In a traditional image of mental health services, provider and patient face one another in a one-on-one encounter aimed at addressing individual, psychologically rooted issues. But in an era of diminished resources, health care leaders are reframing that approach in favor of an integrated model they believe delivers care more efficiently and to a greater number of patients with a wider variety of issues.
The change is in evidence at University of Colorado Hospital’s AF Williams Family Medicine Clinic. There, primary care providers (PCPs) call on a team that includes attending psychologists, post-doctoral fellows and residents to offer relatively brief, in-clinic consultations. The goal: give guidance to patients, not only for mental health issues, but also for behaviors that may affect their physical health.
Psychologists traditionally have been involved only in mental health…that’s necessary, but not sufficient for primary care, where we need to take care of the whole person.
It may surprise some that a psychologist has a role in helping a patient manage his or her obesity, diabetes, hypertension or other chronic disease. But “health psychology” is actually an emerging specialty area, says Abbie Beacham, PhD, a psychologist with the CU School of Medicine’s Department of Family Medicine and a member of the AF Williams team.
Mind-body issue. The underlying assumption of the approach, she says, is that primary medical care and behavioral health are tightly interwoven. With quick, focused interventions, psychologists can help patients make simple lifestyle changes that can improve their health.
It’s a more efficient approach than the traditional delivery model whereby PCPs separated mental health or behavioral issues from their practice realm and referred patients out for help to mental health professionals who, in turn, were not expected to play a role in a patient’s medical care, Beacham believes.
“Psychologists traditionally have been involved only in mental health,” she says. “That’s necessary, but not sufficient for primary care, where we need to take care of the whole person. We’re doing a better job of not being siloed and of working within a team and the whole health care system.”
The need to join the two realms is clear, maintains Colleen Conry, MD, a PCP at AF Williams. “Fifty percent of patients who seek primary care have a psychological or behavioral health diagnosis,” she says. “Many health problems, including obesity, diabetes, heart disease and substance abuse, are related to behavior and can be treated with behavioral change.”
Building the continuum of care. The idea of integrating primary care with mental and behavioral health services is a natural one for AF Williams, a developing patient centered medical home where providers take responsibility for developing and coordinating all aspects of their patients’ care (Insider, Aug. 31, 2011). The clinic has been a training ground for psychology residents for more than three decades. But having a psychology team on-site opens up new possibilities, Conry says.
The psychology team screens patients for depression and anxiety, with psychologists providing up to five sessions and “building a bridge” to community providers for patients with more severe problems, Beacham says. But they’re also available to help patients understand the role that lifestyle and behavior plays in their health.
For example, a process-improvement pilot launched by the green “pod” – one of several AF Williams medical teams – targets patients newly diagnosed with hypertension. When Conry sees one of those patients, she calls the behavioral health team, who talk to the patient about lowering his or her salt intake, doing more exercise, taking medications and understanding what it means to have a chronic disease that won’t get better on its own.
“The key is we’re co-located, and talk all the time,” Conry says. The two teams share a “care algorithm,” she adds, that specifies the care the behavioral team will deliver.
Lowering the pressure. A behavioral consult with a hypertension patient generally takes about 10 minutes, Beacham says. The goal is to help support the PCP’s medical recommendation.
“We want to find how we can help patients in overcoming barriers, like getting medications, taking the meds the way they are prescribed, improving their diet and exercise and building the confidence to set and achieve those goals.”
Conry explains the idea of the consultation to the patient, makes what she calls a “warm handoff” to the psychology team and talks with them afterward. It’s all documented in the Epic electronic medical record so the clinic can track the services provided to and eventually the outcomes for patients in the clinic’s hypertension registry.
The approach could bridge what remains an enormous gap in health care coverage for patients. Insurance often doesn’t cover mental health services or carves them out from medical coverage, says AF Williams Practice Director Jeff Raikes. Patient no-show rates for mental health appointments average 50 percent, Conry adds.
That could change, Beacham believes, if PCPs and psychologists create common ground as they have at AF Williams. “If psychologists are introduced as part of a team that is working with physicians to help people with smoking, sleep management and so on, patients will go with the model,” she says. “As time goes on, it will be a normal part of people’s care, and something they look for.”