Perhaps one of the best measures that the integrated primary behavioral health care model is gaining wider acceptance is through a simple Google search. Typing in “integrated care” yields 82 million results, while a finer tuned search on “primary behavioral health integrated care” still stacks up over 5 million links.
The amount of information and chatter continues to swell every day. More data on enticing economic and clinical outcomes is starting to be easier gained, although one still needs to closely examine the perimeters and methods of the studies to extract true knowledge. Sample sizes, adequate study time, experimental/observational methods and other criteria should be considered as you browse through the data and reports – as you should any study you review.
However, one very common thread that I see in many of these reports and articles on integrated care tends to slightly bother me. Often, while extolling the virtues of an integrated approach, people will write that it is a way to beat stigma, that it will allow people to receive mental health treatment in a place where they are more comfortable such as in primary care. I guess in some sense that is a true enough statement. But it doesn’t tell the whole story. It’s sort of like saying that the beach is a great place to see beautiful models with sculpted bodies, and perfect families picnicking together under whimsical umbrellas. We’ve all been to the beach. Certainly there are gorgeous people and nice families, but there is also a whole lot of…well…”normal.” The statement about accessing mental health care in an environment where one is most comfortable should be received cautiously as it is loaded with caveats and “it depends” qualifiers.
And it all starts with how one defines “mental health treatment.” Many health centers have imported mental health clinicians into their practices; most often we see this as some sort of partnership where a therapist (typically a licensed social worker) is given some office space and sees patients based on a referral process in a co-located system. They might even talk of “warm hand offs” and “curbside consults.” Most often in these arrangements, however, they offer a traditional mental health approach meaning the therapist maintains a rather controlled schedule, receives referrals and sees the patients on a well-prescribed basis in 40-50 minute blocks. So yes, in this sense, a patient can receive mental health treatment in an environment of his comfort preference. But is that really integrated?
For that statement - integrated care can help people receive mental health treatment in a place where they are more comfortable – to be true, the organization needs to be practicing a rather complex model that offers real-time behavioral interventions based on a brief therapy approach to the total patient population. It should utilize highly-skilled behaviorists who function as primary care providers, and assist patients with emerging or current mental health issues, as well as disease management techniques. The idea should be to maintain as many of the patients as possible in primary care; but for those who require a higher intensity of care, access to more intensive services should be readily available. New roles such as consulting psychiatrists, population-based case managers, and primary care providers who are more comfortable dealing with behavioral issues are vital. Anything short of that simply isn’t truly integrated. In fact, one might even judge that an organization has become integrated when the staff stops talking about integrated care. Instead they just talk about healthcare.
Every primary care visit has a behavioral component. Each and every visit. Whether its a patient who needs to stop smoking, lose weight, change diets, take a pill every day, reduce stress, get more exercise, sleep better or manage a complex chronic illness – there is always a behavioral factor. To sell integrated care as simply a method where people can access mental health treatment in primary care is short-sighted, and almost a bait-and-switch. It is much, much more than that. It is true reform.
There is definitely a need to find ways to extend mental health services to those in need – and there is, without a doubt, a lot of need. However, sheltering a therapist who provides traditional mental health counseling in a primary care setting is simply not integrated care. It is a valuable service, no question; but it is not what we think of in terms of integrated care. Perhaps a better way to make the statement is “integrated care is a wonderful population-based healthcare model where people can access high-quality services from a variety of skilled providers, including mental health professionals.”
Just had to get that off my chest. Now, let’s clear this exam room for the next patient!