It is not just about integrating primary health and behavioral health; it is about integrating the cultures that come with it

Working for over 20 years with an agency that provided community-based mental and behavioral health services gave me a great knowledge base of what integrated care should be. My last 5 years at this agency allowed me to work on a Substance Abuse and Mental Health Services (SAMHSA) Primary and Behavioral Health Care Initiative (PBHCI) project. This grant provided support and resources for communities to coordinate and integrate primary care services into publicly funded, community-based behavioral health settings. Working with individuals with severe mental illness, I quickly learned that they often lacked primary care. When I inquired about this, patients would share their frustration of being judged, misunderstood, not taken seriously and often being overlooked.

Primary care physicians are often on the front line seeing the initial symptoms of mental illness, but they lack the time and resources to best support these patients. Providers would often comment on a patient’s ‘laundry list’ of psychotropic medications and the fear of adding yet another medication and the effects of it. It wasn’t a lack of compassion, but rather an intimidation of, “What are all these meds and are they all really needed, what will my prescribing of a blood pressure med do to this patient?”   

I’d be remiss to say that implementing the integrated model didn’t come without its challenges. Seeing a patient that was actively experiencing suicidal thoughts was intimidating. Unfortunately, in one particular case, this was the reality of the illness. Respecting and understanding the perspectives and expertise of both the behavioral health and medical needs, is critical. Prior to working in the integrated model, the protocol for the primary care provider would have been to send this patient to the ER. With the support, education and expertise of the behavioral health clinician, the provider would soon experience that such symptoms for this patient were baseline, a reality this patient faced most days, and a visit to ER was not needed. Both providers seeing the bigger picture ensured that the patient received needed care.

Now, having worked in the reverse setting, with primary care providers for the past 2 years, I have a better understanding of the medical perspective and the lack of time providers are allotted for evidence-based approaches to support patients with mental health or behavioral health needs.

I recently spoke to a primary care provider, who has practiced close to 40 years in a small independent practice, and who is also planning to retire. He hired a Licensed Mental Health Professional (LMHP) 7 months ago. He reflected and shared his feelings of this thus far. His first comment was, “Why didn’t I do this sooner?” He said part of it was the fear of opening a ‘can of worms’ he wasn’t equipped to handle. Seeing generations of the same family, he felt he had a pulse on their social, emotional and medical needs. It wasn’t until he committed to take the step of screening his patient population for social needs and depression that he really uncovered patient needs. Needs that were previously not reported or went unnoticed. By talking with his patients he learned that they were often fearful of overburdening themselves with such things like, “I don’t have the $2 co-pay for this medicine, my transportation service only allows me a ride home, not a ride to the pharmacy, my best friend died and I feel lost.”

Screening for depression and social determinants of health are vital for successful whole person care. A diagnosis of an ear infection and instructions for using the medication seemed simple, “Here is a script for a z-pack, you will feel better in a few days”, BUT not knowing that this patient didn’t have the $2 copay for the medication or the transportation needed to have it filled at the pharmacy, set this patient back… dealing with earaches, which increased irritably, which increased fatigue, which increased the level of depression and isolation. Often the success of such a simple visit requires the patient to take 99% of the responsibility to follow through with orders after they leave their visit. Orders that for much of the population seem simple, logical and doable, for patients in our example, may be overburdening. With a LMHP in the practice, the provider was able to refer and often provide warm handoffs for patients with positive PHQ scores and/or identified social needs to the LMHP. If the LMHP was in a session, the handoff was passed to a dedicated trained care manager to further assess, provide resources and develop a plan, which included a follow-up appointment with the LMHP.

Mental health and medical clinicians best serve people when they understand each other’s cultures, share perspectives and responsibilities, and listen to the patient’s voice. When embedding behavioral health into a primary setting, or vice versa, it is important to involve patient’s voice and expectations.

Here are some examples of patient feedback:

• Talk to me like you talk to everybody else.
• Don’t judge me for my diagnosis, instead see me for who I am, a person not the diagnosis.
• Ask me questions about my diagnosis and let me tell you what to look for if I’m having a bad day.
• Understand that some of my medications cause weight gain, don’t assume I’m lazy.
• Be patient with me, explain what you are doing and why.
• Ask for my opinion, and if I refer you to speak to my psychiatrist. Please do so, because I have faith in team decisions that include everyone.

“Mental Health is not a destination, but a process. It’s about how you drive, not where you are going.”
Noam Shpancer, PhD
 

Angie Schindler-Berg, Project Lead, HealthTeamWorks