January/February 2010 Issue

Integrating Behavioral Health and Primary Care — The Person-Centered Healthcare Home
By Christina Reardon
Social Work Today
Vol. 10 No. 1 P. 14

Strong behavioral health/primary care partnerships can create person-centered healthcare homes where those with serious mental illness can receive the best care—the care they aren’t getting now.

Taking steps to stay healthy—eating right, getting enough exercise, following medical advice—can be challenging for anyone. But for people who also struggle with mental health conditions, the task can seem nearly impossible. It may be difficult to prepare nutritious meals; psychotropic medications may cause weight gain; visits to crowded and fast-paced doctors’ offices can bring on anxiety and frustration. And the consequences can be deadly: People with serious mental illness (SMI) die, on average, 25 years earlier than people in the general population. Many of these deaths are caused by preventable conditions such as cardiovascular disease and diabetes.

In response to this alarming statistic, a growing number of advocates for people with SMI are looking for ways to bridge the physical, policy, and cultural gaps that traditionally have existed between primary healthcare and behavioral healthcare. New practice models are emerging that integrate primary healthcare into behavioral health settings or recognize the need for increased behavioral health services in primary care.

The continued debate over healthcare reform provides an opportunity for social workers, with their understanding of the connections between mind and body, to advocate for these new models of care and ensure that integrated services become the norm.

“Social workers absolutely have a role to play in this integration,” says Barbara J. Mauer, MSW, CMC, of MCPP Healthcare Consulting in Seattle. “It’s well on its way to becoming a standard of practice.”

Models of Integration
Mauer has written extensively about integrated care. Among her recent works is “Behavioral Health/Primary Care Integration and the Person-Centered Healthcare Home,” a report published in April 2009 by the National Council for Community Behavioral Healthcare.

In the report, Mauer discusses the need for the integration of behavioral health services into the patient-centered medical home, a model developed by the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association. The model calls for each patient to have an ongoing relationship with a primary care team that collectively works to meet the patient’s healthcare needs in a way that is accessible, coordinated, and quality driven.

Mauer also highlights several other models that could be used nationally to successfully bring together primary care and behavioral health. Among these models are the following:

• The IMPACT model is based on a program developed by the University of Washington that has been successful in treating patients with depression. In the IMPACT program, a primary care doctor works with a behavioral health provider to implement a treatment plan. If this initial treatment plan does not lead to an improvement in a patient’s condition, the doctor and the behavioral health provider consult with a psychiatrist to design and implement changes.

• The Cherokee model is based on integrated programs offered by Cherokee Health Systems, an organization that provides primary care and behavioral health services in Tennessee. Under Cherokee’s approach, behavioral health providers are embedded, full-time members of primary care teams, and primary care providers are included in behavioral healthcare teams.

• The partnership model has primary health and behavioral health providers maintain separate organizations but partner to ensure that patients with SMI are receiving optimal physical healthcare. Components of this model include regularly screening patients’ glucose, lipid, and blood pressure levels and weight when using psychotropic medications; locating primary care providers in behavioral health facilities; and creating wellness programs to help patients manage their health conditions.

These models recognize that keeping primary care and behavioral health services separate is not in the best interest of patients who may not be able, or willing, to seek out two different organizations to meet their needs, Mauer says.

That’s what officials at Health & Education Services Inc., a behavioral health network in Massachusetts, found when they compared the healthcare utilization patterns of clients with SMI to those of people without SMI. The population with SMI accessed emergency department care six times more often and primary care one half as often.

When clients with SMI were asked why they did not use primary care for treatment, they reported that they had trouble getting to appointments, that crowded waiting rooms made them nervous, that they felt uncomfortable disrobing in front of doctors, and that they felt doctors did not really listen to them, among other factors.

Health & Education Services then took that information and created a program to integrate primary care into its existing behavioral health services, explains Judith B. Boardman, RN, MSNCS, PhD, PMHCNS-BC, the organization’s vice president for quality management. The program places nurse practitioners in behavioral health settings to offer physicals, laboratory testing, and other services. The program is currently operating in three Health & Education Services sites, including one that serves a primarily Spanish-speaking population.

“We have changed clients’ beliefs and attitudes about healthcare. We also have seen that people are now taking better care of themselves, both physically and mentally,” Boardman says. “They find that they can make a difference in their medical care, and they are transferring that to their psychiatric health as well.”

Primary care organizations also have found success integrating behavioral health services into their settings. One such organization is the Charles B. Wang Community Health Center, a federally qualified health center in New York that focuses on serving Asian Americans, primarily Chinese immigrants. In 1998, the center started its Mental Health Bridge Program, which allows patients who come in for physical health services to access mental health providers as well. In addition, patients who come in for physical exams are screened for depression.

Offering behavioral health services within the context of a primary health center is especially important when serving people who are immigrants, says Teddy Chen, LCSW, PhD, director of the bridge program. That’s because many immigrants are wary to admit mental health problems and instead manifest them through physical symptoms. People who are immigrants also face cultural and linguistic barriers when attempting to access mental health services.

“There is no way for our people to get into the mental health system easily,” Chen says. “Here, they know that there is always someone in the background who can help.”

