“Integration is in response to the fragmentation of health care. As individuals we are not fragmented, we are whole people. The current health care system does not recognize this. Integration is trying to fix a big problem, which is that we have two separate systems that take care of our health. Integration is a game changer for health care.”
Benjamin Miller, Psy.D., A Family Guide: Integrating Mental Health and Pediatric Primary Care
Behavioral health (BH) services are part of general medical services, but typically function in parallel, or even separately, from the rest of the medical field. There are many reasons for this, but there also are many benefits when integrating care. While integrating care may be challenging for professionals, it would provide significant benefits to patients with behavioral concerns—and professionals are likely to benefit as well.
Care integration between behavioral professionals
Even though psychiatrists, psychologists, chemical health specialists, and other BH professionals appear to have a lot in common, they traditionally have not excelled at coordinating care with each other. There are several possible reasons for this. There is a long-standing, significant shortage of psychiatrists. As a result, psychiatrists are extremely busy, and are likely to view coordination of care with psychotherapists as a lower priority than their many other pressing tasks.
Psychiatrists tend to come from training programs with relatively uniform training standards, while psychotherapists (psychologists [LP], marriage and family therapists [LMFT], social workers [LICSW], and mental health counselors [LPC and LPCC]) come from very diverse training programs, with a wide range in the quality of training standards, and little, or no, training in coordination of care. Psychiatric training programs routinely emphasize the importance of coordinating care with other medical professionals, but coordination often does not include psychotherapists. While many psychotherapy training programs now teach the benefits of coordination of care, the current ranks of psychotherapists include several generations for whom coordination of care is either a low priority or not part of their routine practice. In general, only recent graduates have had training that emphasizes the importance of coordinating care.
Since behavioral services often involve highly personal problems, many BH providers are highly sensitive to patient concerns about sharing personal information with others “outside” of the therapeutic relationship. Rather than categorically not sharing information, and therefore not coordinating care, the current thinking is that it is possible to work collaboratively with the patient to carefully select which information can be shared. This is a relatively new process that has not yet been adopted by many behavioral professionals.
How the patient benefits
There is an evolving understanding of how behavioral patients benefit from the coordination of care between psychiatrists, psychotherapists, and other BH specialists. Considerable research shows that medication can help behavioral patients, especially those with more severe and disruptive symptoms. Medication can have a wide range of effects, from simply making the patient more comfortable to reducing severe symptoms. Some patients even find that medication provides a cure for their behavioral problems (as long as care continues). For those patients in therapy who need medication, their psychotherapists must routinely coordinate services with the patient’s psychiatrist or other prescriber.
A recent and emerging body of research supports the benefits of psychotherapy services for most patients with behavioral problems, including both psychiatric and substance use issues. For example, behavioral patients who have received only medication may continue to have behavioral symptoms, and these patients often benefit from adding psychotherapy to their treatment plan. For some behavioral conditions the combination of medication and psychotherapy has been established to be more effective than medication alone, sometimes providing faster, broader, or more durable benefits.
Psychotherapists typically have more time to spend with their patients than psychiatrists, and that enables them to develop a higher level of rapport, obtain more detailed information, and evoke questions and concerns that the patient has about their behavioral treatment plan. Psychotherapists have specialized training and skills that enable them to provide illness education and address behavioral treatment compliance concerns. Psychotherapists also may be the first professionals to recognize the patient’s response to medication therapy, by identifying side effects as well as benefits.
It is in the patient’s best interest for psychiatrists to routinely discuss the potential benefits of seeing a psychotherapist, and to coordinate services with psychotherapists and substance abuse colleagues. In addition, psychiatrists with full schedules could potentially partner with behavioral colleagues who could see new patients while they wait for the intake appointment with their psychiatrist. This could help with a patient’s comfort and initiate the treatment process more promptly by providing psychotherapy, education, and support to the patient and their family.
Overall, both groups of BH professionals would benefit from exchanging information about their shared patients. Each professional has a unique understanding about patients based on their training and treatment orientation, and likely will have gaps that may be filled in by a professional from a different behavioral specialty.
Integrating primary care physicians into BH care
Primary care physicians (PCPs) provide a sustained partnership with patients and families that is often the gateway to BH services. Most people with behavioral problems, including psychiatric disorders, substance use disorders, and health behavior problems initially seek treatment from their PCP. They may feel more comfortable in a primary care setting due to the stigma associated with seeking care in a BH care setting.
