Imagine you’re a primary care physician. It’s Monday morning and your patient is a young adolescent boy who was recently discharged from a psychiatric hospital because of anger issues.
You’re seeing this patient after he has run out of medication. He had been prescribed an antipsychotic that you’re not trained to manage, and you don’t have anyone in your office you can consult. He is distressed. His mom is also distressed.
Inevitably, the visit that was allocated for 15 minutes takes over 60 minutes. And you’ve got three other patients in the waiting room who are angry. What do you do? You refill the antipsychotic, continuing what he was discharged with from the hospital.
You don’t feel good about this. It doesn’t feel like good care, but child psychiatry is not your field of expertise. You don’t like writing antipsychotics for kids, but what else can you do?
The Case for Behavioral Health Integration
There are many reasons to improve the integration of behavioral health care into primary care. For example, behavioral health issues are major contributors to medical morbidity, mortality, and elevated costs.
I also believe that well-integrated behavioral health care will be one of the rare things that can help us meet all aspects of the Triple Aim while also increasing joy in work — what some call the “Quadruple Aim” — because this has been our experience at the Dimock Center in Roxbury, Massachusetts. We have seen that deeply integrating specialty behavioral health, medical, and substance use disorder care can:
- Enhance the patient experience by treating the whole person — This means not only addressing their biological needs, but their psychological and social needs. Integration also improves a patient’s ability to access care.
- Improve population health — By some estimates, 70 percent of the drivers of health outcomes are psychological and social in nature. By integrating care, we would improve both physical and mental health.
- Reduce costs — It is estimated that behavioral health integration can save the American health care system $38-68 billion a year. Patients, particularly high-utilizing patients, but also patients in the overall population, can see reductions in medical costs when their behavioral health and substance use disorders are treated.
- Reduce burnout — I’m both a primary care pediatrician and an adult and child psychiatrist. I can say as a primary care doctor that it is wonderful to have a team of specialty behavioral health experts literally sitting next to me. I can come to them for help while I’m doing the many other things I need to do as a primary care doctor in a 15-minute visit. This immensely improves my quality of life as a primary care doctor. As a behavioral health provider, it’s also beneficial to be sitting with the medical team and getting questions about medical health answered right away.
I emphasize specialty care because many practices are now integrating behavioral health care, but it’s often focused on shorter-term interventions or less severe diagnoses. We include full-service, specialty, expert behavioral health care as part of primary care.
If, during a brief assessment in the primary care office, the social worker and the patient decide it makes sense to have a more in-depth discussion, they can schedule a behavioral health intake. When the patient returns for that visit, they can check in at that same waiting room. At Dimock, after that intake, if the patient and provider agree that long-term therapy would be helpful, we can place that patient in the schedule of a long-term therapist. This often only takes a week or two and the patient, again, would return to the same primary care clinic instead of being referred out.
The Challenges to Integration
Management structures can be big barriers to behavioral health integration. Different treatment cultures — medical, behavioral health, and substance use treatment — can lead to barriers to care (including long wait times, stigma, inefficient policies, or financial barriers) when they’re misaligned.
For about the past 10 years, Dimock has been able to counter some of these challenges by fully integrating our management systems. We used to have a separate outpatient specialty behavior health department. It’s now fully incorporated as part of primary care. All the social workers and psychiatrists report to the medical clinic director who reports to the chief medical officer.
With a primary care doctor and primary care nurse sitting next to a social worker, psychiatrist, or community health worker, we’re now one team. This allows us to have a singular focus on the patient experience and patient care.
From a patient’s perspective, care at Dimock is a destigmatizing experience because you’re in a primary care doctor’s office. If you need help with depression or anxiety, for example, the doctor you know and trust simply introduces you to her colleague. If the patient feels that there is a stigma attached to working with a mental health clinician, this process overcomes those barriers, creates access to care, and begins the process of potentially entering specialized behavioral health care.
Some of our results surprise people. For example, we have no wait list in our pediatric clinic. No wait list for intakes or long-term therapy. Scheduling an intake can happen the same day after the warm hand-off from a primary care physician. There is a median of 12 days from the warm hand-off to attending the behavioral health intake session and a median of 14 days to attend long-term therapy.
You can go from having no need identified on day zero, to having a warm hand-off, intake, two or three visits with a long-term therapist, resource support from a community health worker, and medications from a psychiatrist — all within 30 days from identifying a need.
We’re also seeing progress on population health. We know epidemiologically that about 30 percent of people have an active mental health diagnosis within the past year. About 20-25 percent of the patients in our pediatric and adult primary care clinics receive specialty behavioral health care. So, I think there’s an argument that we’re meeting an important part of our population’s needs here within primary care.
Cost Savings Without Burnout
Many people assume that behavioral health loses money. (I know that was my understanding before integration.) Dimock can challenge this assumption because the billing per masters-level behavioral health clinician here improved by 80 percent after integrating our adult program.
We have more social worker FTEs than primary care provider FTEs because our masters-level clinicians are financially self-sustaining. They cover their own salaries and a little more. Being able to say that behavioral health clinicians are revenue neutral is a significant change because it allows us to provide high levels of staffing to better meet the needs of our population.
This also helps us maintain a good environment for our staff. Recently, we had a team of students from the MIT Sloan School of Management survey our staff using the Maslach Burnout Inventory, an evidence-based scale of burnout for medical providers and behavioral providers. They found that 79 percent of our medical and behavioral health staff felt engaged in their work. They also found that 0 percent felt disengaged or burnt out. This compares to one national study that found 43.9 percent of physicians reported having at least one symptom of burnout.
The Difference Specialty Behavioral Health Integration Can Make
Let’s go back to the story of the young adolescent boy. I’ll describe what really happened because he came to the Dimock Center and he was my patient.
After hearing about his hospitalization and doing a brief assessment, I connected him to a full behavioral health intake. His mother signed consent forms so we could work with him and communicate with his school. In this process, we also learned that his mom was facing some mental health issues.
Within a couple of days, he was set up with an intake, and then a long-term therapist. His mother also received enhanced care in Dimock’s adult integrated primary care program with substance use, behavioral health, and medical treatment.
Connecting the child with his own individual therapist and treating psychiatrist got him stabilized. He got to the point where the team determined he didn’t need the strong antipsychotic medication anymore. The team helped him and his family do better. We were able to provide the support that two generations of a family needed.
For the Dimock Center, specialty care is part of primary care. This family’s story helps illustrate why this is so important. We believe it’s the most patient-centered way to provide care.
Michael Tang, MD, MBA, is a primary care pediatrician, child and adult psychiatrist, and the Chief Behavioral Health Officer at the Dimock Center in Boston, Massachusetts. To learn more about the Dimock Center’s work, join MH11: Impact of Behavioral Health Integration on Healthcare Utilization Patterns at the IHI National Forum on Monday, December 9 from 12:30 to 4:00 PM.