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A plan to improve integrated care

Posted On: Sunday, September 15, 2019 Posted By: Adrienne A. Williams Tags: Care Teams, CIPC, Family Medicine, Integrated Primary Care Competencies, Practice Improvement, Primary Care, Primary Care Behavioral Health, Team based competencies

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Late this spring the CIPC faculty read with interest a special issue of Journal of Clinical Psychology in Medicals Settings on “The Primary Care Behavioral Health Model of Integration”.  One particular article caught the attention of CIPC Director, Daniel Mullin.  The author, Adrienne A. Williams, PhD discussed in “The Next Step in Integrated Care: Universal Primary Mental Health Providers” the binary view of mental health, either a patient is mentally healthy or is mentally ill.  The author cites examples of how this view reinforces stigma associated with seeking mental health services, even within current integrated care models.

Williams suggests as a solution, a primary mental health provider, “In contrast to the binary view, where some people are seen as needing an MHP and others do not, this model would be similar to the primary care model of health and would involve development of primary mental health providers (PMHPs). These PMHPs would be to mental health care what primary care physicians (PCPs) are to physical health care.”

This radical but creative idea prompted an outpouring of comments and questions.  We ask you to read the Williams article HERE and then read the Q&A with CIPC faculty.

  

Christine Runyan, PhD, ABPP, Director of Behavioral Science for the Worcester Family Medicine Residency Program: I have been working with family medicine physicians for years, and many of them really enjoy, pride themselves, and want to address many of the areas of health and well-being that this model proposes would be in wheelhouse of the PMHP. This would fundamentally change some of the role of the family medicine PCP, perhaps not in a desired way. What ideas do you have about how to ’sell’ this to family medicine docs? 

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Adrienne Williams: With the implementation of any new model, people are always nervous about, and often resistant to, potential changes.  One of the advantages of the PMHP model is that it was designed to complement, rather than replace, the work already being done by primary care physicians.  PCPs would still be able to screen for depression and anxiety, counsel about tobacco use, and talk about eating patterns, in addition to other behavioral medicine topics.  When emergency rooms started incorporating substance use and intimate partner violence screening, this did not interfere with PCPs or psychologists also talking to their patients about these topics.  Instead, it allowed a greater blanket of coverage for patients, and different health care providers could know more pertinent history even if they did not ask the questions themselves.    This would work the same way with PMHPs.  Some of the content may overlap, which reinforces the topic for the patient, but does not diminish the effect of the health care provider having the discussion.  

The PMHP model, however, addresses a problem that PCPs often have.  Many studies have surveyed physicians about why they do not address a number of various topics (e.g. sexual dysfunctions, opioid use disorder, bullying, PTSD, eating disorders, etc.)  PCPs report the same two barriers over and over again:  not enough time and not enough training.  The PMHP model would relieve PCPs of the pressure to try to cover ALL of the topics, which they realistically would not have the time to do.  Additionally, it would allow PCPs to focus on areas where they are truly competent, rather than trying to gain marginal competency through a brief training.  Many topics (e.g. marital/partner relationships) are not being addressed at all. 

 Finally, it is important to note that while some family physicians pride themselves and want to address some of the same topics as that a PMHP would, this cannot be said of all primary care physicians.  While many of my colleagues, who are family physicians at an academic health center with integrated mental health care, are very interested in learning about and addressing the psychosocial-behavioral aspects of health, they are not representative of all PCPs. Most PCPs do not work at academic health centers or at integrated primary care sites and may not be family medicine physicians (i.e. internists, pediatricians). They might not be as interested in addressing the areas of health and well-being that PMHPs would address. If a patient’s PCP is focused primarily on physical health, the patient will still need a PMHP to address the other half of their health.

 Ellen Endter, MAT, CIPC Marketing Manager: In Sandy Blount's online PCBH course, he stresses that patients tend to search out someone in the practice in whom they invest their trust and confidence.  This is usually the physician.  Would having two co-equal primary care practitioners responsible for their health erode or distort this trust? Both from patients' point of view and from within the culture of physician-led primary care?