Research tells us that about a third of the patients seen in the typical PCP office will meet the criteria for a behavioral disorder. In addition, another third will have behavioral symptoms even if they do not meet the criteria for a specific disorder. Unfortunately, research also tells us that PCPs, for various reasons, tend to not diagnose co-occurring behavioral conditions adequately. They typically provide behavioral diagnoses for less than one third of their patients with behavioral needs.
Many patients with chronic medical conditions have more behavioral symptoms than the average patient, such as unhealthy self-care habits, depression, anxiety, and treatment compliance problems. PCPs typically do not, however, have the skills or time to provide adequate behavioral interventions for these patients.
There are several possible factors that may contribute to coordination of care challenges for PCPs and BH specialists. Medical, or “physical,” health care professionals and BH professionals historically have had separate training tracks, often with little or no opportunity to work collaboratively during their professionally formative years. While psychiatrists probably make reaching out to their patients’ PCPs part of their standard practice, most psychotherapists probably do not do this. Their reasons for this range from, “Psychotherapy is too personal to discuss with outsiders,” to “Family doctors don’t want to be bothered with information from nonmedical providers.” When PCPs have a patient receiving BH treatment they often describe the behavioral component as a “black box.” They know that their patient is receiving some sort of treatment, but do not have access to the details.
In addition, PCPs have historically been trained using the biomedical model, which focuses on biological explanations for diseases. This model historically has viewed nonbiological factors as relatively unimportant, or even irrelevant. This model has promoted a mind/body distinction that results in more attention to biological factors, and less attention to “mental” or behavioral factors.
Another challenge to coordination of care comes from the typical office schedule for PCPs, who have intense demands and expectations to manage during their typical office day. In an ideal world, a PCP who becomes aware that a patient also is seeing a BH professional would take the time to discuss the benefits of coordinating care. The PCP would obtain a release authorizing coordination of care, would use the release to reach out to the BH colleague, and maybe even bird-dog the situation to make sure that they obtain a response from the colleague. Obviously, this is just not practical for the average PCP, who probably already feels overwhelmed by their daily tasks.
What needs to be done?
It is clear that the U.S. health care system is undergoing historic structural changes. There are powerful factors that now promote, among many major changes, the importance of primary care services and, in particular, the benefits of integrating behavioral services with medical services.
At the local level, the Minnesota Department of Human Services (DHS) is promoting coordination of care between PCP and BH providers. In the past, DHS had a benefit that covered psychiatric consultations provided to primary care physicians. According to DHS staff, no psychiatrists ever billed for this service, so obviously it was not being provided to primary care physicians even though it was a potentially helpful service. DHS recently expanded this benefit to cover consultations to PCPs by licensed psychologists, as long as the psychologist works within the scope of his or her license. This benefit may significantly expand opportunities for formal, structured coordination of care by direct consultation.
At a national level, the Patient Protection and Affordable Care Act (ACA) has several provisions that promote and support the integration of primary and behavioral care, such as establishing accountable care organizations and patient-centered medical homes. These provisions likely are to include “pay for performance” measures that will reward integrated services that improve treatment outcomes. Many of these measures have behavioral components, such as improving treatment compliance. In the future, PCPs are likely to benefit from close partnerships with BH specialists who can help them with their “numbers.”
The value of PCP services relies on providing optimally comprehensive care, which is the most effective treatment approach for caring for patients with chronic medical problems, many acute disorders, and patients in need of preventive services. Medical outcomes research has clearly established that comprehensive, coordinated care provides higher quality care and results in better treatment outcomes.
Optimal coordination of care will clearly benefit the people who matter the most, the patients. In addition, it will help PCPs with many of their most complex, challenging, and time-consuming patients. It also will help BH professionals by increasing treatment resources for the biological factors, such as mood, energy, appetite, and sleep disturbances that often are part of the patient’s treatment needs.
Richard Sethre, Psy.D., L.P., has a general practice in psychology in Golden Valley, with a special interest in coordinating care with PCPs, pre-surgery assessments for bariatric patients, and BH consultations on general medical units at Fairview Ridges Hospital.
John E. Simon, M.D., is board-certified in psychiatry and practices geriatric and addiction psychiatry in Minneapolis and Litchfield, Minn.
Reprinted from The Minnesota Physician.
