INTEGRATING MENTAL HEALTH SERVICES IN PRIMARY CARE FROM THE PATIENT’S PERSPECTIVE

WHAT TO EXPECT – BENEFITS YOU’LL GAIN – YOUR ROLE

What’s Happening:  There is a major change coming to how patients receive their healthcare:  treatment for mental health and drug and alcohol care provided to them in a comprehensive, coordinated fashion in their primary care clinics.  This development is especially important for patients who have both chronic (ongoing) medical conditions such as diabetes, heart disease AND also mental health conditions such as mild/moderate depression or anxiety, or alcohol or drug abuse issues.

For the past 40 years, primary care patients with mental health issues were mostly referred out to external mental health professionals such as psychologists or psychiatrists for mental health care.  Most fell through the cracks and received no or subpar mental health care. (Note that external referral to psychiatric specialists remains essential for patients with a diagnosed serious mental illness). Treating mental health issues in primary care should over time lead to high-quality total healthcare for patients, improve health outcomes, lower total health costs over time, improve the patient’s clinical care experience, while building on the trusted, confidential doctor-patient relationship. However, making integrated medical-mental healthcare a reality in clinics and health systems across the country faces challenges which health professionals, policy people, elected officials and patients will all have to work together to surmount.

What Integrated Care Will Look Like:  The integrated medical-behavioral care provided in primary care will be supported by strong scientific evidence of its effectiveness and success in producing good outcomes. So far there are several proven approaches to providing integration of mental health that doctors can choose from which they think works best in their clinic and which can address their particular patents’ needs.  A hallmark of research on integrated care is that primary care physicians must have flexibility in how they integrate mental health into their practices.  They need the ability to choose a proven approach that best suits their practice’s local values, resources, capacities and needs, and importantly, patient needs. This is vital given that every primary care clinic is a unique environment with varying characteristics such as finances, resources, geographic location, patient population needs, accepted insurance plans, among others.

Another signature trait of proven integrated care will be measurement and team-care.  The mental health services coordinated with their medical care, will wrap around the patient in a coordinated, thorough way.  The care team (doctor, nurse, mental health professionals, social workers, case managers, case management support, staff) will be trained in how to deliver proven effective integrated care.  The composition of the team will vary from practice to practice, but a constant will be the essential role patients play as a member of the care-team.

Recent studies have shown that often medical and mental health problems occur together in clusters, such as depression with diabetes or coronary heart disease, or depression with chronic pain and substance use disorders.  Integrated care will target such common clusters in patients.

Measurement and team-care will be a key signifier of integration.  Your care team will seek to treat all your medical and behavioral health conditions in a coordinated way, monitoring and tracking your symptoms and adjusting treatment when needed to achieve improvement or recovery.  The care-team will all work off a shared electronic health record (EHR) and care plan to which you have contribute. The goal is to avoid at all costs patients falling through the cracks of clinical inertia.

Step Up!  The first action the clinic care team will undertake is to identify which of its patients have a mental health/substance use needing treatment. It is critical that patients come to their primary care visit ready to raise and discuss their mental health, addiction, and social stressor issues, in addition to their physical issues, with their doctor and care-team.  If your doctor doesn’t make time to listen nor show interest in your behavioral issues, consider finding another high-quality practice that does.

Patients will be asked to complete questionnaires or surveys initially to detect signs of a mental health concern, reveal symptoms, and which help the care team do an assessment leading to a treatment plan.  Surveys will also look for social issues which can impede patients’ health such as poverty, food, housing, transportation, physical/emotional abuse, domestic violence issues).  The care team will note social barriers and try to connect the patient with community services organization that can offer relevant services or resources.

Integrated Care Team Functioning: Medical research and clinical care are in the early stages of developing successful integrative care approaches.  Of those shown effective, in one, a mental health professional is physically embedded in the clinic care-team working alongside the medical doctor offering consultative advice and guidance on mental health techniques such as evidence-based psychotherapy.  Once the patient completes initial surveys and assessments are done by staff, the doctor may ask the mental health consultant to join him/her and the patient in the clinic exam room.  This request might be communicated through intra-office instant messaging to help preserve patient privacy.

The physician might introduce the mental health professional to the patient in an endorsing manner, and explains their role, and, if the patient agrees, that consultant can then assist with the patient’s specific mental health/substance symptoms, or functional improvement, in a focused intervention whose time will vary depending on healthcare professional and patient need.  The consultant may assist the patient on how to use behavioral techniques such as motivational interviewing, or behavioral activation, or problem-solving to help with patient’s own self-care.  When follow-up is needed, there might be scheduled individual appointments with the consultant for brief psychotherapy. If a patients’ mental health concerns still do not improve, they may be referred to a mental health specialist outside the clinic for a higher intensity level of care. In that case the medical doctor should have established arrangements in place to communicate and coordinate with the external mental health specialist and stay abreast of that specialty care progress. One of the benefits of the onsite consultant approach is that it also aims to improve the whole clinic care team’s knowledge and experience of mental health/substance conditions.

Another proven integrative care approach involves an offsite psychiatrist reviewing the patient’s record and offering the medical doctor advice and recommendations on a mental health diagnosis, treatment approaches and mental health medication management.  A key feature of this collaborative care approach is the care manager member of the care-team, often a nurse or social worker, who is supervised by the primary car doctor and psychiatrist, and who works closely with the patient on education, health and treatment status checks, connections to outside resources such as social services in the community.  The care manager checks with patients on medications taken and discusses any concerns or problems.  Studies show that this care manager role is absolutely vital to patient’s success in good health results from integrative care.

Stay Engaged!  Integrating mental health/addiction care is a new world for primary care.  Multiple studies show the great need for this innovation and the value it can potentially bring.  It will take time to accumulate substantial data on improved outcomes, lowered costs, and which approaches work best for which patients and practices.  During this period of change it is key for patients to engage with this innovation and play their central role in shaping its evolution, as we bring wider access to mental health care and hence better overall health to all Americans.