Bringing mental health and substance use disorder (SUD) services into primary care practices is something that both physicians and their patients have long needed—and even more now that COVID-19 has taken its toll on our collective mental health and well-being. This article makes the case for why that is, explains briefly what mental health integration looks like in primary care, and offers advice to primary care physicians on the type of skillset a mental health clinician should have to work in primary care.
To better keep up with the demand for mental health and addiction services, one of our biggest untapped opportunities is to meet people where they are, starting with the first place most people go when they aren’t feeling well: primary care.
Primary care physicians are no stranger to mental health. In addition to the day-to-day stressors that naturally come with being a frontline clinician when there isn’t a public health emergency, primary care physicians often see patients presenting with mental health and SUD needs in their offices, even if those needs aren’t the primary reason for the visit. With 50% of counties in the United States having no psychiatrist and half of the people in those counties needing to drive more than one hour round-trip for services, paying their local primary care doctor a visit to discuss their mental health is one of the best-possible options considering the relationship they likely have with their primary care physician. Visiting a primary care physician is a much better alternative to a patient showing up in an emergency department (ED) when there’s no place else to go. EDs are often ill-equipped to manage mental health concerns, and in some instances, EDs are actually “boarding” mental health and SUD patients in hallways for days at a time. During the pandemic, each month, boarding increased between 200%-400% in Massachusetts hospitals alone.1
Boarding in EDs is something that should never be occurring, let alone be increasing. However, part of the reason why boarding is occurring and increasing is that people of all ages are struggling with their mental well-being at alarming rates and having difficulty accessing care. This has major downstream implications. In 2019, more than 156,000 Americans died from alcohol, drugs, and suicide2—yet another year-over-year increase that is likely to increase again when 2020 data becomes available.
We need to bring care to where people are—beginning with primary care—and clearly establish an understanding of what integration is, what mechanisms are needed to support it, and the type of workforce primary care clinicians should be recruiting to join them in care delivery.
Defining and Enabling Behavioral Health Integration
To bring mental health and SUD services into primary care without disrupting too much of the clinical workflow, we must first come to understand exactly what integration is and is not. While any definition should allow for local adaptation and flexibility so that practices have the freedom to implement the integrated model of care that works best for them, there needs to be a shared understanding and standard for integration. This operational definition by the Department of Health and Human Services’ Agency for Healthcare Research and Quality3 hits on a few key points, and therefore acts as a good definition for the purposes of this article:
“The care that results from a practice team of primary care and behavioral health clinicians, working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population. This care may address mental health and substance abuse conditions, health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stress-related physical symptoms, and ineffective patterns of health care utilization.”
Medical and mental health clinicians working together under one roof is a fundamentally different approach to frontline care delivery that will require a few policy fixes before we see broader widespread adoption. Our healthcare system’s predominant payment mechanisms reinforce a siloed delivery model rather than support an integrated one. While there are some examples of broader scale implementation using federal funding in the Veterans Administration and Federally Qualified Health Centers, how we pay for care is a major barrier for integrated models. There have been some changes to support integration, such as the addition of the Collaborative Care Codes, and while their adoption has been slowly increasing, they’re still very limited.
Rather than continue this way, a better approach would be to fix existing payment structures so that they support and enable integration. Medicaid Managed Care Organizations, Medicare Accountable Care Organizations, and Medicare Advantage Plans all could be potent vehicles for scaling integrated efforts—should they allow for flexible spending that enables a practice to onboard properly and deliver truly team-based care without the limitations of fee for service.4
Core Competencies Mental Health Clinicians Should Possess
When able to begin hiring and onboarding mental health clinicians, primary care physicians should know what to look for in a mental health clinician. The following eight competencies can help ensure that their new team members have the appropriate knowledge, skills, and attitudes:
- Identify and assess behavioral health needs as part of a primary care team so that they can get a whole-person view of the patient’s well-being and work with the primary care physician to collaboratively and accurately identify, screen, assess, and diagnose the patient.
- Engage and activate patients in their care so that patients can start to clearly see how mental health and physical health are connected and why they must work to take care of both.
- Work as a primary care team member to create and implement care plans that address behavioral health factors, to ensure that primary care physician efforts and mental health clinician efforts aren’t duplicative or contradictory.
- Help observe and improve care team function and relationships so that the strengths and expertise of both the primary care physician(s) and mental health clinician(s) are fully leveraged to produce a positive patient outcome.
- Communicate effectively with other clinicians, staff, and patients, as communication is key to preserving a team willingness to initiate patient or family contact outside routine face-to-face clinical work.
- Provide efficient and effective care delivery that meets the needs of the population seen in the primary care setting. This means setting agendas with roles and goals for the patients and their care team, balancing length of patient encounters effectively, and identifying when immediate intervention and follow-up care is necessary.
- Provide culturally responsive, whole-person, and family-oriented care that takes into account all of the lifestyle factors influencing a patient’s well-being, biologically, psychologically, socially, spiritually, and culturally via patient and family beliefs, values, culture, and preferences.
- Understand, value, and adapt to the diverse professional cultures of an integrated care team to prevent internal conflict and best meet patients’ unique needs.
Primary care physicians should note that these core competencies are specifically designed for licensed mental health clinicians working on a team in primary care and are written in such a way that they should hold true no matter which integration approach a clinician takes. These competencies were originally synthesized from seminal articles on the topic of integration and highlight what skills mental health clinicians need to possess to work in primary care.5
Primary care physicians equipping their clinics with staff capable of helping of meet their patients’, and potentially their own, escalating mental health and addiction needs is key to addressing out nation’s mental health and addiction crisis. Primary care and mental health care have always been inseparable, and now, it’s time we make integration the standard of care.