The recognition that mind and body are intertwined is inspiring hospitals to integrate both types of care.
The emerging models encompass inpatient and outpatient services for physical and behavioral health and are able to reach more people despite a shortage of behavioral health specialists. They also enable hospitals to manage patient populations better.
Outpatient behavioral health services traditionally involve a primary care doctor who manages the care or refers patients to a behavioral health care provider. But a variety of roadblocks have left too many people without the care they need, says Jürgen Unützer, M.D., professor and chair of the University of Washington's department of psychiatry and behavioral sciences (pictured).
The roadblocks include the misplaced stigma of mental illness, which discourages patients or their families from seeking care, a lack of training among some primary care physicians and a dearth of behavioral health providers, especially psychiatrists.
Unützer estimates that 10 percent of UW’s 350,000 patients need mental health or substance abuse treatment at any given time. But in the five-state area it serves — Alaska, Idaho, Montana, Washington and Wyoming — the vast majority of communities don’t have a mental health provider and probably never will. UW set out to solve the problem in the early 1990s by bringing mental health services to where patients get their care — primary care doctors’ offices.
Under the model, named Collaborative Care, behavioral health professionals work in the primary care physicians’ offices and help them to manage patients with mental health or substance abuse problems.
For each office, a designated psychiatrist advises the primary care physician and behavioral health professional. The psychiatrist’s focus is on adjusting treatment for patients who are not making progress, explains Unützer. For offices near Seattle, those conversations take place in person; for more remote communities, they are conducted via telemedicine. The typical psychiatrist commitment is four hours a week.
“It’s my Tuesday afternoon clinic; it just happens to be in a primary care clinic that’s four hours away,” says Unützer, director of UW’s AIMS Center — AIMS stands for Advancing Integrated Mental Health Solutions — which develops, tests and helps to implement Collaborative Care. “There is never more than a week that goes by that they don’t have a chance to consult with me on their patients. If it’s urgent, they page me during the week.”
The psychiatrist also will meet in person or by teleconference with patients who have particularly complicated problems. Those with conditions that can’t be managed in the primary care setting are referred to a specialist. “The notion is to say, ‘Let's start the treatment in primary care,'” Unützer explains. “Let’s support it as much as we can in a very systematic way, and when it’s not working, then we go to specialty care.”
All patients are screened for depression annually. Patients take a short questionnaire each time they visit the practice so the team can track whether they’re improving. Routinely treated conditions include depression, anxiety disorders, panic disorder, and post-traumatic stress and attention deficit disorders.
Many behavioral health patients also have chronic illnesses. A five-state Collaborative Care study found that, on average, behavioral health patients had 3.7 chronic medical illnesses. Chronic illness can lead to mental health problems, and mental health problems can interfere with patients’ management of their chronic disease.
“It’s a vicious spiral,” Unützer says, noting, for example, that “worse diabetes makes you more depressed, and worse depression makes you not take care of your diabetes.”
Patients benefit from having their primary care physicians treat both types of ailments, Unützer says. “It’s the same doctor who will say: ‘You’re not a person who has one thing. You have two things. You’re depressed in the context of diabetes, so let’s see if we can treat both of these things together.’”
Treatment in a primary care office also helps to ease a patient's concerns about the stigma still too often attached to mental illness. A doctor can just walk down a hall and introduce a patient to a counselor.
Executive Corner: Brushing Up on Behavioral Health in 7 Steps
The American Hospital Association in October 2016 published “7 Steps to Expand the Behavioral Health Capabilities of Your Workforce: A Guide to Help Move You Forward.” It offers tips and tools that hospitals and health systems can use to address patients’ behavioral health needs more efficiently and effectively.
Step 1: Assess your current workforce knowledge and skills as well as your patient population.
Step 2: Ensure that your workforce is knowledgeable about the socio-economic determinants of health and the challenges facing your community, and make sure staff are culturally competent.
Step 3: Educate your entire workforce to identify the signs and symptoms of behavioral health disorders and know where and how to refer for screening.
Step 4: Set up a procedure of assessment, treatment and referral so that behavioral health care is happening at the site of visit, if possible.
Step 5: Use interprofessional education and training and team-based care for your current and future workforce to begin integrating primary and behavioral health care.
Step 6: Contact higher-education programs in your area to establish partnerships that address the needs of the population your hospital or health system serves, as well as enhance the recruitment and retention of behavioral health professionals.
Step 7: Engage the broader community, including community groups, mental health and substance abuse treatment providers, community health centers, social service agencies, law enforcement and judicial systems, schools, and churches and religious organizations. This can strengthen care transition and integration.
More than 80 randomized controlled trials have shown Collaborative Care to be more effective than usual care, according to the AIMS Center. A review by the Cochrane Collaboration of 79 randomized controlled trials found that the model is associated with significant improvement in depression and anxiety outcomes compared with usual care.
Momentum is building for the integration of primary and behavioral health care. In Washington, Gov. Jay Inslee set a goal to integrate medical, mental health and substance abuse care statewide by 2020.
In January, Medicare introduced four billing codes for payment to physicians and nonphysician practitioners for behavioral health integration services.
The American Psychiatric Association states that it is training 3,500 psychiatrists in the Collaborative Care model. Training is funded through a four-year, $2.9 million federal grant. Last year, the association and the Academy of Psychosomatic Medicine published a report that reviews the current evidence base for Collaborative Care, its essential implementation elements, lessons learned by implementers and recommendations for how to advance its use.