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Williams:  Historically, medicine has operated from a hierarchy that has been criticized for its patriarchal method of patient care and physician-centered approach.  In recent years, medicine has been moving towards a more patient-centered approach.  This transition to patient-centered care has been gradual and there are many components that remain physician-centered. 

 The PMHP model is a patient-centered model.  This means that the answer to the question “who’s in charge here?” would be “the patient.”  Similarly, the patient would not have two primary care practitioners responsible for their health.  The patient would be responsible for their own health, and they would have two co-equal primary care practitioners to guide and care for them.  Given the different areas of expertise of these two practitioners, it will be possible for patients to invest trust and confidence in both.  This is the case in many aspects of our lives - from having different teachers for different subjects in school to getting help from sales associates at different types of stores.

One change in trust that may occur is that the type of trust that patients give their clinicians. In a physician-centered model, that trust is an assigned trust - similar to the type of trust we instill in our bus drivers or airline pilots - we trust who we are assigned to, but not because that trust was earned.  In the patient-centered model, clinicians may need to transition to an earned trust, which would require improved patient communication, which can benefit both the patient and providers.

Patients have demonstrated that they often prefer to be the top of the hierarchy in their care.  The preferred provider organization (PPO) model of health insurance is one of the most popular forms of health insurance plans because it allows patients to make their own decisions about their health care.  With patients desiring more control over their own health and health care, the PMHP model is likely to be welcomed as increased access and sense of control when compared to the traditional culture of physician-led primary care. 

 There are some patients and providers who may prefer the physician-led model.  As a patient-centered model, the PMHP model does not prevent this type of practice.  That is, a patient could still choose to place their physician at the top of the hierarchy and trust only their primary care physician.  Since this is the patient’s preference, it continues to be patient-centered. Some patients currently choose to only see a doctor when something is wrong, skipping all the screening tests and preventative measures, so not all people currently participate in the primary care model, but it is still important to offer primary care.  It is important to note that even if some patients may not choose to participate in a PMHP model, that would not be a reason to not offer it to the many who would be interested and would benefit.

 Ultimately, it is important for patients to have co-equal providers as it is impossible for a single provider to have knowledge of all things, especially as medical and psychological scientific knowledge continues to grow.  The reality is, with Cartesian mind-body dualism, physical health and mental health training were split long ago.  PCPs are trained for about 7 years after college on mostly physical medicine, with some education about psychosocial behavioral topics.  In contrast, psychologists are trained for about 7 years after college on mostly psychosocial behavioral topics, with some education on physical health. While there is overlap, the level of competency on different topics varies amongst the professionals.  It is important for patients to start learning to trust a team of people as this is a more realistic approach than the all-or-nothing approach of placing all trust in a single clinician.   

Dan Mullin, PsyD, MPH, Director of the Center for Integrated Primary Care: Family medicine is an approach to primary care that attends to the needs of family systems.  How might a PMHP address the needs of families?

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Williams: It is essential for PMHPs to address needs of families as family physicians do.  As any mental or physical health condition can impact both the patient and their family, it will be important for the PMHP to work with families to help explain the nature of a patient’s condition, provide caregiver support, and educate family members on behaviors they can change to aid in treatment.  For example, families of patients with bipolar disorder, substance use disorder, or dementia may need specific support and guidance for coping with the disorder and the family dynamics that are impacted by the disorder.  Families may need to learn new coping skills, how to collaboratively work to change a family dynamic, and how to deal with caregiver stress.    Families would also learn about patient triggers or vulnerabilities and what they might need during treatment, such as not offering the patient a problematic substance or helping with reminders. This, in turn, helps the treatment of the patient.  

PMHPs could also play a role in helping families talk about difficult topics such as illness and health behaviors.  Helping families to improve communication can help improve family dynamics as well as address health concerns. 

