In a pilot project dating to 1986, Health Partners, a large Minneapolis-St. Paul HMO, began to partner physicians and psychologists in the care of patients.
We have learned a great during the intervening years about improving care, about recognizing more fully that the mind-body split is entirely artificial, about placing psychologists and other mental health professionals–particularly psychiatric nurses–side by side into primary care settings. We have also come to recognize the mistakes made along the way, and we have worked to circumvent them.
The effort to integrate mental health services into primary care and practices began in 1986 when C. J. Peek, Ph.D., a Minneapolis psychologist, helped place clinical psychologists with special training in health psychology at eight primary care practice sites.
Although these psychologists met periodically to discuss cases with primary care physicians, the primary care system as a whole did not focus on integrated care for the next six years. When I became associate director for primary care in 1995, my challenge was to reorganize the operation of 550 physicians, 19 clinics and Ramsey Hospital and clinics. Moreover, my challenge was to add new life to the longterm efforts to integrate mental health into the primary care within these owned practice sites covering approximately 240,000 capitated patients, plus fee-for-service patients at several sites.
To lead us into a new future we began to ask about the nature of problems for which patients seek help in primary care practices–the “top 20” diagnoses recorded by our primary care clinics. We found that depression/anxiety and related disorders ranked third as the most common diagnostic cluster for primary care followed by general medical exams and respiratory infections as most common reasons for primary care visits.
These data added significant validity to the argument for improving the mental health clinical depth of all primary care clinics, moving our mental health integration effort into a top delivery system priority. It helped us efficiently manage certain kinds of mental health problems within the walls of those primary care practices.
In a large care delivery system operating in a very competitive market, such data drive how we make major strategic decisions better than do charisma, enthusiasms and passion. Our data not only helped us redefine our top priorities in primary care, but are not gaining increasing acceptance nationwide.
While we believed that it was pivotal to integrate mental health professionals into our primary care practices, we also saw as a seriously confounding factor the need to reduce the overall costs of the mental health system within the Health Partners-owned delivery system. This led to staffing reductions while the next stage of integration activities were playing out. As a next step, Health Partners, supported by Bristol-Myers Squibb, began studies in 1996 to plan the future.
They dissected our past experiences with health psychology using focus groups and semi-structured interviews with patients, physicians and health psychologists. This qualitative study suggested that just co-locating psychologists in primary care practices did not guarantee effective collaboration. While collaboration improved in some settings, the experiment never moved into rewarding teamwork overall. The results were much more troublesome than we anticipated before the study.
From extended discussions we learned that, before moving ahead with new collaborative teams, we needed to set aside precious time for assessing the perceived needs of the primary care providers (nurses and physicians) at each new site.
It was also apparent that the mental health clinicians headed for primary care locations needed special training in order to integrate successfully. Primary care, linking mind-body, offers opportunities for futureWhat we have learned from this qualitative research is a series of requirements that should carry special interest for psychologists and other mental health professionals. Among them:
- Mental health clinicians need a wide range of diagnostic skills to diagnose reliably the major mental health disorders, including substance abuse and addiction.* They must be helpful in crisis management. * They must be able to accept different time realities within primary care settings and agree to short 10-20 minute consultations on some patients.
- They must be able to understand that most patients with mood disorders and a wide variety of difficulties related to dealing with chronic medical illnesses will continue to be managed primarily by primary care physicians and nurses.
- They must comprehend that each clinic has different perceived needs, including what they determine is a specific target population, such as elderly, addicted individuals, and so forth, needing the most assistance.
- They must be willing to assist nurses and other staff members who need support and occasionally specific skill development in dealing with challenging patients.
In fact, this last prerequisite–staff development and support–may be one of the most under-recognized benefits of integrating mental health. Everyone, from receptionist to nurse and physician, must interact with professional demeanor and some degree of therapeutic intent with those few patients who visit the clinic frequently and, yet, defy or thwart efforts at assistance.
We have learned that out of 240,000 patients, we had 6,000 who visited some part of our system over 50 times per year. We discovered a remaining group with more than five medical conditions plus depression or other mood disorders. This group is a special “target” population for our primary care mental health team members.
From our successful integration sites, we have continued to learn from a series of humbling lessons. First, pre-placement needs assessment interviews with on-site primary care providers can lead to some surprisingly under-recognized preferences for assistance. Some clinics are actually not ready to accept a new member of their team. Such clinics may be struggling with new leadership transitions, cross-discipline tensions within primary medical specialties that need resolution before trying any new team expansion, unusual economic strain, or local medical leaders who do not accept that there would be a benefit to trying to integrate mental health into primary care.
We have also learned that each site may need a different type of mental health professional. Specifically, psychiatric nurses have been highly regarded for placement in primary care clinics for a number of practical reasons. They have a wider-ranging knowledge of psychopharmacology and can reinforce the primary care physicians when there are medication questions that often do not need a psychiatric referral. They also have proven effective at streamlining triage and efficient referral when psychiatric referral/consultation is needed.
Therapists themselves do not have to be Ph.D. psychologists to be effective and fully appreciated by primary care clinics. This has become important enough for us to shift the name for this integration effort to “primary care mental health” rather than “health psychology.”
Nonetheless, as body-mind collaboration increases in hospital and medical settings, primary care should offer expanded opportunities for psychologists.
Macaran A. Baird, M.D. is Associate Medical Director for Primary Care at Health Partners, a staff model not-for-profit HMO serving Minneapolis-St. Paul and surrounding environs. His professional universe includes the 550 physician Health Partners Medical Group, its 19 clinics, and Ramsey hospital and clinics.