By integrating a behavioral health team and a telemedicine component into all 250 of its primary care practices, Carolinas HealthCare System is trying to head off a potential behavioral health crisis in doctors' offices and emergency departments.
Mental health deserves, but fails, to garner the same amount of attention that guns get whenever there is a mass killing involving a firearm. The mental health question is asked, but never really explored in mass media the same way that guns and the laws that govern them are.
Maybe the television talking heads can't find two experts to talk about this complex issue because there is a nationwide shortage of mental health providers. Or maybe it's too complicated to fit into a 30-second sound bite.
Whatever the reason, emergency departments around the country are seeing patients whose behavioral needs are not being met at increasing rates. The growing shortage of mental health providers, services, and facilities is national, but one health system is trying to head off impending crises in primary care offices.
Carolinas HealthCare System has begun integrating a behavioral health team into all 250 of its primary care practices. The initiative comes on the heels of CHS opening an inpatient psychiatric facility, Behavioral Health-Davidson, serving the Charlotte area, where the nonprofit integrated health system is based. The 66-bed psychiatric hospital also includes an adjoining outpatient clinic.
Services for behavioral health in North Carolina mirror shortages that are found in the rest of the country. According to the federal government's last count in 2013, thirty-six of the state's 100 counties are designated as Mental Health Professional Shortage Areas (HPSA), and another report estimates 28 counties are without a psychiatrist.
Martha Whitecotton, senior vice president for Behavioral Health at CHS says the organization is providing a behavioral health team to its primary care practices for a couple of reasons. One is that patients are less likely to feel the societal stigma of mental illness in their primary care doctor's office.
Equipping Physicians
Another important, and potentially overlooked reason, is that while primary care doctors often prescribe medications addressing common behavioral health conditions, such as anxiety and depression, physicians are not adequately supported to initiate a conversation about mental healthcare and/or follow up with those patients.
"When a patient does speak up to their primary care doctor, if intervention doesn't happen, no one knows it doesn't happen," Whitecotton told me.
And if there is no intervention, the likelihood of a crisis with that patient increases. Those crises can be scary for the patient, their families, and the public.
Setting aside the divisive issue of whether physicians have a public health role to play in educating patients about guns, there is no question a doctor's guidance at the right time can help a patient in need.
Embedding Mental Healthcare in Primary Care Offices
Whitecotton says CHS is taking a tactical approach to the behavioral health team that will be available to its primary care practices.
"We deconstructed the behavioral health provider," she explains. "If you think of the roles, there is [a gamut from] diagnosis… to scheduling. We took all those roles and put them in a team the practice could access virtually via telephone or video."
The team also includes a health coach, psychiatrist, and psychopharmacist.
CHS has a long history of providing telemedicine, which Whitecotton says was a big help in moving this type of service forward. The system can't afford to embed mental healthcare physically at each practice, but the team will spend about a month at each primary care office educating the physicians about drugs, dosing, screening, accessing the team, and getting comfortable with the types of conversations they will have with patients about mental and behavioral health.
"The [behavioral health] team becomes part of the primary care team," says Whitecotton. "As each week goes by, they spend less and less time physically there, but more virtually."
CHS has rolled out its new behavioral health model in one practice, a five-physician family practice in Mint Hill, NC, a suburb of Charlotte. At this location, physicians will hone their skills at screening patients.
"We're not screening everyone, we don't have the resources to handle that onslaught of volume," says Whitecotton. "We're relying on patients who self-identify or a provider, upon evaluation, identifies a problem."
Patients who are prescribed anti-depressants will also be screened. If their screening indicates further diagnosis is needed, the patient will be moved out of an exam room and into another room where the behavioral health team can be accessed for a diagnostic interview.
Drugs and dosage are decided there, and the patient is given a health coach who will call "at prescribed intervals" to make sure the medication is being taken. "The health coach is a safety net," says Whitecotton, who estimates that CHS will eventually have 40 health coaches when the initiative is fully up and running at all of the primary care practices.
Patients also have access to online cognitive behavioral therapy (CBT). Whitecotton says CHS can offer eight online CBT treatments for the price of one face-to-face appointment.
"We're striving to do things that are economically viable," she says.
Some Challenges
Fitting mental health into a primary care practice does bring challenges, mainly time. Primary care physicians are already squeezing patients in, sometimes for only 12–15 minutes at a time.
"We need much more capacity in our healthcare system for mental health to work," says Molly Cooke, MD, FACP, president of the American College of Physicians, who last week renewed its advocacy for treating gun-related violence and deaths as a threat to public health.
Cooke, who is a general internist, says she is used to screening for depression, but with more people coming into the healthcare system through the exchanges and the expansion of Medicaid, the ability to provide some mental healthcare to patients will get even more "challenging."
Removing the shame that comes with a diagnosis of depression, anxiety, bipolar disorder, and other mental health conditions could help patients adhere to medication and other treatments. It's an unexpected benefit that in addition to treating the disease, doctors can also help ease its stigma.
Jacqueline Fellows is a contributing writer at HealthLeaders Media.