Successful Integrated Care Takes a Village, Too

According to the Substance Abuse and Mental Health Services Administration (SAMHSA), integrated care is defined as “the systematic coordination of general and behavioral healthcare.” Put simply, integrated care provides whole-person care in coordination with different health professionals.

What is Integrated Care?

Integrated care includes everything from evaluating a patient’s psychosocial support before recommending bariatric surgery and conducting preventative PHQ-9 and GAD screenings with every wellness exam, to considering when physical symptomology overlaps with depressive symptoms and accounting for that in the differential. Physicians are asked to consider a more holistic scale to determine all causes for symptomology, for example, patients who present with symptoms like fatigue that they associate with menses.

Whole-person care also includes connecting with patients through motivational interviewing and assessing their readiness for change. For example, to qualify for bariatric surgery, physicians are asked to determine a patient’s ability to comply with a diet and their psychosocial support. While you can physically change someone through surgery, sustained change will require behavioral changes and environmental support. Meanwhile, behavioral health providers are encouraged to consider the side effects of the medication they may prescribe including haloperidol, clozapine and carbamazepine, which may cause medicine-related weight gain that can affect a patient’s health outcomes, especially if the patient is already overweight. Coordination with physical health providers can enable the care team to make more informed decisions, including weighing benefits and risks, when considering medication side effects and interactions.

Challenges In Providing Integrated Care

While the need for treatment is expected to rise, the National Council for Behavioral Health anticipates that the amount of available psychiatrists will be less than 50 percent of what the healthcare system will demand by 2025. This makes it increasingly important for general and family medicine practitioners to be the frontline of behavioral health. Final recommendations from the U.S. Preventative Services Task Force (USPSTF) recommend “screening for depression in the general adult population, including pregnant and postpartum women.” However, the recommendation also indicates the screening should be conducted when “adequate systems [are] in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up,” further underscoring the need for integrated and coordinated care. The lack of patient follow-up emphasizes what healthcare systems are moving toward addressing creatively: transitions in care are the key inflection points that determine a patient’s trajectory through the healthcare system.

Successful Examples of Integrated Care

While primary care physicians (PCPs) are often bound to their 15- to 20-minute visits with a patient, innovative healthcare systems like Memorial Hermann have an in-house psychologist within the group practice. This grant-funded program allowed PCPs to identify patients who may be in need of additional mental healthcare. Appointments are then scheduled one week later at the same clinic to focus on behavioral health with a mental health practitioner. This gives the mental health practitioner the opportunity for a longer conversation about the patient’s psychosocial history and can lay the groundwork for continued mental health care. The mental health practitioner and the PCP then connect after the visit to ensure coordinated care.

When asked about the role of the PCP in integrated care, Dr. Shayna Upchurch said, “My role is twofold 1) to be cognizant and aware of how mental health and well-being is impacting the patient at the moment and if there is something to identify and 2) to be able to practice team based care.” She went on to outline situations when the patient’s mental health condition warrants a referral to a psychiatrist, for example, when a patient is not responding to first- or second-line treatments for bi-polar disorder. However, the challenge is that typically, only 50 percent of patients who receive a referral to a mental health provider follow through with the appointment. PCPs have the opportunity to be mindful of the social determinants of health in their referrals, considering things like referring working patients to clinics that offer extended hours or referring Medicaid patients to well-known psychiatric units that work well with their insurance. Additionally, hotlines provide increased access to mental health supports.

Building rapport and understanding the patient more fully can help PCPs direct patients to the appropriate resource as well as encourage follow-ups. For example, an immigrant worker who typically works odd hours and speaks Spanish as a first language, may be hesitant to follow up with an appointment during work hours or when care and conversation are primarily conducted in English. When initial screenings for depression indicate that a follow-up is needed, PCPs and social workers can consider these social determinants of health. If a physician builds rapport, arranging for a follow-up appointment – including a warm hand-off to a bi-lingual psychiatric professional during accessible hours – can facilitate this patient’s appointment compliance. Additionally, something as simple as the physician saying, “I would like to follow up with you to discuss that you have been feeling down” can be disarming to patients who feel like spending time talking about “feelings” can be burdensome to others.

The responsibility of integrating care does not only call for physical health providers to understand more about mental health; it also places an onus on behavioral health providers to have a better awareness of physical health. One example of a behavioral health provider who has worked toward bridging this gap is the Greater Nashua Mental Health Center, a community mental health center that brought a nurse practitioner from a federally qualified health center (FQHC) on site. They developed a physical health report card in conjunction with other wellness programs through a SAHMSA grant. One way the community mental health center empowered patients was to give them a paper report card about their health including weight goals v. current weight and normal blood pressure range v. current blood pressure reading. By simply shifting the mindset of patients to consider that physical health should be part of the mental health conversation, Greater Nashua Mental Health Center connected with patients about physical wellness when many may not have attended an annual exam otherwise.

There is No Health Without Integrated Care

The belief that there is no health without mental health has reverberated worldwide. In the United Kingdom, the Mental Health Five Year Forward View, outlines integrated mental and physical health pathways through integrated models including Increasing Access to Psychological Therapies (IAPT). In fact, from April 2018, the clinical commissioning groups are required to offer IAPT services integrated with physical health pathways. In addition to increasing access to psychological care through general practitioners (GPs) who have a specific focus on those with chronic conditions, innovative UK Trusts are engaging the community to truly provide wrap-around care. As part of Mersey Care Trust’s Zero Suicide Policy, the Trust has connected with the community to reduce suicides through community engagement in training. One example of this is the Trust training local cab drivers to know how to respond when they pick up a lone passenger who asks to be driven to locations that are common for suicide attempts. By engaging the community in mental health initiatives, promoting mental wellness spreads from beyond clinical settings and into the community.

So Now What?

By continuing to observe successful models of integrating care, providers can consider community-specific ways to better integrate care. Integrated care calls for the active participation of all members of a care team and requires collaboration between the patient, clinicians and community resources to address the whole person.

Special thanks to Dr. Shayna Upchurch for contributing to this blog post and sharing innovative integrated care practices at Memorial Hermann. Dr. Upchurch is a general practice and family medicine resident physician practicing at Memorial Family Medicine in the Memorial Hermann healthcare system. She is passionate about the patient-physician relationship, coordinated care and women’s health. Her undergraduate and medical school education is from Texas A&M University.