Adventures in Integrated Care
NOW THEY CAN’T
PRACTICE WITHOUT HIM
Just two years after integrating a psychologist into its
staff, this family medicine practice is reducing emergency
room visits and improving overall patient care
BY AMY NOVOTNEY
A
sign at the nurses’ sta-
tion at South Nassau
Family Medicine Cen-
ter reads “Go Get Dr. Cavera!”
It’s an enthusiastic reminder for
the medical staff to tap the exper-
tise 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 behav-
ioral 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 physi-
cian 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 behav-
ioral 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
60  M O N I TO R O N P S YC H O LO G Y
2018-05-Monitor.indb 60
patients to outpatient coun-
seling. In 2016, Cavera’s first
full year on staff, he referred 99
patients for outpatient coun-
seling, 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 s­ ervices 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 medi-
cine 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
● M AY 2 0 1 8
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 class and relatively healthy,
mental health
assessments and but many are low-income and
consultations to ethnic-minority patients, includ-
patients. ing a high percentage of Latino
adults who are uninsured or
underinsured and dealing with
chronic medical diseases and
co-morbidities, including diabe-
tes 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 med-
icine 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 diffi-
cult, Kahn-Scolaro says.
4/11/18 10:24 AM
 Cavera, whose training in
school and community psychol-
ogy had provided him with an
expertise in mental health consul-
tations, 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 men-
tal health counseling center, so
he was familiar with the patient
base and the issues many of
them face.
Cavera spends his days at
ROBERT ADAM MAYER
Oceanside in what he terms “all-
day on-call mode,” pulled into
appointments on an as-needed
2018-05-Monitor.indb 61
basis by physicians and medical
residents to provide brief mental
health assessments and con-
sultations 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 defi-
nitely all catching more patients
M O N I TO R O N P S YC H O LO G Y
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 treat-
ment, then facilitate a referral
to the hospital’s mental health
center for longer-term coun-
seling for conditions such as
anxiety, depression or schizo-
phrenia. 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 intro-
duce them to their counselor.
This way we’re providing not just
● M AY 2 0 1 8   6 1
4/11/18 10:24 AM
Adventures in Integrated Care
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 hyper-
tension. A lot of this work is
cognitive-behavior focused, help-
ing 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 treat-
ment 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
62  M O N I TO R O N P S YC H O LO G Y
to also see the patient to check in.
The team also works together
to address the needs of patients
with depression and uncon-
trolled diabetes. Several studies
have found that people with
diabetes have a greater risk of
depression than those without
the disease (Diabetes Care, Vol.
31, No. 1, 2008). Depression can
also make it harder to practice
good diabetes self-care, so treat-
ing the depression with cognitive
behavioral therapy can make a
big difference in these patients’
health outcomes and overall
treatment costs.
Last year, the practice ran-
domly 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 endocri-
nology. 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
● M AY 2 0 1 8
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 psy-
chiatric and psychosocial aspects
of their patients’ illnesses.
“Rob provides real-time,
on-the-spot education in dif-
ferential 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
Dr. Cavera meets to stick with the new doctors,
daily with medical he says. Last year, for example,
staff to discuss
high-risk patients. he was treating a patient with
hypertension and intense anx-
iety 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 phy-
sicians and other medical staff
think, and increasing their will-
ingness and confidence to think
outside of the box,” he says. ■
● The Monitor’s “Adventures in
ROBERT ADAM MAYER
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.