FEATURE ARTICLE
A Family Physician’s Perspective on
Integrated Behavioral Health
By Walt Mills, MD
About one-third of Sonoma County’s primary care physicians (including almost 100 at Kaiser and more than 50 at community clinics) already practice in environments that embrace Integrated Behavioral Health. This integration of primary care and mental health is closely tied to the concept of the Patient-Centered Medical Home.
Last year, four national organizations representing more than 330,000 primary care physicians agreed on the following principles of the medical home:[1]
Personal physician. Each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care.
Physician-directed medical practice. The personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients.
Whole person orientation. The personal physician is responsible for providing for all the patient’s health care needs or for appropriately arranging care with other qualified professionals.
Care is coordinated or integrated across all elements of the complex health care system and the patient’s community.
At a presentation in Santa Rosa earlier this year, Dr. Rich Roberts, president-elect of the World Organization of Family Physicians, emphasized the prevalence of mental health comorbidities for those who have chronic, complex, expensive conditions. He noted that, “Disease management and chronic-care management focus primarily on biomedical illness, not the whole person. Integrating behavioral health into primary care practice offers potential to provide intensive care management, improve outcomes and satisfaction, and reduce costs.”[2]
Studies show that 30% to 75% of patients seen by primary care physicians need mental health services.[3] You might be thinking of the “traditional” psychiatric diagnoses, like anxiety, depression, or bipolar disorders; but consider this partial list of simple issues that trouble patients in our offices who don’t carry a psychiatric diagnosis (yet): tobacco cessation, weight management, sleep disorders, relationship stress, chronic pain, chronic illness, alcohol and chemical dependency. Now broaden the list to include postpartum issues, parenting of children, and coping with death and dying. In any day where a primary care physician sees 20-25 patients, how many don’t have at least one or more of these or related issues?
Many patients are capable of behavior change if a clinician “problem solves” with them, but this takes time and skill. How much time? Some estimates find it would take a primary care physician more than 20 hours per day! No wonder things aren’t working.
Proponents of integrated behavioral health (IBH) recognize that many patients seen by a primary care physician have mental health and/or chemical dependency disorders. They also note that psychiatric medications are laden with medically significant side effects, and that people with serious mental illness have much higher incidence of diabetes, heart disease and cancer, often living a decade less than people without mental illness.
About 10 years ago, Kaiser Permanente launched its first IBH programs. At Kaiser Santa Rosa, each physical “module” of about a dozen primary care physicians works with one behavioral health consultant, who is located in or near the module.
What is it like to practice IBH in my Kaiser module? Consider the story of “Mary,” a middle-aged recent divorcee whose chief complaint was fatigue and poor sleep. After obtaining the appropriate exam and ordering labs, I advised Mary that stress was a likely underlying cause for her symptoms, and she agreed to investigate this diagnosis further.
Using our e-consult system, I booked Mary an appointment with Carol, my behavioral health consultant, for two days later. I printed up the appointment with the location (20 yards down the hallway) and phone number. When Mary arrived for the appointment, Carol had all the health records available in our electronic health record, as well as the specifics of the appointment from my description in the e-consult.
Carol did a behavioral health intake, with Mary scoring in mild depression range on the Patient Health Questionnaire. Mary received information on the symptoms, causes and possible treatments for depression; some initial self-management prescriptions (exercise, nutrition); and a referral to the Health Education Library across the hall for the Feeling Good Handbook. She also signed up for a psycho-educational program on depression. Carol arranged for a phone follow-up in a few days, and a return appointment in two weeks. She also sent me her notes on the visit. I saw Mary a month later. She had already received a copy of her labs electronically and had sent me a note stating that she was feeling a bit better and thought she was on the right track.
For patients who need more timely care, I use a “warm handoff” by walking the patient from my office to Carol’s and introducing them. Carol will either fit the patient in right then or arrange for a visit in the next 24 hours. Depending on the circumstances, Carol will then arrange for a psychiatric referral, call me directly, or leave me a voice message with recommendations. Communication is coordinated and timely in both directions. Unlike traditional psychiatric care, Carol and I work on the same team, and the medical record is shared as it would be with other specialists. This sharing eliminates the dilemma that many primary care physicians face when trying to elicit mental health information needed for care coordination.
