It is no longer a new idea that the mind and body are intrinsically connected; Socrates via Plato, described this around 360 B.C. Yet, we still separate and silo these aspects of care; treating behavioral health needs like schizophrenia in mental health clinics and physical issues like diabetes in primary care clinics. Although primary care providers increasingly treat common behavioral health issues such as depression and anxiety, they still only reach a fraction of people who need these services and have not historically provided high-quality care for people with these diagnoses (Barkil-Oteo, 2013). Meanwhile, those living with serious mental illnesses (SMI) generally lack adequate primary medical care and are more often seen in behavioral health settings (Olfson et al., 2019). This dichotomy in care fails to address the realities of comorbidities and whole-person needs.
Integrating behavioral health and primary care bi-directionally (providing primary care in behavioral health settings and behavioral health services in primary care clinics) is a powerful and necessary tool to address a wide range of needs both for staff and patients (Skillman et al., 2016). While there is much work to be done to transform our policy and payment systems to support integrated care, a more tangible yet often overlooked necessity is preparing the behavioral health workforce to deliver integrated care. We can equip our staff through three key mechanisms: interprofessional collaboration, clinical competency, and supervision.
Often behavioral health staff have trained in discipline-specific settings (e.g., schools of social work, psychiatric clinics, or psychotherapy settings) and may not be familiar with methods for communicating with and sharing clinical responsibilities across other disciplines. Health organizations can overcome billing, scheduling and infrastructure barriers to integration only to find that a breakdown in communication between team members stalled an entire organization’s integration efforts. A traditionally-trained behavioral health professional may never have written a brief, quickly digestible note germane to primary care setting records, nor be familiar with how to contribute their skill and perspective within a cross-discipline team huddle or curbside consultation. Integrated settings often illuminate differences in staff priorities and goals (e.g., changes measurable by lab results and screening), language (e.g., terms like ‘patients’ vs ‘clients’, ‘primary complaint’ vs ‘patient goal’), and expectations such as metrics and clinical encounters per day.
To sustain buy-in, cooperation, and collaboration between team members, early wins and shared goals should be established. Screening can be one valuable starting point. Whether improving depression screening or screening for colorectal cancer, both behavioral and medical staff can identify opportunities to jointly improve a single metric or outcome. In these efforts, staff may find ways to reduce duplicative processes (in the case of depression screening), or to learn from one another about risk factors for disease and opportunities to jointly address different components impacting a single issue (such as improving rates of colorectal cancer screening). Shared initiatives will provide opportunities for staff to cross-train, improve fluency in behavioral or medical terminology, and build strong communication.
The ability to effectively deliver evidence-based clinical interventions can help behavioral health staff feel efficacious in their work and comfortable in their role within the integrated team. For example, individuals living with SMI are highly likely to also experience chronic sleep difficulties (50-80%; Harvard Medical School, 2019) and numerous other chronic health conditions. At the same time, poor sleep broadly impacts much of the general population seen within primary care clinics, worsening other medical conditions and potentially even increasing or exacerbating the presence of budding mental health conditions (Khurshid, 2018).
Evidence-based behavioral interventions for insomnia (i.e., cognitive behavioral therapy for insomnia) are now recommended by groups such as the American College of Physicians and the American Academy of Sleep Medicine as gold-standard treatments, often more effective and safer than available medications. Chronic, comorbid conditions such as insomnia carry significant behavioral components, presenting an opportunity for integrated behavioral health providers to impact a common medical condition and assist patients in self-management. Unfortunately, relatively few behavioral health providers offer this line of treatment or see themselves as primarily responsible for addressing insomnia, and similarly few primary medical providers are aware that this may be an option for their patients.
There are ample opportunities to grow clinical competencies in the integrated behavioral health workforce, but the first and perhaps most important step is finding a starting point. When developing a new clinical offering, a few key steps can be helpful:
- Explore the electronic health record, frequently used billing codes, or simply ask clinical staff: what are the most prevalent health conditions within the clinic? If there are behavioral health components to any these (which exist for most chronic medical conditions), it is probably a good area for intervention.
- Consult with relevant subject matter experts or examine the literature to determine an appropriate evidence-based behavioral health intervention. From insomnia to tobacco cessation, weight management to chronic pain, there is almost always an opportunity for integrated behavioral health providers to help the team and their patients address chronic medical conditions.
- Training and consultation should be utilized to ensure competent practice and can usually be obtained both in person and at-distance and can be informed by each discipline’s professional organization.
- Map a pathway to address the identified clinical need and consider perspectives of all members of the care team. For example, what are the criteria and means by which nursing staff, medical assistants, peer support staff, or others can identify and refer patients for treatment? If a physician identifies a patient in need of behavioral intervention, have they been trained in quickly discussing this with patients and is there a plan for the behavioral health provider to be available to address this need?
- Ensure a full communication loop. If a patient is referred or handed-off for this new intervention, will the referring staff get feedback or recommendations to address next time they see the patient? How will they know if the effort they put into referring the patient for treatment have been fruitful?
- Finally, develop a realistic plan to determine if this new area of intervention and pathway to care has been successful. If addressing insomnia, it is possible that not every patient diagnosed will be asymptotic after one month, but perhaps after a few months there is a decrease in first-line zolpidem prescriptions within the clinic.
There are success stories of enhanced clinical competencies in integrated settings. Smoking cessation, which straddles both the behavioral and physical health realm, is increasingly a competency for both primary care and behavioral health professionals. Both groups should feel comfortable asking, discussing, using motivational interviewing techniques and giving evidence-based advice to clients who use nicotine products. Both primary and behavioral health providers can support the use of multimodal nicotine replacement and counseling. This increase was the result of years of cultural and educational change efforts. Today, the same sustained change needs to be accomplished for a wider range of needs.
Developing staffing infrastructure to support the needs of providers working within integrated systems is critical. Behavioral health staff new to integrated settings may feel overwhelmed and underprepared in helping to address medical concerns, seeing a higher volume of patients, or switching between very different presenting concerns. Supervision should be a built-in component within the workflow of health care organizations, crucial to the development and maintenance of new staff competencies, preventing burnout, and fundamental to integration. Supervisors should themselves be clinically competent in integrated care models, and ideally be experienced care providers in this area. Regular meetings to discuss complex cases, and constructive feedback on clinical performance are key components of a supervisor’s role. In analyzing workload and clinical hours, supervisors in integrated settings should understand expected issues such as ramp-up time for a full clinical load, and a need to build in unique integrated care elements such as consultation time and space for patient hand-offs.
Supervisees should be encouraged to consider potential deficit areas in knowledge and experience and seek opportunities to develop these skills further. A fully-integrated system should enable physicians to seek experience and feedback from behavioral health professionals and vice versa, as part of continuing professional development. Organizations can be well-served by also developing supervision and training programs with graduate education programs; this helps develop a pipeline of qualified staff and helps graduate programs see a need to prioritize integrated training.
An integral and necessary investment in transforming our systems of care is investment in the people that deliver this care. By empowering integrated teams to function cohesively, equipping staff with effective tools for change, and ensuring adequate and meaningful supervision, we have an opportunity improve patient experience, decrease provider burnout, and better address a full range of complex and interwoven health needs. Integration cannot be “won.” It must continually be earned via strategic investments in a skilled workforce as well as policy and regulatory improvements.
The Primary Care Development Corporation is a nationally recognized nonprofit providing strategic investment and technical assistance to support and expand health care – primarily in low-income, underinvested communities – to achieve health equity. For more information visit www.pcdc.org or call (212) 437-3900.