Behavioral health specialists are not the only ones advocating for integrated models. The concept also has won support among members of the primary care community.

“(Integration) is so logical that it should happen,” says Jeffrey Borkan, MD, PhD, a professor and the chair of the family medicine department at Brown University’s Warren Alpert Medical School in Rhode Island. “There’s been a change in thinking from the idea that the family doctor can do it all to the idea that we need a team.”

Making It Work
But creating a program that successfully integrates primary care and behavioral health while improving client outcomes is easier said than done. Many barriers to integration exist and each one must be considered carefully when designing and implementing a program.

“You can’t just show up and start doing this work,” Mauer says. “Primary care and behavioral health have evolved in very separate kinds of ways over the last 50 years. There is a lot of work that needs to be done to create a true team collaboration.”

A major barrier is finances. Policies governing reimbursements make it difficult, if not impossible, for a setting to be reimbursed for offering both physical and behavioral healthcare. Many programs must rely on grants to maintain integrated services.

A related obstacle is the relatively slow adoption of electronic records in the healthcare field. The lack of electronic medical records slows the exchange of information between providers that is needed to make integration work, says Chad Boult, MD, MPH, MBA, a professor at the Johns Hopkins Bloomberg School of Public Health in Baltimore and director of the school’s Lipitz Center for Integrated Health Care.

“I’m afraid that if we don’t change the funding and the technology support, then the providers won’t communicate any better than they have in the past,” he says.

Creating a physical space that accommodates primary care and behavioral health can be a challenge as well. For example, a behavioral health setting that brings in a primary care provider also will need to have examination rooms and the equipment medical personnel need to do their jobs.

In addition, there can be a clash of cultures when primary care and behavioral health providers are brought together, Mauer says. For example, behavioral health professionals used to spending long periods of time with clients may recoil when faced with fast-paced primary care settings in which they may have only a few minutes to assess a client.

Primary care providers also must make adjustments when they enter the behavioral health realm, according to Boardman. The nurse practitioners who provide primary care in Health & Education Services’ behavioral health sites must accommodate walk-ins, have a high tolerance for no-shows, and be patient in collecting personal medical histories from patients.

“Our nurse practitioner may wait two or three visits before asking people to take their clothes off for an exam,” Boardman says. “It’s a stages-of-change model. We take it in baby steps.”

Overcoming these barriers may be a challenge, but the task is not impossible for any organization that mixes a commitment to serving the best interests of patients with a bit of creativity, says Frederick S. Johnson, MBA, an assistant professor and the deputy director of the division of community health at Duke University Medical Center in North Carolina.

“You need to be able to put in the time to make this work,” Johnson says. “You need to have entrepreneurial spirit and the willingness to be a risk taker who thinks outside the box.”

Social Work in an Integrated World
Chen believes social workers will have to get used to practicing in integrated settings, but he’s not sure many of them are ready for the change.

“I believe there is no way to turn back. Everyone’s talking about integrated services,” he says. “But I’m concerned that the social work schools are not ready to prepare people to meet this type of need.”

Richard J. Gabriel, LCSW, may be a model of things to come. Gabriel, manager of behavioral health and social work services at Central DuPage Hospital in Illinois, describes himself as a hybrid—part social worker, part medical expert.

He has four pieces of advice for social workers who want to serve in integrated settings. First, learn more about the physical health issues that mental health clients often face. Second, obtain a strong understanding in the psychiatric diagnoses necessary to confidently do assessments in the fast-paced environment of hospitals and primary care settings. Third, recognize interviewing as a bedrock social work skill and use it to obtain an understanding of physical and mental issues the patient faces. Finally, be willing to cooperate with a client’s medical providers. See them as partners, not competitors.

“Physical health and behavioral health are going to be brought closer together in the future, and providers on both sides are going to have to understand how they work together,” Gabriel says. “The key is to understand each other’s roles so you can move forward together to serve the patient.”

— Christina Reardon is a freelance writer based in Harrisburg, PA, and an MSW candidate at Temple University.

SMI’s Connections to Morbidity and Mortality
People with mental health conditions are at risk for physical health problems that deteriorate their quality of life and lead to premature death. The risk is especially high for people with serious mental illness (SMI) such as schizophrenia, bipolar disorder, and major depression.

A 2006 report from the National Association of State Mental Health Program Directors pulled together the results of various research studies related to morbidity and mortality among people with SMI. The report highlights how members of this population often fall victim to preventable health problems.

Among the findings are the following:

• Medical conditions such as cardiovascular, pulmonary, and infectious diseases account for 60% of premature deaths among people with schizophrenia.

• People with SMI have higher rates of risk factors that put them at increased risk of illness and death, including smoking, alcohol consumption, poor nutrition, and unsafe sexual behavior. For example, 75% of individuals with addictions or mental illness smoke cigarettes compared with 23% of the general population.

• Second-generation antipsychotic drugs are associated with weight gain, diabetes, high cholesterol, insulin resistance, and metabolic syndrome.

• People with SMI undergo fewer routine preventive services, have lower rates of cardiovascular procedures, and have inadequate diabetes care.

The full report, “Morbidity and Mortality in People with Serious Mental Illness,” is available online. Visit www.nasmhpd.organd click on the “Publications” link.

— CR