By: Brooke Babyak, MD and Shannon Perkins PhD
Reprinted from the spring 2019 issue of The Ohio Family Physician.
Historically, family physicians have been ahead of the curve in recognizing the importance of behavioral health. Family medicine residencies have included behavioral science in their curriculum since the 1960s.1 As behavioral science in family medicine has evolved, the discipline has increasingly focused on training family physicians to work collaboratively with behavioral health professionals to provide comprehensive care to their patients.
Family medicine residencies have been on the forefront of the Integrated Behavioral Health model, which is defined as “care that results from a practice team of medical 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.”2 Integrated behavioral health care aims to treat mental health and substance abuse conditions, health behaviors, life stressors and crises, stress-related physical symptoms, and adaptation to chronic illness.
The necessity of integrating behavioral health care in primary care is well-documented including such rationales as high frequency of mental disorders, lack of accessible behavioral health treatment, interconnectedness of behavioral and physical health, reduced costs associated with untreated mental illness, and reduced stigma associated with seeking behavioral health treatment.3
Integrated care models range on a continuum from coordinated care, to collocated care, to integrated care.4 A recent review found that one type of integrated care, collaborative care management (CCM), is associated with improved mental health outcomes in multiple ethnic groups and in patients with medical illness as well as mental illness.5 CCM also appears to contribute to improvements in A1C in patients with diabetes. There is some evidence suggesting that CCM may improve outcomes related to substance abuse, but more research is needed in this area.
The Summa Family Medicine Center is the training home for our family medicine residents. Our primary care clinic provides treatment for an urban, primarily Medicaid population with complex medical and behavioral health needs. The residency has had a full-time behavioral science faculty since our program was founded in the 1970s. Over the last few years, in response to growing awareness of our patients’ behavioral health needs and mirroring national trends, we started integrating behavioral health services into our clinic. We began by partnering with a psychiatrist for indirect consultations and adding two full-time behavioral health consultants (BHCs) who are embedded within our practice.
We also expanded the duties of the behavioral health science faculty to provide consultations to our inpatient service. In the last year, we launched a Medication-Assisted Treatment (MAT) program to better meet the needs of community members struggling with opiate addiction.
Offering in-house behavioral health services is a huge benefit to patient care and resident education. However, we have become more aware of our patients’ unmet behavioral health needs. Essential specialty mental health and chemical dependency services are not always available to our patients, with reasons ranging from lack of transportation and insurance to patient discomfort with seeking care outside of their medical home.
In our effort to meet the needs of our patients by deepening and expanding behavioral health integration, we developed a comprehensive program for integrated Behavioral Health Care: “All The Care You Need Is Here.” (See Figure 1).
Figure 1 shows how patients in our clinic will be connected to behavioral health services through a variety of routes, including universal behavioral health screenings, which will occur for all patients, as well as by referral, (self-referral or referral by an employee or physician). Additionally, patients on Long-Term Opiate Therapy (LTOT) and patients with uncontrolled diabetes will all receive behavioral health services integrated into their primary care services.
Our behavioral health team, in coordination with our primary care clinicians, will determine the level of behavioral health care recommended for each patient. Treatment protocols for different conditions are under development and our “Living with Pain” program is expected to launch in early 2019. This program will integrate behavioral health care into all visits for chronic pain, as well as provide group behavioral health treatment for coping with chronic pain. Our MAT program is growing to meet the needs of the local community and we will be integrating individual and group chemical dependency counseling on-site. We anticipate full implementation of this model to take three to five years, depending on multiple factors, such as our ability to hire additional behavioral health and support staff. We expect the model (Figure 1) to change and evolve over time as we evaluate our programs and associated outcomes.
References available on the OAFP website.