Collaborative Care requires a change in practice culture, Unützer says. Primary care physicians have to become comfortable talking with patients about their mental health and must be willing to co-manage them with behavioral health counselors. The counselors also have to adapt to working with the PCP rather than in their own independent practices.
“I tell them to lose the sign that says ‘in session,’” Unützer says. “If the doctor walks a patient down the hall to your office and seven out of eight times when they get there they see ‘in session,’ you become invisible.”
Psychiatrists have to adjust to the idea of population health, which means they work with a whole panel of patients, some of whom they’ll never see. “There are a good number who say: ‘That is not what I went into psychiatry for. I want to do traditional, one-on-one care,’” Unützer says. “Then there [are] a number who say, ‘I like this because I can reach a lot more people.’”
Speeding inpatient care
On the inpatient side, the desire to integrate physical and behavioral health care is resulting in programs that do away with the typical psychiatric consult service and, instead, place mental health professionals in medical units.
A number of factors drove Yale New Haven Hospital’s decision to move to an integrated model that started with a pilot project in 2009. The hospital had a high rate of psychiatric comorbidity in general medicine units, and the nursing and medical staffs were frustrated by the complexity of dealing with patients’ behavioral issues without feeling adequately trained, explains Hochang Lee, M.D., a consultation-liaison psychiatrist at Yale New Haven Psychiatric Hospital and director of psychological services at Yale New Haven Hospital.
Medical teams could call for psychiatric consults, but they often waited until a crisis point. “By the time [patients] are fully paranoid, psychotic, having bad withdrawals or are very depressed and anxious, there is a lot for us to undo. There already has been a lot of delay in services, they might actually need a transfer to a psychiatric hospital, or sometimes procedures get canceled.”
The six-week pilot project placed a psychiatrist in a medical unit with a high rate of psychiatric comorbidity. The psychiatrist screened patients and rounded with the medical team. The number of psych consultations rose, and lengths of stay and sitter use dropped. Next, Yale ran an 11-month test in which a team consisting of a consulting psychiatrist, a clinical nurse specialist and a social worker covered three medical units.
Positive results spurred Yale to create permanent behavioral health intervention teams, assigned by floor and staffed by psychiatrists, advanced-practice registered nurses and social workers. Each morning, the APRNs look over the previous night’s admission notes to develop a list of at-risk patients to screen. In the electronic health record, they review the problem list, look for past mental health diagnoses and scan for key words that could indicate a behavioral problem. They touch base with the charge nurses, who might add someone to the list.
When patients screen positive, the APRN or psychiatrist provides services based on patients’ individual needs. They check patients’ medication lists to make sure they’re on psychiatric medications if needed and make sure patients aren’t prescribed drugs that could worsen their mental health.
Peer-to-peer education via curbside advice and informal collaboration is a big part of the teams’ work. “Quite often, there’s a gap in understanding the behavior of patients with pre-existing psychiatric illness,” Lee says. “Sometimes we have to work with nursing staff so that they know what to expect.”
The behavioral intervention teams are now in 11 medical units at Yale’s York Street and Saint Raphael campuses, with plans to expand to the remaining two medical units by year’s end. Lee is exploring the idea of adding teams to cardiovascular services and the cancer center.
Strangers no more
Other hospitals have taken different approaches to proactively addressing patients’ behavioral health in inpatient medical units. At New York–Presbyterian Hospital, one part-time and two full-time psychiatrists have joined with medical teams, comprising third-year residents and attending physicians, to co-manage patients with behavioral health problems. A full-time social worker provides support.
Under the traditional consult model, psychiatrists were essentially strangers to the medical teams, says Philip R. Muskin, M.D., professor of psychiatry and senior consultant in consultation-liaison psychiatry. “One of the problems with that is when the team doesn’t know you, they’re not all that likely to follow your advice.”
Now, psychiatrists round with the medical teams and are able to write orders on patients, as opposed to just making recommendations. They get to know residents, attendings and the nursing staff.
They also are able to teach their colleagues. “You get a better sense of things when the psychiatrist says to you, ‘I wouldn’t use Prozac in this patient because it interferes with a lot of other drugs, and he’s on a lot of other drugs. I would suggest using Effexor or Lexapro,’” Muskin says. “That resident is never going to forget that.”
Beyond working with patients with existing behavioral health diagnoses, the psychiatrists through their rounds are able to detect and treat previously unknown problems or behavioral issues that have emerged as a result of hospitalization.
The model, first started in 2011, partly through a $500,000 donor gift, produced positive results in its first year. Co-managed patients were seen earlier in their hospitalization, and the adjusted length of stay dropped 1.19 days, according to an article in the May/June 2016 issue of Psychosomatics.
Although the program, now fully funded by the hospital, doesn’t make money, it helps to avert financial losses, Muskin says. The hospital anticipated that it would reduce lost days — extra days beyond expected lengths of stay — by 750, Muskin says. The study found that the program eliminated 2,889 lost days. Using a conservative estimate of $600 per extra hospital day, Muskin estimates that the program saves $1.7 million a year.
But one of the most important effects is a change in relationships. “What’s special about it is that it re-engages psychiatry and medicine in the same way that Collaborative Care in the outpatient setting re-engages psychiatry and medicine,” Muskin says. “It relinks communication.”