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I have big ideas. Ideas that could potentially change how we deliver health care. Ideas about how behavioral health could potentially be involved in almost every visit in primary care. Ideas about how we can be more involved in all things early detection and prevention. Ideas about how chronic disease management is all about behavior and we are the experts on that. Ideas about how a patient’s world view, how their feel about themselves, the meaning they make of their chronic condition, all inform their behavior. As you can imagine, sometimes these ideas get me in trouble.

Our clinic is metric driven. Like full on slap-happy about meeting our metrics. There was the one time we did a Papapalooza month with a competition between care teams to do as many pap smears (as indicated) as they could in 30 days. The competition was fierce. But our winning team got a pretty incredible handcrafted, bejeweled (never used!) speculum!

So that brings me to this fall. We were nearing the end of the year and we needed to move the dial on our patients with high blood pressure, STAT! An email went out to clinic staff motivating and inspiring them to work on this hypertension metric. It was directed to primary care providers, nurses, and medical assistants, even pharmacists, but not one mention of behavioral health. I blinked, read it again, scratched my head, and screwed up my face in a twisted knot. Deep breaths, I told myself. I composed myself and engaged in an email exchange that went something like this:

Dear Quality Team,

Have you thought about how behavioral health providers can support clinical quality metrics?

I have lots of ideas! Here are a few for your consideration:

1)      If patients are not taking their medications behavioral health can be helpful in identifying, “What are the barriers?”  Often times there are underlying issues including self-esteem, meaning making of the condition, locus of control, not seeing the value of taking the medication, depressed mood, cultural considerations, and the impact of trauma that can influence how someone takes medication. Sometimes it can simply be they “forget” to take their pills, but more often it is much more complex, and behavioral health can use our interviewing and assessment skills to uncover what is driving (or not driving) their behavior and make a plan for how to address these underlying influences.

2)      At scheduled behavioral health visits we could look at the last blood pressure reading in the medical record and if it is out of range (greater than 139/89) we could initiate a re-check by a medical assistant or have a provider see the patient quickly to adjust meds.

3)   Behavioral health can also consult on or see patients who are struggling with issues that directly impact blood pressure for example lack of physical activity, obesity, stress, heavy alcohol consumption, sleep apnea, diet/nutrition, and stimulant abuse. Primary care providers can introduce behavioral interventions as part of the treatment plan to address their health condition.

I wanted to share some specific ideas/workflows about how behavioral health can be involved and helpful in meeting our controlled hypertension rates. These are just a few of the many ideas I have about to contribute to this work.

Thank you for considering,

Joan

Dear Joan,

Thank you for asking! This is a perfect example of where our clinical leadership erroneously separate “medical” and “behavioral”, and as you nicely call out, barriers and motivation are all in behavioral health realm! You are spot on, and we need to include this thinking moving forward. Let’s talk more!

Sincerely,

Your Quality Team

Hypertension isn’t the only physical health condition for which behavioral health can, and should, have a place at the table. Behavioral health should be helping to move the dial for some of our clinical quality metrics for which our clinics or health systems are accountable. We should be part of the work from the beginning of planning the strategy for how to meet the metrics to being part of the workflow or intervention in the clinic.

Have you thought about how behavioral health providers can support quality metrics?

The clinic I work in has metrics on patients with diabetes getting an eye exam, patients who need colorectal cancer screening getting a colonoscopy, and patients who need breast cancer screening getting a mammogram.  These screenings are so important and prove to be so difficult for some patients to complete. Many of the reasons patients don’t get these tests are due to underlying issues including low health literacy, poor system navigation, underlying anxiety (this one’s huge!), and SDoH factors like lack of transportation.

My dream is that behavioral health get involved with all patients who have had “care as usual” phone outreach or a visit with a provider and who still have not completed the one of these screenings after several months. We could engage with these patients and really work to understand what is getting in their way of getting their colonoscopy or mammogram (both uncomfortable and anxiety provoking procedures).

I encourage behavioral health leaders and providers to consider how involved their teams are with this work. I encourage them to learn about the clinical quality metrics their clinic or health system is focusing on and talk with leadership about how they can become more involved.  Because, once again, we are experts in behavior, and behavior is a strong influencer on health.