Integrated Medical and Mental Health Care

Almost every time I bring up the topic of behavioral healthcare being integrated with general healthcare delivery, a private mental health practitioner responds questioning how this could possibly work. In response to my June post on this issue, one of our customers shared his thoughts (see comments) about just how this might occur and the obstacles to making it happen in the private setting. I responded like this:

I think many private practitioners are in the same position you are. Unless they do a very health-oriented practice, they see themselves continuing to function quite separately from general healthcare.

The picture is not the same in the public arena. At this time, about 60% of the funding for all mental health and substance abuse services comes from public, not private, sources. Of the people receiving such services, a large percentage have serious physical illnesses as well.

SAMHSA and The National Council for Community Behavioral Healthcare are moving forward with pilot programs and research on the integration of general and behavioral healthcare since this makes lots of sense in the public sector for the seriously mentally ill. But it may also have implications in the private arena. In fact, the move to provide integrated healthcare services in the public sector, and wherever possible in the private sector (like in Accountable Care Organizations – ACOs) has many folks exploring obstacles that may exist to such integration and ways to overcome those obstacles.

Yesterday, I was reading a September SAMHSA-HRSA Center for Integrated Health Solutions newsletter that linked to an interesting article on the use and evaluation of Telephone Administered Cognitive Behavioral Therapy (CBT) for depression. The research started from the current reality that most treatment for depression is provided in primary care physician offices. Of course, this treatment usually consists of medication. While patients prefer psychotherapy to medication for treatment of depression, and both CBT and medication appear to be about equally effective, access to psychotherapy is limited for most people. Cost or convenient access to a psychotherapist covered by their health insurance or some other equally valid reason interferes with provision of psychotherapy.

The research demonstrated that telephone administered CBT was more effective in keeping the client participating in therapy. Both telephone administered CBT and face-to-face CBT were equally effective in diminishing symptoms of depression at time of termination. Face-to-face CBT seemed to maintain the effects better at a six-month measure.

At this point in reading the results, I was reminded of Dr. Suzanne Bennett Johnson’s initiative as President of American Psychological Association (APA) for 2012. She wanted to remind psychologists that they are part of a healthcare profession, and that most of us are well-trained in conducting research. We are ideally suited to design and conduct the studies that will demonstrate just where psychologists and other mental health professionals can best serve in integrated healthcare. I could instantly imagine the re-design of the study reported above to include Skype or other Internet service-based delivery of the CBT so that at least some of the elements of the face-to-face therapy would be present.

There is already lots of opinion about the potential benefits and detriments of remotely-administered behavioral health treatment. Psychologist David C. Mohr, Ph.D., Professor in Preventive Medicine, Medical Social Sciences, and Psychiatry and Behavioral Sciences at Northwestern University lists Internet Intervention and Telemental Health as significant aspects of his interests. Quoted in that 2008 Time Magazine article, Dr. Mohr sees distinct areas where teletherapy or other internet programming might be of use, especially CBT for depression.

Other cutting-edge practitioners have already added internet-based services including videotherapy into their retinue. Given a solid research foundation, video-based therapeutic services might well be a way for the private practitioner of behavioral healthcare to integrate their services with general healthcare.

We can sit back and watch as our healthcare system changes all around us, letting others dictate to us the role we will play. Alternatively, we can be active participants in designing the models for inclusion of behavioral healthcare in primary care. We can design the models, do the research, and market the methods to ACOs, health plans, and medical providers.

We would love to hear from any of you who already work in a setting where mental health services are integrated into primary healthcare. Please let us know your experience and what you think.

 

0 thoughts on “Integrated Medical and Mental Health Care

  • Laura Morrison says:

    I wanted to respond to your article about using remote or telephone administered CBT. I think that could be one way to ensure that mental health services are available to more patients. But there is another way. At least in California, there are beginning to be primary-care health clinics that have mental health practitioners in the same clinic, working closely with the primary care physicians to provide services to patients. I don’t work in one at this point, although I work with some of the PCPs in my area. But I’ve been talking to colleagues who are working in such clinics; they’re popular with patients and psychotherapists as well. I’ve been told that at first, the PCPs aren’t sure what to do with the mental health clinician and only refer pain management patients, but they begin to expand as they understand more about how mental health services can enhance their work with patients. Working in such a clinic would be a good opportunity to help doctors learn more about non-medication alternatives. I talked with a doctor who runs a rural health clinic not too far from my area; he said that the doctors in their clinic refer about 80% of their patients for some kind of psychotherapy or mental health intervention. It’s very popular with patients, surprising in a rather conservative rural area. But the most interesting thing is that new doctors are very interested in this approach; he said that a large percentage of general practice residents from a nearby medical school want to do a residency in their clinic.

    Maybe we psychologists and psychotherapists should start thinking about working more in primary-care settings; maybe we could even help doctors understand that prescriptions aren’t the only option. And patients may not have convenient access to our offices, but they nearly always have access to a primary care health clinic (private or public). I would personally prefer that to working by telephone with a patient I’ve never seen.

    Comments, anyone?

    Laura Morrison

  • Integrating psychologists or mental health practitioners in primary care practices is a focus of healthcare reform. This has been explored here in the Phila area by psychologists and the large insurers. Problem is, no one wants to pay for it!
    The research studies that herald this type of intervention have been funded by grants whereby the psychologist is paid via the grant money. Once the grant money dries up, the integration goes away. Some insurers are trying to set this up whereby the psychologist can bill just like they are in their own office. But the typical session length will vary widely in a PCP office and MH billing procedures typically do not allow such flexibility. Again, the problems with this are financial as well as pragmatic.

    e.g., Pt in to see her PCP. PCP recognizes the need for mental health intervention and so walks the patient down the hall to the psychologist for a “warm handoff.”
    Problem 1: the above works if the psychologist is free. If psychologist is busy, does patient wait until psychologist is free? Does patient have to come back?

    Problem 1a: if psychologist is any good, they will have a fuller and fuller schedule, thus preventing any warm handoffs. Most psychologists I know need to keep busy in order to get paid, given the already poor reimbursement rates.

    Problem 2: if psychologist is free, who is going to collect the copay. How will patient reaction when they realize that there is another copay?

    These problems begin to go away if there is true integrated care where the psychologist and PCP work under the same financial umbrella, and share the same financial risk. This is a part of the ACO model (accredited care organization).

    These are good and interesting ideas. But, as this is a capitalistic country, make sure you follow the money!

    • Thanks to both Vince and Laura for your comments. The logistics of providing behavioral health services within the ACO or Medical Home will undoubtedly take on many forms. I just got information about this new webinar that might interest some of you.

      Integrated Care within the Patient Centered Medical Home:
      The Health Center Perspective

      Date: Thursday, November 8, 2012, 12:00-1:30 pm EASTERN TIME
      Audience: Health center clinical staff, health center administrators, and behavioral health program staff
      Register: http://www.integration.samhsa.gov/about-us/webinars

      If any of you attend, please let us know what you think after the presentation.

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