Mental illness often overlaps with medical illness. In an acute care setting, which group of providers should lead the patient's care? Nurses are natural integrators, but can't do it without support from leadership.
I have known five people who've lost their lives through suicide—one for each finger on my hand. I don't have enough digits to count the number of people I know who have dealt with anxiety, depression, eating disorders, alcoholism, or bi-polar disorder. And those are the ones who are willing to talk about it.
I'm sure many more friends and acquaintances silently cope with mental illness because of its social stigma, and there's data that supports my hunch. According to the National Alliance on Mental Illness, one in four adults experiences mental illness in a given year.
Martha Whitecotton, RN, MSN |
Behavioral health is something worth talking about, and healthcare providers need to get in on the conversation if they want to improve patients' mental and physical health and provide value-based care, says Martha Whitecotton, RN, MSN, senior vice president of Behavioral Health Services at Carolinas Healthcare System.
"The real drive is starting around this now because of population health, because of accountable care organizations, and because of the way that people are going to be paid—placing their payment at risk for overall health and overall cost," she says. "It's forcing the conversation around what do we do about mental illness."
Two Sides of the Coin
Anyone who has worked in a clinical setting knows behavioral health diagnoses and medical diagnoses are often treated with a siloed approach. Whitecotton gives the example of a patient experiencing severe psychosis who is also in need of dialysis. In an acute care setting, which group of providers should lead the patient's care?
"Those two things (dialysis and psychiatric care) don't exist in one place, so nobody wants to take care of the patient because they don't have an essential piece that they need to take care of him," she points out. "It's a real problem that we're going to have to address."
The way CHS has chosen to address these issues is by creating an integrated system, which the SAMHSA-HRSA Center for Integrated Health Solutions describes as systematic coordination of general and behavioral healthcare.
"It's bringing behavioral health treatment into the medical care space, and it's also bringing medical care into the behavioral health space," says Whitecotton.
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This is important because behavioral health issues do not exist in a vacuum. Patients with mental illness may also have medical issues such as diabetes. The 2003 National Comorbidity Survey Replication found that "68% of adults with a mental disorder had at least one medical condition, and 29% of those with a medical disorder had a comorbid mental health condition." Often, those with behavioral health issues end up using the emergency department for their healthcare needs.
"The sickest of the sick with mental illness often do not seek any kind of medical care other than the emergency room. They don't have a primary care provider," Whitecotton explains, "so you've got to make sure you're integrating physical healthcare into that side and mental healthcare into the physical side."
Attitude is Everything
Whether it's done in primary care, the ED, or on an acute care unit, nurses can be valuable assets when it comes to integrating behavioral healthcare, Whitecotton says.
"Nurses are natural integrators. That's what we do," she says. "We're taught from a very early educational foundation to think of the whole person and to understand, 'I'm not going to get this person well if we don't address all of these issues.'"
Some nurse leaders, however, are less than enthusiastic about dealing with behavioral health needs.
"Some of them talk about behavioral health patients as if they are poison… as if their issues are secondary to everything else that goes on in that hospital," she says.
"When you start to model that sort of behavior, you send a message that runs counter to what we really want leaders to be thinking about, which is whole person care."
Leaders who have the most success building their staff nurses' confidence in caring for patients' behavioral health needs put providing whole-person care in a positive light.
"At the nursing unit level, the degree to which my team was willing to accept something new was all in how I presented it," Whitecotton says. "It's setting the example of really modeling whole person care, and it's fascinating to watch those that don't and those that do and the impact it has on their staff's confidence."
In addition to a positive attitude, leaders can support staff nurses by providing the tools needed to care for these patients.
"If you have a large number of psychiatric patients in your emergency room, you probably need some technicians that are actually trained on how to do one-on-one care with a psychiatric patient," Whitecotton says. "You can't ask the nurses to be all things to all people in all moments. So how do you support them to do the work that they need to do?"
For more on integrating behavioral health into primary care, join Martha Whitecotton, RN, MSN, FACHE, senior vice president of behavioral health services at Carolinas Healthcare System for the HealthLeaders Media webcast, "Integrating Behavioral Health: Decreasing Costs and Improving Care"on November 17 from 1:00 –2:00pm ET.
Jennifer Thew, RN, is the senior nursing editor at HealthLeaders.