Additionally, as family members of patients with bipolar disorder, substance use disorder, and dementia are at increased risk of developing these conditions themselves, they could have more frequent screening by their PMHP, as well as preventive or early interventions. 

Mullin: Primary care addresses the needs of many patients with medically unexplained symptoms.  Patients with medically unexplained symptoms typically have co-occurring mental and physical symptoms that cannot be reliably distinguished.  How would a PMHP work together with a PCP to care for a patient with medically unexplained symptoms?  

Williams: The PMHP/PCP collaboration could be an ideal model for addressing medically unexplained symptoms.  Currently, the assessment and treatment pathway for medically unexplained symptoms often looks something like this: a patient presents with symptoms; the physician does some tests that come up negative and communicates this to the patient; the patient becomes anxious about what is causing the symptoms and possibly concerned that the physician will not believe them; more tests are run, which all come up negative;  this can further increase patient anxiety (and also symptoms); the physician states or implies that since the symptoms are not caused by anything they tested for it must be psychological and refers for mental health treatment; the patient feels dismissed and further distressed. 

When a PMHP works together with a PCP, all care would be based on the foundation of the interplay of mind and body.  This would communicate to the patient that symptoms are addressed both psychologically and physically from the beginning, avoiding the communication of “it’s all in your head.”  This would ensure adequate screening of psychosocial-behavioral factors that may be contributing to the symptoms, whether they are the cause of the symptoms or a possible contributing factor.  Regular screening by the PMHP for a history of trauma and adverse childhood events so that treatment for these events could begin early would also be beneficial as trauma and adverse childhood events are associated with medically unexplained symptoms.  Importantly, the PMHP/PCP collaboration can reinforce the idea that negative test results do not mean that there is nothing wrong with the patient physically and that mental health treatment is part of the treatment for certain symptoms (e.g. pain) regardless of cause.  

Runyan: You propose that psychologists would be especially well suited to these roles. You also notably address the potential barriers of workforce shortages. I am concerned that advocating for psychologists to fill these roles (as there are already many fewer of these than master’s level clinicians) would further undermine and dilute the adequately trained workforce to assess, diagnose, and manage patients with Axis I mental health needs. Can you comment on this and expand on your ideas about how this model could effectively have psychologists serving in these dual roles?

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Williams: Workforce shortages are common throughout healthcare.  Long waiting lists for healthcare have been found in both primary and specialty care.  Here in Chicago, a number of specialty clinics have a six-month wait for an initial appointment. While it would be preferable for patients to be able to get in right away, the services are valued enough that they are offered now while they are working on improving the problem of workforce shortages.  Put another way, I have never heard someone say that we should not start a cardiology clinic because we will not have enough providers to meet patient needs.  Rather, a cardiology clinic would be founded, subsequently expanded, and solutions implemented to increase patient access.  It is likely that the PMHP model would have to grow in a similar way.  Fortunately, our primary care physician colleagues have already been working on addressing workforce shortages, and psychologists can use some of the same strategies. 

PCPs often talk about “working to the top of their license.”  This means that they are purposeful in trying to spend their time doing the parts of care that only physicians can do so that nurses are doing the parts that nurses can do, and medical assistants are doing the parts that medical assistants can do.  PCPs still will do some of these tasks, but by focusing on doctoral-level tasks, they are able to see more patients.  In the same way, in a PMHP model, psychologists could work with master’s levels clinicians who might do some of the screening or counseling.  This would free up psychologists to work to the top of their license and see more patients.  The psychologists would be able to assess, diagnose, and manage patients, and then the master’s level clinician may take over for the counseling of certain conditions, such as the ubiquitous adjustment disorders. 

The Primary Care Behavioral Health model has also already introduced some solutions to workforce shortages.  This behavioral health model has shorter visits, with a focus of seeing a higher number of patients.  With so many psychologists currently seeing patients for hour-long visits, we could see twice as many patients if psychologists saw patients for 30 minutes, or sometimes 15 minutes.  

