This article originally appeared in the spring 2022 edition of Minnesota Family Physician magazine.
by Dana Brandenburg, PsyD, Christine Danner, PhD, LP, and Lisa Zak-Hunter, PhD, LMFT
As we pass[ed] the two-year anniversary of the COVID-19 pandemic [earlier this year], communities continue to see a sharp rise in mental health and substance use concerns across the lifespan. Over the course of the pandemic, the number of adults reporting symptoms of anxiety or depression have increased from 1 in 10 to 4 in 10 (1). Negative impacts on mental health and well-being include difficulty sleeping (36%) or eating (32%), increases in alcohol/substance use (12%) and worsening chronic conditions (12%) due to worry and stress related to the pandemi (1). Children’s mental health has also suffered, particularly for those with social disadvantages (2,3).
While telehealth increased access for some, in many areas, community mental health resources are strained to meet this growing need. Family medicine has always provided frontline care to screen, identify and treat mental illness, and this has never been more true than within the current context. Given the mismatch of need and available services, along with prolonged wait times for specialty mental health care, we can expect that primary care providers will need to bridge this care gap for patients with mental health concerns longer than would be typical in other times.
Fortunately, the skill set of primary care physicians makes them well equipped to address and treat these concerns. Yet, many barriers exist to addressing these conditions adequately within the allotted time in a busy primary care clinic. Primary care providers are already stressed by the tremendous pressures of addressing complex patient needs with limited time and few resources.
INTEGRATED BEHAVIORAL HEALTH: THE GOLD STANDARD
Integrated behavioral health (IBH) models are a means to support physicians, address patient concerns and reduce barriers to the provision of mental health treatment. IBH is “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, life stressors and crises, stress-related physical symptoms and ineffective patterns of health care utilization” (4). Considered to be the gold standard of care, IBH is shown to facilitate efficient access to mental health care, improve patient outcomes and support primary care physicians who are addressing mental health needs (5).
Doherty and colleagues (6) proposed that there is a continuum of levels of integration in IBH. This was simplified to three levels by a Substance Abuse and Mental Health Services Administration workgroup in 2013 (7). (See table for these levels and their qualities.)
The Institute of Clinical Systems Improvement (8) released a “call to action” report stating that fully integrated care is the optimal approach to care but, in instances where full integration is not possible, co-location can be pursued as a means to improve access and care. The increased mental health needs spurred by the pandemic have led to the introduction of legislation (Bill HR 5218) at the federal level to provide funding to primary care practices to invest in Collaborative Care models. While this is promising, it will still take time for this legislation to move forward.
STARTING WHERE YOU ARE AT: STEPS TOWARDS INTEGRATION
When full integration on site is not possible, there are still steps that health care organizations and clinics can take to improve care for their patients.
- Community Partnerships: Reach out to mental health agencies in the community to examine how pathways between agencies and local primary care clinics can be created or enhanced to decrease barriers for patients trying to establish care and to allow easier communication between the two facilities to coordinate care for patients.
- Collaborative Care: Collaborative Care is a specific model of integrated care based on principles of population health management, focusing on patients with common mental health concerns, such as depression and anxiety. The primary care clinic utilizes registries to systematically track identified mental health patient populations. Care coordinators manage the registries; primary care and/or embedded behavioral health clinicians provide psychosocial or medication-based treatments and a psychiatrist provides regular consultation. Various iterations of this evidence-based model may occur based on clinic resources. For example, if a clinic does not have a behavioral health provider on staff, the primary care provider may provide most of the treatment with consultation with a psychiatrist for the more challenging cases. A consulting psychiatrist could be shared among a number of clinics in the health care organization.
- Behavioral Health Care Coordination: Hire on site care coordinators who have a background in addiction counseling or clinical social work who could provide additional mental health related services (SBIRT model), such as crisis intervention, comprehensive substance use assessments or basic psychosocial interventions. One example of this is the Behavioral Health Home program created by the state of Minnesota. This program not only provides a service to complex patients, it’s also set up as a billable service that allows it to be financially self-sustaining (see the Resources section at the end of this article).
