The benefits of integrated behavioral health are many — improved health, enhanced patient and provider experience, reduced costs — but implementation can be daunting for primary care providers.
Among those best able to assist is Andrew Philip, Ph.D., LP. A clinical health psychologist and PCDC’s new Senior Director of Population Health, Dr. Philip brings extensive national experience in large-scale training and integration efforts.
His role includes oversight of PCDC’s Population Health team, experts in clinical and population-based prevention and treatment. Their collective work helps various partners — state and local health authorities, Federally Qualified Health Centers, HIV and AIDS service organizations, community clinics, and integrated hospital systems — improve capacity and service delivery.
Recently he talked about how providers might approach integration, what to expect, and why the outcomes are so worthwhile.
Can you talk more about your experience with integration and when you first became familiar with it?
Developing an integrated care practice truly became familiar in my work as a licensed psychologist in primary care clinics, and then later in training primary care staff across the country. But really, my earliest experiences with integrated care were years before I knew what integration was.
Even as a teenager I noticed strange silos when I interned on inpatient psychiatric units. We were addressing acute psychosis and discharge planning narrowly, with no mention of how to address chronic — and at times profound — medical needs of our patients. Even then I thought, “Why can’t we just address all the needs of the patient while they’re here?”
Yet, the problems were not just in the mental health treatment arena. During my graduate training, I worked in a family medicine residency clinic that served low-income Medicaid patients. There were maybe 15 or so residents and physicians with over 10,000 patients. The psychologist and I were there to address the behavioral health needs of the population.
We quickly realized that nearly every patient had something other than their primary concern going on that was contributing to their health. If they were struggling with managing their diabetes, for example, there were also behavioral health components — they were managing depression and stress, or they had other things going on in their life that made medication management a struggle. Some of them had serious mental illness and paranoia and other difficulties.
So we had to devise a method that assured maximum reach to an entire clinic population, while also providing high-quality and individualized direct care to each person who walked through the door.
What did that care look like?
I was seeing 15 or 16 patients a day for very brief visits in exam rooms, because we simply didn’t have the space or the capacity to have a special behavioral health setting. It was a much different experience than a traditional, 90-minute mental health appointment, where you see somebody for a year or more. It’s also usually quite expensive and hard to access.
But we were getting people who had never seen a behavioral health provider, although they had arguably needed to for years. They would never have been able to access this care in the traditional primary care setting.
And sometimes even after just one visit, we could chart the patient’s course or change their health trajectory where they could either get on medication, start addressing their depression, or troubleshoot some behavioral issues related to their medical needs. It really did offset the stagnancy in their treatment.
How did the physicians react?
We saw this sort of osmotic effect where the physicians and residents started picking up behavioral health techniques from us and learning the lingo. For example, how do you address crises in a clinic setting? How do you decide about a behavioral health or substance use referral for a patient? It became a whole team of people involved.
It also set the stage for refining those methods, and learning more about what the field has to offer for truly integrating behavioral health into primary care, and vice versa.
Of course, in later years I also learned so much by working shoulder-to-shoulder with the primary care doctors, nutritionists, and pharmacists in my clinics. I was helping patients lose weight, pharmacists were starting to work with patients that had been avoiding injections due to needle phobia — it was a delightful intermingling of competencies combined with careful interprofessional consultation. We were all providing better care by learning from one another.
Essentially, in a traditional primary care setting, the patient likely would never have seen a behavioral health provider. They would never have had that conversation, and their care team simply wouldn’t have had access to behavioral resources even if they acknowledged a need. It would have just ended up being the same conversations with their physician — “You need to start taking your medication, you need to lose weight” — for years and years.
You’ve worked with the country’s largest health care systems integrating services. What are some of the main outcomes you’ve observed in those settings — for patients and providers alike?
One is cost savings. Several studies have found that integration not only improves the utilization of primary care services, but also decreases visits to the emergency department, which are unnecessary, costly, and inefficient in many cases.
Another outcome is decreased wait time, particularly for mental health appointments. In some cases it also increases the availability of primary care physicians who otherwise would have been consumed by behavioral health [concerns].
Clinically — beyond decreases in depression, anxiety, and so on in patients — we see an improvement in the patient experience. Clinics’ and hospitals’ surveys show that patients feel that they’re getting better and more holistic care when they’re treated in integrated care settings.
And then there’s the health care provider experience, part of the Quadruple Aim that we talk so much about. We’ve seen that health care providers themselves in integrated care teams report better satisfaction, and in some cases, less burnout than if they were functioning in a more traditional setting.
I and others attribute this to the team-based care that’s inherent in integrated care settings — not feeling like you are totally alone in caring for the complex needs of a patient.
Behavioral health providers can also be leaders within their care teams: helping colleagues work through difficult issues, not necessarily clinically, but by facilitating conversations. They can help peers understand how to help patients with complex needs without completely exhausting themselves, and by using behavioral techniques that amplify good medical practice.
What have been some of your most satisfying moments in working with patients?
In my primary care clinics, patients were somewhat begrudgingly handed off to me by their primary care doc; they often weren’t excited about seeing a behavioral health provider. Many of those conversations began with, “I’ve never talked to a shrink before, I’ve never talked about this issue before, but my doctor said to trust you so I’m going to go ahead and do it.”
That’s literally life-changing for people — both in addressing their behavioral health as well as their medical needs, because we know that these things are intrinsically connected. And it’s extremely gratifying as a clinician.
What would you tell a partner organization that is interested in integrating services, but not sure where or how to begin?
Doing a basic needs assessment is almost always a good starting place — figuring out the current landscape of your clinic and the needs of your population. Are there high-incidence chronic medical conditions? Do we know that there’s high rates of substance use or have we even begun screening to find out? Certainly we’re seeing this a lot with the opioid epidemic.
The second factor is capacity. Is there capacity to hire someone new right now? Do you have to maybe start with the staff that you have? Is there space available? Are proper billing mechanisms in place?
In integration there isn’t a “wrong” way. Usually anything is better than completely siloed care. PCDC helps organizations figure out what enhanced services can look like, and what’s possible for them.
What are your top priorities as PCDC’s Senior Director of Population Health?
Although primary care is clearly the focus of PCDC, we’ve been doing work in the integration space for some time. We also hold national contracts focused on HIV prevention and treatment and have offered training and technical assistance for years on care management, chronic disease management, health literacy, and motivational interviewing.
My priority is to merge and amplify this work. It’s a new position, which I think reflects a broader recognition about the interconnectedness between behavioral health and medical and primary care needs.
We’re looking to build bridges between areas that have existed in isolation — for example, bringing together infectious disease management and a behavioral health or sexual and reproductive health, and primary care and preventative health screening. We’re addressing gaps in health care and building whole-person care.
It’s a matter of thinking broadly about clinical and population health. Because if even we’re doing everything clinically possible — the gold-standard treatments for individual clinical interactions — but we’re only addressing a small percentage of the population that we serve, or not addressing the systems-level issues, then something will always be missing.
And the opposite is also true — if we only focus on macro or population-level needs, how do we know that the individual clinical interventions are high quality?
We’re merging these ideas because we need to do both. We need to educate people on building things like care registries, on monitoring access and using data to understand a population. But we must also ensure that actual clinical interventions being offered are meaningful, impactful, and the best available.
Soon when you or I walk — or video! — into our primary care clinic, we won’t be handed a list of referral options or directed to go across town or even states to get our needs met. We’ll be treated as whole people, deserving of person-centered care in a comfortable, accessible, and equitable environment. This is the future of primary care.