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Interview with Gerardo Rivera Torres, Psy.D., MS, M.P.H., HSP Senior Consultant in Integrated Mental Health, Clinical Psychologist, Subspecialist in Health Psychology and Geropsychology
The sustained increase in mental health conditions in Puerto Rico, where it is estimated that nearly 25% of the population presents some form of mental disorder or problematic substance use, has transformed the clinical and administrative operations of medical offices. Within the context of Plan Vital, administered by the Puerto Rico Health Insurance Administration, this situation requires more organized structures to sustain access, prevent operational disruptions, and comply with the integration model.
Dr. Gerardo Rivera Torres, Psy.D., MS, M.P.H., HSP, Senior Consultant in Integrated Mental Health, explained that historically mental health has been an overlooked and poorly understood issue. He mentioned that the most common disorders are anxiety (18%) and depression (10%), and noted that approximately 79% of patients with complaints associated with mental health are initially seen by primary care physicians. “This gives us a clear picture of the volume that offices manage on a daily basis,” he indicated, particularly in dual cases that include substance use disorders.
Rivera Torres noted that this increase impacts operations at multiple levels. The lack of adequate knowledge about mental health among both clinical and administrative staff generates tension and discomfort. When management is not integrated, overall health outcomes are affected, treatment adherence decreases, and costs increase due to high utilization, particularly in emergency rooms and medications for pain or sleep disorders. He added that fragmented management could be up to 50% more costly.
In addition, these patients require more time for care, which places pressure on physicians and makes efficient management of the professional team more difficult. This is compounded by staff burnout in response to psychosocial complexity, crisis episodes that require clear protocols, and financial impact due to lack of knowledge of appropriate billing procedures.
From an administrative perspective, the doctor noted that when referrals and follow-ups for mental health increase, the processes that are first affected are daily registration, the appointment calendar, including scheduled visits and walk-ins, accurate billing with CPT and ICD codes, and performance and quality metrics. Without a defined structure, the additional volume generated errors, delays, and operational overload.
To prevent this, the clinical psychologist emphasized the importance of clear protocols. Just as guidelines exist for complex physical conditions, specific processes must be established for mental health cases:
- Referrals to outpatient mental health or problematic substance use treatment in adult and pediatric populations.
- Identification of and referrals to partial or full psychiatric hospitalization.
- Activation of Law 408.
- Identification and management of suicidal ideation.
- Basic knowledge of psychopharmacology for primary care physicians.
Having these processes in place prevents improvisation and reduces the risk of adverse events.
The administrative team also requires preparation:
- Basic mental health training, such as Mental Health First Aid.
- Training in service billing, including CPT codes and common diagnoses.
- Creation of an updated directory of community mental health providers.
- Collaborative agreements with specialists and coordination with psychiatric hospitals for crisis situations.
- Designation of a case manager or patient navigator with knowledge of available resources.
The lack of organization, he warned, can become a barrier to access. Knowing the patient population, a principle of the Patient-Centered Medical Home model, allows the identification of those who require follow-up. When roles are not clearly defined, he noted, it generates lack of coordination and improvisation, which in the worst-case scenario can lead to a sentinel event.
Telemedicine also represents a strategic tool: appointment reminders, follow-up on studies, treatment adherence, optimization of operational workflows, management of prior authorizations and billing, communication among specialists, and remote monitoring. In addition, it facilitates the assignment of certain administrative tasks to remote staff, maximizing resources.
Under Plan Vital, Rivera Torres highlighted that one of the most common administrative errors is not having a co-located mental health provider. He explained that the integration model promoted by ASES seeks to incorporate services within the medical group, with designated hours based on the number of assigned lives. He also noted limitations when there is no updated directory of providers or a clear protocol for referral coordination. In the absence of an integrated professional, he recommended establishing collaborative agreements and partnerships with external providers.
To balance efficiency and empathy, he stated that this can be achieved through continuous education in culturally sensitive communication, management of stigma and bias, Mental Health First Aid, and Trauma-Informed Care. He noted that it is the responsibility of the management team to ensure that staff have these tools and that clear processes exist to provide quality care without sacrificing efficiency.
Finally, he recommended that before implementing adjustments, the medical office should accurately understand its patient population and needs. Based on that analysis, cost-effective solutions can be adopted:
- Partnerships with universities for internship programs in psychology or social work.Training staff as patient navigators.
- Establishing collaborative agreements with psychologists, psychiatrists, and psychiatric hospitals.
- Facilitating the exchange of clinical information while safeguarding confidentiality.
- Integrating screenings such as PHQ and GAD along with evaluation and progress notes into the medical record.
- Adopting a team-based care model, in which the physician leads a group that includes nursing and case management.
“If health is addressed as a whole, the structure of services must also respond to that vision,” concluded the clinical psychologist. 
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