Behavioral Health Integration
Wednesday, August 6, 2014
Posted by: Joy Ingram
By Kirk Strosahl, PhD, Behavioral Health Consultant, Community Health of Central WA, and Patricia Robinson, PhD, Director of Training and Research, Mountainview Consulting Group
Practicing primary care providers as well as researchers have known for decades that primary care is the “de facto” mental health system in the United States and, for that matter, in almost all civilized countries throughout the world. We believe that the problem of skyrocketing health care costs is the direct result of time constraints on primary care providers that preclude their adequately addressing psychosocial factors of health. The consequence is that unrecognized and/or untreated psychosocial problems tend to worsen over time and create a revolving door situation that drives up unnecessary health care utilization and costs. Studies too numerous to mention suggest that as much as 25% of the ambulatory health care dollar in the US is squandered on this mismatch between what the patient is seeking, and what the health care center is able to provide.
Fortunately, there appears to be an end in sight for this multi-decade bleeding: It is called the Patient Centered Medical Home, or PCMH if you’re into acronyms. While there are many notable features of the PCMH approach, the one we are interested in has to do with the redesign of the primary care team to include some fresh new faces that should make a big difference in how psychosocial problems are addressed in daily practice. The PCMH approach places behavioral health clinicians and care coordinators in the midst of the primary care exam room action. Indeed, the level of conviction in this approach among funders and policy makers is so strong that HRSA Bureau of Primary Health Care is about to invest millions of dollars to help fund behavioral health integration programs in FQHCs across the country.
We call behavioral health integration the “heart” of the PCMH model because it is the most humane and effective way to address the psychological suffering of literally millions of people that do not have ready access to mental health care. Anyone familiar with the population served by community health centers knows that problems like depression, anxiety, drug and alcohol abuse, domestic violence, obesity, chronic pain and smoking (to name a few) are at near epidemic levels. These problems are present to one extent or another in nearly every medical visit, and their sheer volume requires us to think outside the box when designing a behavioral health integration program. In the next few sections, we want to address some of the most important ways that behavioral health integration in primary care will be different from the traditional approach followed in the mental health sector.
Population Vs Case-Based Care
When the prevalence of psychosocial problems approaches 50% or higher of the clinic population, as it does in community health centers, it makes no sense to adopt a specialist approach to mental health care. Instead, we must adopt a population health approach in which behavioral health services are delivered in a far more efficient fashion and where the emphasis is on immediate access to care and time-limited skill building interventions. This means we must embrace a “generalist” approach in which the “client” is the entire clinic population. The job of the PCMH behaviorist is to address the psychosocial needs of the entire clinic population, not just a select few who are lucky enough to receive specialized and intensive mental health treatment. This is a huge change from the case-based mentality of specialty mental health, where the focus of concern is on this particular client, without regard to other clients like this.
Primary Care Behavioral Health
The next big paradigm shift is to imagine what a primary care version of mental health care would look like. If we are going to put a behaviorist on the primary care team, then the behaviorist must function like a primary care provider. This means that patients must be able to access behavioral care at the point of service, and in real time rather than through an arm’s length referral to the behaviorist. This means “warm handoffs” from primary care provider to the behaviorist should be the typical way that care is accessed. To make this transition work, the behaviorist must do away with the traditional one-hour mental health appointment approach and go to a much more dynamic and brief intervention approach. For example, rather than having one hour appointments, the behaviorist should have 20-30 minute blocks that basically resemble the medical provider schedule. The behaviorist should have at least 50% of available appointment slots held open for same day handoffs. Rather than being secluded in some distant part of the medical clinic with a “do not disturb” sign on the door, the behaviorist is located centrally in the exam room area, and can be interrupted at any time with a service request from a primary care colleague.
Team Based Vs. Specialty Care
The reality is that even if a health center could hire multiple behaviorists, they would not be able to take care of the burden of psychosocial issues in general practice. These problems are far too prevalent to shift them over to a few behaviorists and expect them to go away. This means that the old model of “dump and refer” must give way to a more dynamic and collaborative arrangement between the behaviorist and the patient’s medical provider. To transition to a team-based model of integrative care requires that the behaviorist function as a “consultant” rather than as a “therapist.” In the consulting approach, responsibility for ongoing management of the patient’s psychosocial issues remains with the primary care provider. The consultant is called in to clarify diagnostic issues, make medication and behavioral treatment recommendations and to get the patient started in the right direction. Once this has been achieved, responsibility for the patients care is returned to the primary care provider. Remember, the consultant is present at all times and can be immediately accessed if a particular patient is starting to regress or is not making progress as expected.
The beauty of the consultant approach is that it allows a full time behavioral clinician to see 8-10 times the number of new patients yearly, by reducing the number of visits any one patient will require. Another cool feature is that a good behavioral health consultant, or BHC, will, over time, teach primary care providers the behavioral interventions skills they will need to address the needs of their own patients. Over time - and this outcome has been documented in numerous program evaluation studies of the Primary Care Behavioral Health Model - primary care providers develop more confidence in their intervention abilities and are less likely to just reach for the prescription pad because they don’t know what else to do.
The Future Is Now
Whereas even a decade ago talk of having a behaviorist (or two) placed on every primary care team in America was regarded as a pipe dream, today it is starting to emerge as a reality. Community health centers that are contemplating deploying behavioral clinicians on their primary care teams need to think long and hard about what model of service is actually going to work in the busy halls of the clinic. Rushing behavioral health providers into the clinic without thinking through the issues we have just highlighted is an invitation to disaster. On the other hand, advance planning based upon the principles of population health, with a focus on making behavioral health services instantly accessible at the point of service, will lead to a behavioral health integration that really works!
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