referral," Koch said of the program. "We just facilitate the access. That's our mission."
Caring for immigrants
The mental health offices are in a building next to Casa de Salud's medical clinic. The clinics are on the medical school campus of Saint Louis University, which provides the space as an in-kind donation. The location is within walking distance of SSM Health Saint Louis University Hospital. Casa de Salud's case management program refers patients to that and other SSM Health hospitals as well as to some hospitals that are part of the Mercy system.
Sr. Michelle Salois, RSM, counsels a client in her office at Casa de Salud in St. Louis. Sr. Salois operates Mercy Professional Services, one of 17 provider partners in the clinic's Mental Health Collaborative.
Sid Hastings/©CHA
Casa de Salud's budget of about $1.3 million covers care for a largely uninsured or underinsured and mostly immigrant clientele. Patients come from St. Louis city and county as well as several other counties in Missouri and Southern Illinois.
Casa de Salud is Spanish for House of Health and early on its patient population had been overwhelmingly Hispanic. But that has been changing; although still mostly Hispanic, its patients now come from about 70 nations. At the collaborative's offices, signs are in Spanish, Arabic — the second-most used language for clients — and braille.
Koch said studies have found that the immigrant and refugee population is particularly at risk of having suffered trauma. One study published in the July 19, 2018, International Migration Review and done by a researcher at the University of North Carolina and a researcher at the University of Washington pointed to rates of post-traumatic stress disorder of 19-54% among children and 14-19% among adults from war-torn areas, compared to 2-9% for the general population. The researchers found when "pre-migration poverty" combined with the stress of clandestine entry into the U.S., there also was an increased risk of PTSD.
Signs inside the Mental Care Collaborative's offices are in English, Spanish, Arabic and braille.
Language is not the only barrier for immigrants and refugees seeking mental health care. The immigrant population also tends to have uninsured rates that are much higher than for the general population, according to the Kaiser Family Foundation.
Casa de Salud's sliding scale fee structure addresses that hurdle and the agency contracts with and pays for interpreters who have training on mental health issues. It offers vouchers for reduced cost rides through Uber Health for both medical and mental health patients for whom transportation is a barrier.
Expanding the therapist pool
Sr. Michelle Salois, RSM, is a licensed clinical social worker and one of the Mental Health Collaborative's care providers. In fall 2018, Sr. Salois moved her practice, Mercy Professional Services, where she offers therapy as well as supervision for therapists-in-training, to the collaborative's office.
The collaborative's partners have access to seven counseling rooms with comfortable furnishings for therapists, clients and translators. The scheduling of appointments is done by Casa de Salud staff.
Before her move, Sr. Salois had tried to accept referrals to provide therapy to the immigrant community. Her efforts were stymied by logistics, particularly the need for a translator. "We could never get this to work, that the therapist and the interpreter would reach the client at the same time, to be able to schedule even a first session," she said.
Most of the therapists-in-training who Sr. Salois supervises are graduate students in need of clinical hours for professional certification. The collaborative lets Sr. Salois meet her pro bono requirement by offering therapy sessions from her trainees, which she tapes and then uses for instruction.
The collaborative also functions as an incubator space for licensed therapists and counselors who don't yet have the resources to start a practice on their own. "Casa is trying to promote the capacity in the community at large of therapists who know how to work with immigrants and non-English-speaking clients," Sr. Salois said.
Simplified access to care
Anne Hagen said the collaborative's setup makes it possible for her to maintain a practice where she also treats patients insured by Medicare and Medicaid. Like Sr. Salois, Hagen is a licensed clinical social worker and is happy to have her own practice yet be able to help Casa de Salud with its charitable mission.
"I love that Casa saw a need and said how do we fill this," Hagen said.
The matching of a client to a therapist who they see for the duration of their care is handled by Ben Zeno, Casa de Salud's mental health coordinator. His job also includes recruiting and working with the therapists. Zeno said that Casa de Salud surveys show that patients are grateful to have access to mental health care.
"We have heard from people that, unfortunately, they have had a lot of difficulty accessing mental health care elsewhere but they've had an easier time here in part because we just have one central intake line that they call and that gets them connected to up to 25 different therapists depending on their needs and their schedule," Zeno said.
Life stressors without borders
One of the clients who has gotten counseling through the Mental Health Collaborative called Casa de Salud for help shortly after graduating from college in 2017 with a degree in mechanical engineering. Just as he was struggling to sort out his career options while working in a high-stress restaurant job, his immigrant parents lost their jobs and abruptly decided to divorce, and one of his grandparents died.
"I was in a situation where I was in a bad mental health state and I was doing everything I could to look for support and therapy," said the 24-year-old, who was uninsured at the time.
Through Casa de Salud, he was matched with a therapist whom he met with regularly for about three months. "The visits to Casa were pretty key in bringing some structure to just me figuring out where I was and setting some concrete goals and working towards landing myself in a new situation," said the man, who asked to remain anonymous.
For Sr. Salois, the problems she sees among her Casa de Salud-referred clients are largely the same as those of her other clients, such as anxiety, depression and relationship issues. But the immigrant population she treats at the collaborative also struggles with high rates of trauma from situations in both the countries they left and in their new homeland as well as from social isolation and separation from families.
Without the Mental Health Collaborative, she said many of those immigrants might have no access to mental health care. "As a Sister of Mercy, one of our critical concerns is to care for migrants and the poor," she said. "This has really leveraged our role in being able to do that."