When I first began working as a psychologist in primary care, I was embedded in a busy, 14-provider primary care practice in Kansas City with a 35,000 member panel. I developed a canned speech to explain to friends and family exactly what my new job entailed. My explanation was met with confusion, enthusiasm and doubt as people tried to wrap their heads around the idea of behavioral health care delivered inside the primary care exam room. I am reminded of these reactions by a quote shared with me by Peggy DeCarlis, former COO and CIO of New Directions Behavioral Health, when talking about integrated behavioral health:
“It’s the same each time with progress.
First they ignore you, then they say you’re mad, then dangerous,
then there’s a pause and then you can’t find anyone who disagrees with you.”
– Tony Benn, English politician
The results of our work from 2014-2016 were recently published in the article, The Cost Effectiveness of Embedding a Behavioral Health Clinician into an Existing Primary Care Practice to Facilitate the Integration of Care: A Prospective, Case-Control Program Evaluation (Journal of Clinical Psychology in Medical Settings, Kaile et al). In addition to improving health outcomes and reducing stigma, we found that embedding behavioral healthcare into primary care resulted in a significant cost savings: 10.8% when analyzed by Milliman in a comparison of medical, behavioral and drug claims relative to expected costs from Blue Cross Blue Shield analyses of cost trends for the same period.
Now four years after the program began, I am compelled to reflect on the many things I learned from practicing in primary care.
I learned about the reality of stigma … and its consequences … by witnessing what is gained by reducing it. Seeing patients for behavioral health conditions in the context of their primary care setting helps them feel less ashamed. When their medical provider endorses this service and approaches mental health with an objective, matter-of-fact mindset, it has the effect of placing mental health issues in the same non-judgmental arena as medical conditions. As a psychologist coming from a thriving private practice, I was shocked to realize that had I not been in a primary care setting, the stigma attached to mental illness would have prevented a large population of people from meeting with me.
I learned that most chronic, serious medical conditions have co-morbid behavioral health components.
I learned it is incredibly rewarding to provide psychoeducation! Rather than needing weeks of therapy, a well-timed, accurate, scientifically-based brief intervention with a patient in the primary care setting provided immediate, effective symptom relief. And because people go to primary care at a high point of distress, they have the strongest motivation and readiness to change. As a result, my psychosocial intervention had a greater likelihood of long-term symptom relief.
I learned that reducing depression and anxiety is the bread-and-butter of integrated behavioral health; additionally, specialized services like weight management (with a definite therapeutic component) or substance use disorder treatment can move the needle on health outcomes. Empowerment of the patient, listening, and giving time to each person are central components to effective integrated behavioral health.
I learned that a physician champion is essential to getting any integrated program off the ground. This individual teaches and leads his or her colleagues into improved management of mental health conditions and chronic medical diseases with behavioral components. Once the concept was understood and utilized, primary care providers reported a high degree of satisfaction with it.
A recent poll published by the American Psychiatric Association reveals we are an anxious nation. In fact, almost 6 percent of people in the U.S. will be diagnosed with severe anxiety disorder at some point in their lifetime. We worry about finances, safety and our health. Even our children are developing anxiety and depression. In response to this trend, public and private initiatives are promoting behavioral health integration as an important priority. From my perspective, we are headed in the right direction. Behavioral health integration can make a difference to a country lying awake at night from worry and eating our way into a host of dangerous medical conditions. Primary care is an opportunity for behavioral health providers to be just the right person, at the right time, for the man or woman waiting for you in the exam room.
Debra McQueeney, PhD, is a psychologist who has partnered with New Directions Behavioral Health (New Directions) to promote the integration of behavioral health services in primary care. She is currently a behavioral health consultant for Spira Care, an innovative approach to total person health care piloted by Blue Cross and Blue Shield of Kansas City and New Directions. Debra is committed to providing access to behavioral health care that promotes healthier lives and improved patient experience in the primary care setting.