The PMHP model would also rely on staged implementation.  The model would be implemented at some sites first, and after modifications and success would be implemented at other sites.  Importantly, after some implementation, more people would be aware of this as a potential career path.  If you ask a child what they want to be when they grow up, they tell you professions that they have been exposed to.  Most children and many adults have not seen a psychologist. Even when I give talks to psychology graduate students, students always express that they were not aware that my career in primary care psychology existed.  Thus, if more people started seeing a General Practitioner Psychologist, beginning during childhood, more people would be aware of this career path and would seek it out, expanding the workforce as the model is implemented at more and more sites.  

Amber Hewitt Cahill, PsyD, Director of Behavioral Science for the Fitchburg Family Medicine Residency Program: What you propose in your paper is a much-needed shift in how our society views mental health care - and health care in general. One potential barrier that wasn't mentioned directly is language. I think you start this conversation in many ways, and implicitly direct attention to in your paper. We have clinical and colloquial language that can communicate the spectrum of severity across common less severe physical health issues and more severe or chronic physical disease processes. Unfortunately, this is not the case for mental health. As you point out, language regarding mental health has followed a focus on diagnosis often with a pathological and stigmatizing tone. Can you talk more about your thoughts regarding the shift in language that may be needed both in health care and society in order to actualize the ideal view on health care and use of PMHPs you propose?  

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Williams: There will be multiple steps needed to improve the language surrounding mental health.  The first will be to improve education on words that are already a part of people’s vocabulary.  Often, with my therapy patients, I use handouts to help patients identify the category of an emotion (e.g. anxiety), as well as the intensity (uneasy, worried, scared, terrified). I help people clarify their language so that all life situations are not clumped into one extreme category.  

One example of this is a patient who recently told me they were “depressed” after the death of their spouse.  They were led in a conversation about how “grieving” differs from “depression,” allowing a more accurate description of what they were experiencing, as well as the patient being able to differentiate their depressive episodes from times when they were experiencing sadness proportionate to life events.  One challenge to addressing language will be the current trend of using hyperbolic language and mental health diagnoses to describe mainstream experiences.  For example, people may state that they are “addicted” to their favorite TV show, or that they are “bipolar” when feeling emotional.  Thus, it will be important to start educating the public about what mental health diagnoses do and do not mean. 

There are many avenues to public education, including: incorporating mental health education into K-12 health classes as is done with physical health topics, advertisements such as those used by pharmaceutical companies, use of television and movies to model appropriate use of language, and use of social media influencers.  Celebrities are now sharing their stories of mental health struggles, but without guidance as to how to communicate some of the information accurately.  Many companies currently advertise their products through television, movies, social media, and celebrities.  If companies can impact public awareness of their products through these methods, it is very possible to use these methods to affect public awareness about mental health topics. 

One option that might help is introducing new terms to allow the public to describe their experiences and to allow PMHPs to bill for common symptoms. For example, there could be a term for the cluster of emotional symptoms that is common following the break-up with a significant other (feelings of hurt, loss, confusion, rejection, remorse, anger, loneliness, etc.).  By having a term for this, it would normalize the experience, help people to recognize that these are symptoms that they can discuss with their PMHP, and allow the PMHP to bill for the visit.  

There are already some ICD-10 codes for psychosocial behavioral situations that might present to a PMHP (e.g. Z63.1-problems in relationship with in-laws), however, these describe more of the situation, rather than what the person in the situation is experiencing.  Language is needed so that these types of experiences have labels that demonstrate mental health variations in different day-to-day experiences to normalize and de-stigmatize the experience of mental health symptoms. In some ways, we might not even need new language.  If we could bill for emotions like loneliness, remorse, guilt, rejection, or changes in behavior like decreased socialization the way that physicians can bill for a cough or runny nose, these experiences could be normalized and addressed without pathologizing or stigmatizing. 

If “pecked by chicken” can have its own ICD code (W61.33), it is not unreasonable to have a label and bill for other common human experiences.

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