Collaborating for behavioral health

Trustee talking points

  • An estimated 43.4 million U.S. adults had a behavioral health issue in 2014. 
  • People with chronic medical conditions have an increased risk of depression and vice versa.
  • Worldwide, the lifespan of patients with severe mental disorders is 10 to 25 year shorter than that of the general population. The excess mortality among this group is largely related to preventable conditions.
  • Only 12 percent of people in the U.S. with a mental health or substance abuse problem receive care from a psychiatrist, and only 22 percent receive care from any behavioral health specialist.
  • The U.S. has 4,627 federally designated mental health professional shortage areas, and it would take 3,397 professionals to fill the gap. The federal government estimates a shortage of psychiatrists in the thousands by 2025.

The growing recognition that mind and body are intertwined is inspiring hospitals to integrate care for both.

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.

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 psychiatric 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 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 posttraumatic 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.

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.

New culture

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 elements, lessons learned and recommendations.

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.

“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 behavioral 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 Connecticut 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,” Lee says.

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.”

Geri Aston is a contributing writer to Trustee.

Integrating behavioral health for the future

The trend toward population health was one of the factors that spurred Trinitas Regional Medical Center and St. Joseph’s Regional Medical Center to merge their behavioral health programs in July 2016 into the new Integrated Behavioral Health Network. The hospitals, 30 minutes apart in northern New Jersey and sponsored by the Sisters of Charity of St. Elizabeth, serve largely low-income and racially diverse patient populations.

Leaders hope the partnership will help them recruit much-needed psychiatrists and prepare the institutions for the future.

Behavioral health in the state’s Medicaid program still is paid on a fee-for-service basis, but James McCreath, Trinitas vice president of behavioral health, predicts that New Jersey will move toward managed care contracts for these services.

“Our belief is those managed care entities are going to be looking to contract with larger, regional entities to be able to manage a larger population and achieve one of the newer goals in behavioral health, which is integration with primary care,” says McCreath, the health network’s executive director. “Having two large regional medical centers sponsor this larger, regional behavioral program is ideal because of our depth in primary care as well as psychiatric care.”

The partnership involves standardizing treatment protocols to reduce clinical variation and to better understand the cost of cycles of care. “It puts you in stronger position to negotiate contracts in population management deals, which is what the Affordable Care Act was trying to bring,” says Carlos A. Rueda, M.D., the network’s regional chairman of psychiatry/behavioral health. “In value-based health care delivery and population health models, knowing your cycles of care and controlling your clinical variation will yield more effective and efficient contracts.”

The partners are beginning work to integrate behavioral health and primary care. Trinitas was awarded a four-year, $1.6 million federal grant to open a primary care clinic in its outpatient mental health center, which serves patients with severe psychiatric disorders.

“These are folks who can be homeless; they can be involved with substance abuse and often lack family support or any kind of social support,” McCreath says. “No one is really engaging them in any kind of primary care.”

At the new clinic, advanced-practice nurses screen patients for chronic illnesses and help patients to manage them; refer patients to specialists as needed; conduct labs; and work on such wellness issues as weight loss and smoking cessation.

The program will track patients’ progress in controlling chronic illnesses over time. “We’re seeing people who at first lab have A1Cs of 9 or 10 [high blood sugar levels],” McCreath says. “We’re immediately working with them and monitoring those successive lab tests to see if we can bring that A1C down.” — Geri Aston

Kaiser turns to patients for advice

Two years ago, Kaiser Permanente Northern California developed a behavioral health patient advisory panel, and the insights that have emerged enable the organization to meet patients’ needs better.

“We’ve been doing a lot of work on revamping and improving our services, and we wanted to make sure we were listening to and hearing from people who are actually receiving the care,” says Stuart Buttlaire, M.D., regional director of inpatient psychiatry and continuing care at Kaiser Permanente Northern California.

The advisory group, which includes patients and family members, has provided input on such fundamental matters as whether educational materials describe group therapy in a way that patients understand and whether provider bios include the information patients need to make an educated choice.

When Northern Kaiser developed a new tool to measure progress among mental health and substance abuse patients, the advisory panel was asked not only whether it found the instrument useful but also about how therapists delivered the information to patients. Advisory panel members said they liked the tool but worried that some therapists didn’t understand its importance to patients.

“We made sure to inform our clinicians by saying: ‘People are taking this very seriously. Please take the time to go over it, explain it well and share with people where they are in terms of their improvement,' ” says Buttlaire, former chair of the American Hospital Association’s Section for Psychiatric and Substance Abuse Services.

Manning the advisory panel are three Kaiser representatives — two co-chairs and a point person. The two-hour meetings take place once a month in Oakland.

The number of members varies but is typically eight or nine. Meetings start with chitchat over dinner. That half-hour is vital because after spending time together as people, “patients are more comfortable and more open,” says Buttlaire, one of the panel’s co-chairs.

Panel members are nominated by a health care provider, interviewed by one of the two panel co-chairs and onboarded in the same way as other hospital volunteers. Interviewers look for certain characteristics, including a willingness to share and a commitment to the initiative.

“People get very thoughtful about programs and systems and how things work together, so we spend a lot of time describing our system of care and integrated care," Buttlaire says. “They pick up on that and start having a systems view of things and can give us feedback — contextualizing their own experience within a system.” — Geri Aston

Trustee takeaways

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 socioeconomic 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 care 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.[print hed]2 Medical Centers Prepare for the Future [web hed]