The Santa Rosa Family Residency—where I am the associate program director—recently became affiliated with the Southwest Community Health Center. Our family medicine residents now have access to Southwest’s new IBH program. The program features “on-call” times with a psychologist available for warm handoffs at the end of every half-day. Two drop-in clinics at the Southwest Center’s Lombardi facility and another drop-in group at the residency’s Chanate facility also improve access. More counselors and predoctoral psychology interns will be added this summer.
If this projected model works, most patients seen in the Chanate Family Practice Clinic will get warm handoffs from their family medicine residents on the same day of their medical visit. Others will be able to attend a drop-in clinic with a psychologist or psychiatrist within the same week. Both efforts will dramatically increase those patients’ access to mental health services.
There are systemic obstacles to IBH that any physician would recognize: work pace; demand for multiple services at the same visit; unmanageable panel size; lack of behavioral health care appointment access; heterogeneity of populations, with attendant linguistic and cultural challenges; high physical and/or psychiatric acuity with multiple problems; and inadequate numbers of those trained to provide integrated behavioral health services.
This last point warrants discussion. IBH is not just about proximity of services. It is a unique model with new skill sets required of both physicians and behavioral health consultants. Physicians, for example, need to follow guidelines for types of patients to refer to IBH; use scripts to minimize patient refusals; integrate the behavioral health consultant’s feedback into a team-based biopsychosocial care plan; co-manage patients with a behavioral health team member; and promote population management strategies for patients with mental/addictive disorders.
Physicians need training to “sell” patients on the IBH model. The warm handoff may be the preferred strategy to maximize the teachable moment, but it takes time. Yes, the behavioral health consultant may “leverage” adherence, but forming the written/curbside request before the visit takes more effort than just giving the patient the name of a counselor and leaving it up to the patient. Brief regular meetings with behavioral health consultants improve effectiveness, but they take effort to coordinate. Finally, in many practices the lack of electronic health records impedes coordination and communication.
Several studies have shown that IBH improves health outcomes, patient and provider satisfaction, and reduces costs. For example, Community Care of North Carolina used an IBH model to provide medical homes for 750,000 Medicaid patients, leading to a $250 million savings in 2005, with better medical and mental health outcomes.[4]
If IBH is used to augment rather than replace traditional psychiatric services, there are few disadvantages. Mental health issues can be better managed in a patient-centered medical home than in traditional, fragmented specialty programs. For patients with serious mental illness or other nuances, customized psychiatric care is needed, but again as an extension of a medical home.
Most psychotropic medications are already prescribed by primary care physicians, not psychiatrists.[3] Given the enhanced coordination of care with psychiatry consultants, IBH should improve the effective use of pharmacotherapy. Many physicians in IBH programs report increased comfort in managing medications, though patients with serious mental illness usually still require the care of a psychiatrist and, ideally, sophisticated case managers.
One resource for physicians interested in IBH is the Redwood Community Health Coalition, which is hosting a series of workshops for family doctors and other primary care providers. The goals of the training are to:
- Increase access to culturally competent and integrated mental, behavioral and primary health care services.
- Reduce stigma and disparities in access to early mental health screenings and interventions.
- Strengthen active mental and behavioral health prevention services at community health centers.
For more information on the workshops, contact Pedro Toledo at ptoledo@rchc.net or 542-7242, Ext. 17.
In conclusion, it seems that integrated behavioral health has reached its tipping point. From a primary care perspective, IBH will be a welcome transformation.
E-mail: walter.w.mills@kp.org
References
- American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Osteopathic Association, “Joint principles of the patient-centered medical home,” www.medicalhomeinfo.org (2007).
- Roberts R, “Future of primary care in Sonoma County,” plenary address (10 Jan., 2008).
- Strosahl K, “Integrated primary care: From theory to the exam room,” Primary Care Behavioral Health Webcast, Mountainview Consulting Group.
- Arvantes J, “North Carolina seeks expansion of primary care program,” AAFP News Now (8 Aug 2007).
Dr. Mills is assistant chief of family medicine at Kaiser Santa Rosa.
