08/16/2012

ODMH Medical Director, Mark Hurst, MD's Insight

OPPA newsletter editor, Molly McVoy, MD, sat down recently to pose some questions to Mark Hurst, MD, who was named medical director for the Ohio Department of Mental Health (ODMH) in February of this year. In this role, Dr. Hurst provides leadership and clinical oversight to the medical staff at Ohio’s state psychiatric facilities. 

OPPA:  What do you see as your top priorities in your role as medical director for ODMH?

Hurst:  In my career, I have done clinical and administrative work in private, public and academic settings.  In these various capacities, it has been very evident that great gaps of awareness exist among the various sectors, and even within different aspects of the same sector. These gaps can be divisive. They do not serve our field well and more importantly do not serve our patients well.  I would like for us to close these gaps and encourage increased partnerships which share our expertise and better meet the needs of those we serve. The challenges that we face are enormous.  We must marshal our efforts appropriately as partners to assure that individuals with mental illness benefit from our collective knowledge as private, public and academic psychiatrists, as well as the knowledge and experience of primary care physicians, other medical specialists and our non-psychiatrist mental health colleagues.

There are numerous specific areas that we need to work on in coming years—too many to mention here--but a few include improving access to treatment for all individuals with mental illness, especially children and adolescents. When children who do not receive needed treatment early on, it perpetuates problems that affect them, their families and the community for decades. If we don’t do it then, we have missed an opportunity that may never again present itself.

We need to increase the integration of mental health services with other medical services (including addiction treatment), and break down the artificial silos that have served our patients poorly. Trauma informed care is an important part of this integration, as we now understand that trauma is a causative factor in the development of mental illness, addiction and other medical disorders. More importantly we need to focus on the prevention of trauma.  Prevention is always better than treatment!

Finally, the worst outcome that we face in psychiatry is suicide.  Each year we lose over 30,000 people in the United States to suicide, with their loss affectingtheir loved ones for the remainder of their lives.  We need to better apply the knowledge that we have and advance that knowledge to decrease the occurrence of this tragedy.

OPPA:  What are the major challenges psychiatrists in Ohio will face in the next several years?  What suggestions do you and/or ODMH have for facing these challenges?

Hurst:  I wish that I could accurately predict the future in this area. One of the major challenges that all of us can see is the increasing demand for psychiatric services with an inadequate number of psychiatrists. Psychiatry is not a popular residency choice and it appears that even if all residency slots were filled, the gap would still exist. We need to help trainees see the appeal of psychiatry. 

Unfortunately, our isolation from other medical colleagues has not helped in our recruitment efforts and has frequently not served patients well. I would anticipate that in the next few years, there will be increasing demand for primary care-psychiatry collaboration, with more psychiatrists being imbedded in primary care practices in both the private and public sector. I am excited about this opportunity, as it should increase access for individuals struggling with psychiatric disorders, decrease stigma and improve outcomes. We also need to look at creative ways to promote this collaboration. The increased use of technology and can allow collaboration in many new and different ways and improve access in previously unserved or underserved areas.

One initiative of the department in this area is “”Health Homes.” This project provides for integrated psychiatric and behavioral healthcare for both adults and children with severe mental disorders and could apply to over 150,000 Ohioans.  The first of these Health Homes will be opening this October in Butler, Adams, Scioto, Lawrence and Lucas counties. The remaining counties will be phased in, with all 88 counties providing the service by next July.

In collaboration with community partners, including OPPA, we are also actively pursuing telepsychiatry and examining its current application, future promise, and barriers to implementation. We need to work together to figure out how we can effectively utilize technology to better meet patient needs, while not losing the critical highly personalized aspects of the care we provide.

OPPA:  How do you see mental health changing with the Supreme Court's decision related to the Affordable Care Act?

Hurst:  Despite the recent decision, I am sure we haven’t heard the last word on the Affordable Care Act. As psychiatrists, we have known for many years that treatment of psychiatric disorders not only yields good clinical results, it yields good financial results. “Behavioral Health Care IS Health Care” is an important phrase and speaks to the “big picture” view of health care is that evolving. The Office of Health Transformation in Ohio has taken this “big picture” view, and mental health is at the table for all major initiatives. In my first week as ODMH Medical Director, I was invited to a meeting on “Strong Start”which is an effort to decrease low-birth weight infants. When we consider the increased rate of LBW infants in mothers with mental illness and substance dependence and the impact that appropriate identification and treatment could have, it is obvious that the involvement of mental health is essential. Parity legislation, coupled with new health initiatives carries the potential to help mentally ill patients substantially.

