Primary care physicians can join forces to provide these services.
Physical medicine may focus on the ills of the body, but behavioral and psychological issues are unavoidable for patients in any physician’s practice. In fact, primary care physicians provide half of all mental health services, and 92 percent in elderly populations, according to the World Health Organization.
To reduce some of the burdens of tending to both physical and mental health, shared or integrated behavioral health services may be key.
Patrice Whistler, MD, MPH, a pediatrician with Western Colorado Pediatric Associates, part of Primary Care Partners, in Grand Junction, Colo. has found that, “Seventy percent of your day has some psychiatry or psychology mixed into the basic functioning of every visit.”
Whistler has been using shared services in her practice for over 15 years, long before the concept of shared services became mainstream. In the early days, she would drive to the office of a local marriage and family therapist for an integrative visit, and the therapist would reciprocate.
Whistler and her partners tried other variations as well, including having therapists and psychiatrists come to their office to do intakes, but that became a billing challenge. The psychiatrists asked for 50 percent private pay for their Medicare patients, which wasn’t feasible.
Soon, she joined with several physician groups to create Primary Care Partners, and Young’s mental health care group moved into their building. Then, they applied for funding through an Assertive Community Treatment (ACT) grant, which offered seed money for “creative ways to have integrative visits,” she says.
Eventually, they brought on Raul De Villegas-Decker, PsyD, LCP, director of integrated behavioral services at Western Colorado Pediatric Partners, and one other full-time psychologist. Having De Villegas-Decker has made a huge difference, she says. “You feel you’re not drowning in life-changing psychological crises, which is basically everyday pediatric practice,” Whistler says.
She says that in almost every visit there’s a mental health component. For example, “A kid has a chronic life-threatening illness, or someone gets the HPV shot and can’t stop crying, or you have a postpartum mom who’s too depressed to feed her baby.”
With De Villegas-Decker on board, not only is there extra support for the physicians and other providers, but his presence allows for quick interventions in a crisis. Additionally, they can brainstorm difficult cases together.
This shared relationship can also improve care coordination, she says. “So if a patient goes into a crisis because they are suicidal, and then goes to the ER because there is no bed at the hospital, we can call our behavioral health folks to strategize what might happen.”
De Villegas-Decker knew when he joined the practice that he didn’t just want to create a behavioral health service but “an integrated culture,” he says.
Now, when there is evidence of a behavioral health issue at intake, he or the other full-time psychologist join the physician in the room with the patient, so the patient only has to describe what’s going on once, building upon the trust already established between patient and physician.
If the patient is new to the practice, De Villegas-Decker says, they introduce their team-based approach and identify who will participate in the patient’s care.
For patients who come in infrequently and/or have not established trust with their medical team, but would benefit from meeting with a behavioral health professional, De Villegas-Decker says that the nursing staff and/or medical providers engage in education and motivational interviewing to see if the family is open to having one of those individuals join the visit.
“It is very rare that a family will not accept a greet and meet opportunity,” he says.
The results have been remarkable, he says. “It has enhanced our team-based care, improved staff satisfaction and reduced some of the physician burnout because they had to take on so much previously,” he explains.
They’ve also noticed benefits to the patients. “It promotes health, helps with self-management and increases resiliency,” he says. Moreover, it helps their practice to address behavioral health needs sooner and with less stigma.
Whistler calls integrative behavioral health “transformational,” adding, “There are a billion things you can barely cover in sick and well visits, so it’s helpful to have a partner that can sometimes take over. You can’t do it alone.”
Additionally, she says, physicians tend to want to fix problems, while mental health practitioners understand that for behavioral health, the issues may be more complex and lack straightforward solutions. She gives the example of a father who keeps nagging his teenage son to get to school on time so he can graduate high school. “Raul would say, ‘Let him fail, there’s a point where you have to stop rescuing him.’”
De Villegas-Decker has also seen an unexpected benefit of their integrated approach-physicians have adopted some of the techniques used in behavioral health, such as motivated interviewing and coaching, allowing them to use these skills around such issues as anxiety, insomnia and bullying.
Most helpful to the practice, the psychologists’ presence can take burdens off the physicians. “Every medical condition has a behavioral health component,” De Villegas-Decker explains, “Even something as simple as taking your aspirin every day.”
Physicians, he says, are good at telling patients what and how to take their medications, but may not be able to determine why a patient isn’t complying. “We know how to figure that out. We can decrease the number of times a patient comes in to see a physician,” he says.
For other physicians looking to begin integrating behavioral health, Whistler recommends they first reach out to community and state based programs to find out what courses of action are possible.
Whistler co-authored a paper on integrating a behavioral health specialist into a physician practice. The authors describe five possible levels of integration:
Level 1: Minimal collaboration (referrals only),
Level 2: Collaboration at a distance (referrals and some direct communication),
Level 3: Basic on-site collaboration,
Level 4: Close collaboration in a partly integrated system,
Level 5: Close collaboration in a fully integrated system.
Whistler and her co-authors suggest that the most practical starting point is to create a collaboration where a behavioral health specialist enters into a contract with the practice for space and use of staff.
Every practice will have to find the method that works best for them, she says. If there is a mental health clinic in the same town, she recommends collaboration, perhaps trading clinicians for a few hours every week. However, as her practice has demonstrated, it can be worthwhile to bring in someone who can be physically present all the time. That’s up to the individual practice to decide.
Despite feeling as though they are always struggling to pay for their behavioral health program, Whistler says, “I don’t think I can go back to practicing without behavioral health.”