Long before patient-centered medical homes or accountable care organizations were buzzwords, Salt Lake City–based Intermountain Healthcare was looking at all of the points of care that could improve the health of patients in its system. It did not take long to identify mental health as a problem.
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All too often a patient would come to one of Intermountain’s 185 primary care clinics with multiple comorbidities that were exacerbated by mental health issues such as depression or dementia. So the primary care physician would refer the patient to a mental health specialist, but the next available appointment could be weeks away.
“The other problem with that is the doctors would send them and then the patients would fall into a black hole. The doctors would never hear anything back. There was no linkage,” says Brenda Reiss-Brennan, PhD, APRN, director of mental health integration for Intermountain Healthcare. “So what we did, basically, is said mental health is not just provided by a mental health provider. There’s a whole spectrum of mental health issues and concerns that could be addressed by the whole team.”
Shifting the underlying view of mental health away from being a specialty referral to a routine medical condition that could be treated by the “ primary care team necessitated new roles for some, and additional expertise added to the primary care clinic. “It became more of a consult, and everybody on the team did their part,” Reiss-Brennan says.
A first step was to shift primary care physicians into taking a more holistic view of mental health, essentially empowering them with tools to identify patients who need mental health treatment, and enabling the PCP to provide that treatment for certain more common conditions, including mild to moderate depression.
For many of the PCPs, treating mental illness themselves was a transition they had already made, Reiss-Brennan says. “They felt forced to take care of the depression because there was lack of support and nobody else,” Reiss-Brennan says. Especially in rural areas where mental health specialists were particularly rare, the primary care physicians “felt like they were being forced to become psychiatrists.”
Linda Leckman, MD, CEO of Intermountain Medical Group, says an early part of any mental health integration plan is reeducating the primary care physicians, because most of them have little more than their residency training to fall back upon.
“Once you’ve been out in practice, you lose some of that. So there is intensive education in regard to those conditions that are appropriate to deal with in a primary care practice,” Leckman says. “And what we have found is that about two-thirds of the behavioral health issues that present in a primary care practice can be dealt with by that primary care doctor. And it’s been really interesting, because physicians have found that to be empowering.”
Often the physicians already know which of their patients may have a mental health issue, but for others there are screening tools now in place that the PCP or other team members can use for diagnosis and assessment, starting with a patient health questionnaire, such as the PHQ-9, a series of questions about the patient’s recent mood and behaviors.
Intermountain recognized that improving mental health integration in primary care required more than just asking the PCP to “try harder.” Inevitably, addressing the access problem required adding mental health professionals at locations where they could do the most good: the practices themselves.
Simply adding mental health staff on site, so-called “colocation,” was not the complete solution. Intermountain looked at what the team makeup for mental health should be and added a variety of mental health professionals of various titles and responsibilities. They ranged all the way from psychiatrists to handle the most medically complex cases; to psychologists and psychiatric advanced practice registered nurses for screening and coordination; to RN care managers, social workers, and peer mentors from the National Alliance on Mental Illness to provide patient support, education, and a link to the entire MHI team. The key,however, is not in the staff, but in the integration.
MHI practitioners are assigned in blocks of hours based on the complexity of the patient population at a particular clinic, Reiss-Brennan says. Practitioners often rotate through several primary care clinics, so a clinic with a high number of complex mental health patients with critical needs may have a rotating psychiatrist in for a day a week, whereas other patients with a need for talk therapy can be seen by a clinical psychologist, she says.
A key distinction is that the mental health resources are “supports to the existing patient population of our primary care physicians,” says Jeremy Hernandez, regional assistant operations officer for the North Salt Lake Region of Intermountain Medical Group. “The intention is not to colocate a mental health provider at a location and have patients coming there specifically for mental health. Instead the intention is to integrate the mental health provider into the primary care team where patients can have their medical and mental health needs met at the same location.”
The role of the MHI professional is not to form a permanent therapeutic relationship with the patient, says Laurie Younger, RN, regional nurse consultant for Intermountain Medical Group. Instead, he or she assesses the patient and coordinates with the PCP to develop a treatment plan. In certain cases, however, the MHI provider, in coordination with the care manager, can act as a bridge to keep patients stabilized while the referrals to long-term mental healthcare are in progress, Younger says.
“In one of the cases, the wait time to start long-term therapy was eight weeks,” Younger says. “This patient would have deteriorated further if we had to wait eight weeks to have them see a provider. So the mental health provider in the clinic saw that patient for eight weeks, weekly, until they could get [the patient] into a long-term facility.”
The leadership team assesses need at each clinic regularly to make sure clinics get enough MHI resources to fit their patients’ needs, Younger says.
“We add resources very slowly,” Younger says. “For instance, at one of our sites, which we brought up at the beginning of last year, we added four [MHI] hours once a week. It didn’t take long to where that provider is busy [for] all four hours, so we incrementally add an hour, and then another hour. One of the ways to mitigate that cost risk is to implement slowly to make sure that you’re filling up those provider hours that you’ve allocated there.”
Intermountain also makes sure that the responsibility for mental health integration goes beyond therapists, Hernandez says. The front desk receptionist in the clinic is often the “go-to person” for insurance prior authorizations or checking on coverage. RN care managers who may be assisting patients with diabetes or other conditions will also make sure the MHI referrals are happening, and may even make referrals themselves if they notice an issue with a patient, Hernandez says.
Regardless of which team members are involved, the integration plan is still based in primary care, with the PCP at the center of a “consultative model,” says Wayne Cannon, MD, primary care clinical program medical director for Intermountain Medical Group.
“The primary care physician retains responsibility and stewardship, but not in a control sense,” Cannon says. “The mental health providers help a lot to reduce the burden because they can do a lot of things that the primary care physician can’t do as far as therapy, support, and diagnosis. But when it comes down to keeping the treatment going or making treatment decisions or just who the patient calls [for] a medication refill, that is still based with the primary care physician. So it’s a consultative and collaborative approach.”
The integration work has taken a lot of the burden off of the PCP, Cannon says.
“It helps the physician to have the whole team involved, so it’s not just you. This is the most critical factor for success. The receptionist knows what to do, your medical assistant knows what to do. So just from the very beginning, the process is easier. The evaluation is a lot easier. Before, everyone would have their own little approach to doing this, and I know the one I used wasn’t as time efficient and helpful. Once we have a diagnosis, I have people besides myself that can help.”