OPPA:  How do you see psychiatry participating in the push for integrated care?

Hurst:  We need to embrace it.  As psychiatrists, we are uniquely qualified to not only participate in this effort, but to lead it.  We are physicians first, and psychiatrists second.  The psychiatrist is uniquely qualified to understand the physical, psychological and social needs of patients, and lead teams that promote quality integrated care.

OPPA:  Access to inpatient psychiatry, and child psychiatry beds in particular, continues to be a major problem for Ohioans. What plans does ODMH have to address this in the future?

Hurst:  Access issues are not confined to inpatient, as access to outpatient and crisis resources are necessary parts of an overall system of care that promotes mental health recovery. This is one of the areas where collaboration between private and public sector is essential for success. ODMH has actively encouraged collaboration between the state regional psychiatric hospitals, the private hospitals in those regions, community providers, boards and crisis services to come up with local plans to address issues of access to services. Earlier in 2012, ODMH made money available to these collaborative areas to be utilized to meet the unique needs of each region. Some regions have chosen to use this funding to expand crisis services to help avert hospitalization and improve access for those who require an inpatient level of care.

OPPA:  What plans does ODMH have to address mental health issues in both adults and juveniles in the justice system?

Hurst:  Needless to say, we want to avoid the criminalization of mental illness.  Unfortunately, some individuals with mental illness do end up in the criminal justice system, and while there we want to be sure that they receive competent and appropriate treatment.

ODMH does not have direct oversight of individuals in the adult or juvenile justice systems, but we are active partners with the Ohio Department of Rehabilitation and Corrections (DRC) and the Ohio Department of Youth Services (DYS) in addressing the needs of mentally ill individuals in these systems.  We participated in the development of the recent ODRC plan to expand medication availability to released mentally ill inmates from 14 to 90 days and have liaisons in place throughout DRC to assure that individuals with mental illness have appointments at mental health facilities upon release. DYS is actively examining the most efficient way to provide mental health treatment for individuals in their system, particularly those with severe emotional disorders and we have been collaborating with them as well as with the other human service departments in this effort.

Local and county jails present unique issues.  In many of the rural counties, access to psychiatry is difficult at best. We have been actively working with the Buckeye Sheriffs Association on this and while it is unlikely that there will be a “one size fits all” approach, we are discussing various ways to improve the timeliness and completeness of services in counties throughout the state. Telemedicine is one way we might be able to do this. The Sheriffs are very interested in this issue and have been great partners in trying to be sure that mentally ill individuals in their jails get what they need, even in the face of limited resources. OPPA council has indicated a desire to assist in this area. This is much appreciated, and is the kind of collaboration we need to meet the needs of Ohio’s mentally ill individuals.

OPPA:  Recruitment into psychiatry and child psychiatry, in particular, is an ongoing issue. What suggestions might you have for improving recruitment into our field?

Hurst:  This is a long process and unfortunately, even our best efforts won’t resolve the problem quickly. Only a small number of medical students are attracted to psychiatry, and we need to do our best to show them that it is a dynamic and fulfilling medical specialty. Unfortunately, not only are psychiatric patients stigmatized, so are psychiatrists. We need to be certain that we remain active with the rest of medicine and provide valuable service to our common patients to help increase our exposure and our regard. Taking an active role in integrated care initiatives is a great place for this to start.

Finances are also a real issue with recruitment into our field. Average medical student debt exceeds $100,000 at graduation and for some individuals approaches $300,000, so it becomes obvious why a person with interest in our field (or primary care for that matter), might be dissuaded from it. That’s a real shame. 

Fortunately, new programs now exist which can assist financially. Some medical schools have utilized MEDTAPP grants to offset medical school tuition for students and residents who commit to public psychiatry and that helps. Loan repayment opportunities are increasingly offered in both the private and public sectors.

Much of this falls on us as psychiatrists—we need to project the value of psychiatry to our students and our peers and need to participate in medical education to help demonstrate this. If a student enjoys relationships with patients and wants to be able to help them as they experience life’s joys and challenges, there is no better field. I am proud to be a physician who specializes in psychiatry and subspecializes in addiction psychiatry. If you feel the same—let students know. You might just lead them to a rewarding career that they hadn’t considered!

Finally, I would like to thank Karen Jacobs for inviting me to the OPPA council meeting in June and to Molly McVoy for asking me to participate in this interview.  I look forward to working with all of my colleagues to help provide better treatment to our patients in years to come.

Dr. Hurst has been with ODMH since 1993, when he served as psychopharmacology assistant. He then worked in the addiction services of ODMH and took on many leadership positions in both psychiatry and addiction before taking on the role of medical director.