The integration of primary care physicians with behavioral health specialists is a practice that’s starting to catch on across the country, and in the First State.
A program piloted at Christiana Care over the past year has worked to integrate mental health professionals into the primary care setting.
Peggy, a longtime Christiana Care patient, was feeling "up and down like a yo-yo." After experiencing the loss of a good friend and a family member – while also coping with other health conditions and stress – Peggy wasn’t feeling like herself. However, the thought of seeking help for her mental health never crossed her mind.
“I just did not recognize it in myself, and I think that that's something a lot of people don't recognize," Peggy said. "It may be somebody you live with, it may be just your upbringing that tells you, well you can't have a mental health issue.”
But her primary care physician, over a series of visits, noticed Peggy wasn’t in the best place mentally and suggested she see a mental health specialist: in the same office, and just a few days later.
“I was a little resistant initially, as I say I'm private and I really didn't know if that was an issue," Peggy said. "I thought I could handle it myself and realized, I think, when he pointed it out, I may as well have a go at it.”
After a few appointments, Peggy started seeing a difference.
“I certainly recognized over a period of time that that's just what I needed," Peggy said. "That a third party, somebody who would listen without being judgmental with some - not answers - but positive feedback and some respect for what I was going through - was very helpful.”
Peggy is an example of how Christiana Care expects its Collaborative Care model to work.
Dr. Linda Lang, Chair of Psychiatry for Christiana Care, provided a tour of one of the integrated offices, with three specialists supporting 18 primary care doctors.
The behavioral health specialists are centrally located, where the primary care doctors can access their expertise when necessary.
“We’ve had cases where patients who would never have gone to an office setting – a behavioral health office setting – but they did come here for their medical treatment, and we were able to capture the needs that were being neglected for many years," Lang said.
The new model is part of Christiana Care’s larger reorganization of services. In 2014, it closed one outpatient mental health unit, as well as an intensive treatment program for adolescents. Hoping to streamline care, increase access to behavioral healthcare and cut costs, they re-allocated resources and launched the Collaborative Care model last May. Some of Christiana’s behavioral health consultants were already trained. Trainers from the University of Washington - where the model originated - came to help those who weren’t.
Lang says some offices “huddle” in the morning to discuss their schedules for the day and flag which patients might need a behavioral health intervention.
“We call that the warm handoff," said Cindy Scheffler, a behavioral health clinician working with family doctor Dr. John Yeargan at Christiana’sSpringside office.
She demonstrated how the model works.
“I’m getting introduced by the doctor to the patient in the exam room during the time of their visit and then at that point we’re either scheduling a follow-up appointment in my office, or if that patient is in a crisis at the time of that visit then we’ll try to extend the visit," Scheffler said.
Scheffler’s seen over 200 patients since collaborative care was adopted, and Yeargan says it’s been much easier to communicate with specialists like Scheffler when she’s just down the hall, rather than off-site.
“A large percentage if not most of those patients may have fallen through the cracks if she were not here," Yeargan said. "Because it’s getting them into the system that really has been the biggest hurdle.”
Christiana Care’s Collaborative Care model was developed after seeing the results of The University of Washington’s IMPACT study, which examined depression treatment at 18 practices in eight healthcare organizations across five states. It found the collaborative model improved patient satisfaction and outcomes while lowering overall healthcare costs.
Rebecca Sladek, Communications Manager for the Department of Psychiatry and Behavioral Sciences at the University of Washington, says it took a while for the psychiatry community to get on board. But now she says the American Psychiatric Association fully supports the model, even partnering on a grant to train 3,500 psychiatrists nationwide on how to practice collaborative care.
“It’s different," Sladek said. "Normal psychiatric consultations is the 50 minute hour where you’re speaking to the patient one-on-one and that’s how most psychiatrists in the US have been trained. That’s what they've been trained to do. And this model kind of spins that all on its head where you actually don’t see the patient face-to-face, you consult on a caseload of patients with a care manager: so you’re consulting on individual cases for those folks who are most in need who aren’t getting better.”
Dr. Lang notes all primary care doctors receive some training on how to identify more common mental health issues, such as depression and substance abuse. They’re trained to ask if over the past month a patient has been feeling down, depressed or hopeless or finds little interest or pleasure in normal activities.
Lang says if a patient says ‘yes,' it tells the doctor to invite the behavioral health specialist to get involved. However, she adds that more specialized diagnoses, such as eating disorders or borderline personality disorder, are mostly dealt with on the psychiatric level.
Primary care doctors also administer an annual questionnaire with nine questions asking if a patient has noticed symptoms of depression in themselves, like lack of energy, trouble concentrating, and even thoughts of self-harm - on a scale ranging from not at all to every day.
Christiana Care is just starting to assess how its program is doing, examining a first round of patient and doctor satisfaction evaluations.
Lang says she hopes to see better outcomes with this model. She anticipates doctors – by working collaboratively and sharing patient information – will “catch” mental health issues early on, creating less need for intensive services later.
But Peggy has concerns about using the depression screening tool as the first line of defense.
“I don't know how honest a person can be when filling those things out. I think it needs to be more observation more than ticking the boxes," Peggy said. "They may say they don't sleep well at night. But I think recognizing that you're pulling back on enjoying life or whatever, I'm not sure people are particularly honest about that when faced with a question.”
Peggy says she sees the way primary care doctors engage patients about potential behavioral health needs as a critical step.
“I think it's the way the GP presents the need for behavioral health intervention to a client that makes all the difference in the world," Peggy said. "If it's not dealt with as anything drastic or special, but it's a service that he has or she has. I think that's a really important part of general practice.”
Ultimately, Peggy believes the model can be effective. She says mental health isn’t any different than physical health.
“Every once in awhile it's nice to have a top up if you know what I mean," Peggy said. "It's like maintaining your car in a way. You take it in for a service once in awhile, and I think that that's kind of what you do with your health and mental health. Mental health particularly.”
