Leveraging Primary Care is a Winning Strategy for Behavioral Health Services

A pair of clinical leaders shares how their health systems have implemented embedding behavioral health professionals in primary care practices.

Embedding behavioral health professionals in primary care practices drives significant benefits for patients and health systems.

Providing patient access to behavioral health services is a challenge for health systems.  But Sentara Health and Virtua Health are taking on this challenge by integrating those services with primary care providers.

"For Sentara, it is about access to care," says Charles Dunham, MD, the health system's executive director of medical operations for behavioral health. "For us, the primary lesson learned is that we can get patients seen faster. Patients appreciate this care—they consider it as part of their normal routine of care."

For patients, embedding behavioral health professionals in primary care practices reduces the stigma of seeking behavioral healthcare, says Samuel Weiner, MD, vice president and CMO of Virtua Medical Group, which is part of Virtua Health.

"By embedding psychiatrists in our primary care practices, patients don't have to worry that they have been referred to a psychiatrist's office or a therapy office," he says. "They are just going to their primary care office."

Samuel Weiner, MD, is vice president and CMO of Virtua Medical Group, which is part of Virtua Health. Photo courtesy of Virtua Health.

Models of care

The embedded mental health therapist model at Sentara meets a need for primary care patients, according to Dunham.

"Primary care providers do an excellent job with most patients with behavioral health needs, but there are patients who we wanted to refer to mental health therapists or psychiatrists, and it took a little while," he says. "We came up with a couple of ways to deal with this situation, and one of them was the embedded therapist model."

These therapists provide care in a hybrid model, Dunham explains.

"Therapists spend some of their time in the clinic and some of the time providing services through telehealth," he says.

At Virtua, the model for embedding behavioral health professionals in primary care practices has evolved over time.

"We started with physically embedding a handful of licensed clinical social workers in our primary care practices to provide therapy for patients," Weiner says. "We also had a psychiatric nurse practitioner who was available to support the licensed clinical social workers. The psychiatric nurse practitioner was also able to consult with our primary care physicians regarding diagnoses and recommendations regarding therapy and medications."

The next step was bolstering the medical side of behavioral health services by adding three psychiatrists to primary care practices.

"The psychiatrists can offer what amounts to a consult service for our primary care patients," Weiner says. "So when our primary care physicians are faced with challenging cases in terms of behavioral health or mental health, they can refer patients to be seen by the psychiatrists or psychiatric nurse practitioner, who will then evaluate the patients and start them on medication."

Adding psychiatrists to primary care practices has allowed Virtua to maximize a scarce resource, according to Weiner.

"There is a practical issue that there are just not enough psychiatrists to go around," he says. "If these psychiatrists took patients on and continued to see them forever, they would quickly fill up their patient panels and would not be able to provide services for our primary care patients. They are available for short-term support, then get patients back to their primary care physicians."

Virtua is now offering comprehensive behavioral health services through their primary care practices.

"We have the medical piece with the psychiatrists and the psychiatric nurse practitioner, and we have the therapy piece with the licensed clinical social workers," Weiner says.

Charles Dunham, MD, is executive director of medical operations for behavioral health at Sentara Health. Photo courtesy of Sentara Health.

Advice for other health systems

For health systems that don't know where to start when it comes to embedding behavioral health professionals in primary care practices, Virtua's experience is instructive.

"We had to start somewhere, and we started by establishing our licensed clinical social worker team to come in and provide therapy," Weiner says. "From there, we were able to build the medical capabilities of psychiatrists. Now, we are building a non-clinical social work capability. You need to pick a starting point, then build from there. The needs of the patients are going to guide you."

Some health systems may be concerned about scarce resources and return on investment. According to Weiner, Virtua has seen a strong ROI.

"There is clearly a return on investment in terms of patient satisfaction—patients love these services being embedded in their primary care practices," he says. "It makes them feel like they are being cared for as a whole person."

The ROI also includes reductions in hospitalizations and emergency department visits, Weiner explains.

"There is a clear benefit when patients have easy access to behavioral health and mental healthcare—they just do better in leading healthy lives," he says.

The strategy also benefits health systems, according to Dunham.

"It is better for us financially," he says. "If we have a therapist who can work with a primary care physician either in the office, virtually, or both, then we do not have to pay for extra office space or pay for extra front-desk staff. From an administrative standpoint, this model helps us make sure that these services are sustainable. We have a good contribution margin from the therapists working in this model."

Implementing a model of care such as embedding mental health therapists in primary care practices is "very doable," Dunham explains.

"If you can find a physician champion in primary care who would like to have this kind of support, primary care practices would love to have the support of mental health therapists," he says.