- Brief Intervention Models: There are brief interventions that can assist primary care teams in providing this care to patients as they connect with
other needed services. This includes patient education on depression/anxiety or substance use (SBIRT model); discussion around the interrelationship between thoughts, actions and emotions and how this exacerbates distress; in the moment techniques such as deep breathing or grounding; a behavioral activation plan; or providing brief interventions around various health behaviors such as sleep hygiene, limiting screen time, healthy eating, movement and socialization. The Change that Matters website, changethatmatters.umn.edu, provides training on brief interventions, as well as EHR documentation and handouts that can be used with patients to facilitate this counseling (9).
- Training Partnerships: Another option is to partner with local psychotherapy (e.g., social work, psychology/counseling, family therapy) or psychiatry training programs either to streamline referral pathways for training sites with their own clinics or to inexpensively increase the number of behavioral health providers within the primary care setting. As a reminder, all learners must be supervised, ideally on site, due to the differences in integrated care versus conventional psychotherapy/psychiatric care.
While the pandemic has increased the number of people seeking mental health services and strained the health care system, it also creates an opportunity for health systems to consider how best to support both patients and providers by implementing high quality care models to provide patients with needed and lifesaving mental health and substance use services within our communities.
Behavioral Health Home Information
SBIRT (alcohol/drug screening and intervention)
Toolkits and Implementation Support
- Panchal, N., Kamal, R., Cox, C., & Garfield, R. (February 2021). The Implications of COVID-19 for Mental Health and Substance Use. Kaiser Family Foundation. http://www.kff.org/coronavirus-covid-19/issue-brief/the-implications-of-covid-19-for-mental-health-and-substance-use/
- Racine, N., Brae, A.M., Cooke, J.E., Eirich, R., Zhu, J., & Madigan, S. (2021). Global Prevalence of Depressive and Anxiety Symptoms in Children and Adolescents During COVID-19: A Meta-analysis. JAMA Pediatr, 175(11), 1142-1150. doi:10.1001/jamapediatrics.2021.2482jamanetwork.com/journals/jamapediatrics/article-abstract/2782796
- Ravens-Sieberer, U., Kaman, A., Erhart, M. et al. (2021). Quality of Life and Mental Health in Children and Adolescents During the First Year of
the COVID-19 Pandemic: Results of a Two-Wave Nationwide Population-based Study. Eur Child Adolesc Psychiatry.
- Peek, C.J., & the National Integration Academy Council. (2013). Lexicon for Behavioral Health and Primary Care Integration: Concepts and Definitions Developed by Expert Consensus. AHRQ Publication No.13-IP001-EF. Rockville, MD: Agency for Healthcare Research and Quality. Available at: https://integrationacademy.ahrq.gov/products/lexicon.
- Butler, M., Kane, R.L., McApline, D., Kathol, R.G., Fu, S.S., Hagedorn, H., & Wilt, T.J. (2008). Integration of Mental Health/Substance Abuse and Primary Care. Evid Rep Technol Assess (Full Rep), Nov;(173):1-362. PMID:19408966; PMCID: PMC4781124.
- Doherty, W.J., McDaniel, S.H., & Baird, M.A. (1996). Five Levels of Primary Care/Behavioral Healthcare Collaboration. Behavioral Healthcare
- Heath, B., Wise Romero, P., & Reynolds, K. (2013). A Standard Framework for Levels of Integrated Healthcare. Washington, D.C. SAMHSA-HRSA Center for Integrated Health Solutions.
- Institute for Clinical Systems. (2019). Advancing the Integration of Behavioral Health in Primary Care. http://www.icsi.org/wp-content/uploads/2019/05/IBH-Call-to-Action-1.pdf
- Hooker, S.A., Sherman, M.D., Loth, K., Uy, M.J.A., & Slattengren, A.H. (2022). Change that Matters: A Health Behavior Change and Behavioral Health Curriculum for Primary Care. Journal of Clinical Psychology in Medical Settings. doi.org/10.1007/s10880-021-09836-7