Integrated healthcare requires caution

By Michael R. Bütz, Ph.D.
May 31, 2019



behavioral health primary care integratedIntegrating behavioral health into primary care and other healthcare services has offered another service modality to our field’s bandwidth. It holds a unique place, sharing the boundary between behavioral and other healthcare services, and is best served by integrated teams.

Some have argued there is an urgent need for this treatment modality due to the current state of healthcare.

Ted Epperly, MD, wrote in 2012, “There has been much confusion, anger, myths, lies and fear around reforming our badly fractured and broken healthcare system. I have come to learn that a confused mind takes refuge in the word ‘no.’ An informed and educated mind, on the other hand, will thoughtfully evaluate the possibilities, alternatives and opportunities.”

We are making strides, moving past “no,” evaluating possibilities, alternatives and opportunities.

Reflecting on these evaluations, psychologists are called upon to gauge behavioral healthcare’s integration and consider its reach.

Take note of the models of healthcare that have emerged as integration becomes more popular and better funded and note what innovations have truly come about and how much may be old wine in new bottles.

There are compromises with certain models reflecting quality of care, screening tools and the orientation to the work suggested. There is a bandwidth of behavioral services, from population-oriented integrated models to more traditional services such as assessment and psychotherapy.

One modality is unable to displace all others, since each requires a certain environment, skills and limitations. Maintaining a bandwidth of services is necessary to successfully integrate behavioral healthcare.

A watchful eye is necessary to maintain the field’s integrity since there are certain dangers in opening it up to the broader healthcare community not so immersed in its literature and regulations, e.g. HIPAA and 42 CFR (confidentiality of drug addiction or alcoholism treatement).

Trepidations

Suggesting new models of care is a prospect that should instill trepidations and these informed trepidations may not hold for all seeking to advance this discipline. Background training may not be similar, nor the expectations of scholarship. Some argue manifesting their notions from purported data, while others claim their insights came from independent thoughts.

It merits careful consideration against the standards within the field when introducing models of care, suggested practices and screening tools. There are, for example, screening tools with smart abbreviations offered as if they are equivalent to psychological instruments. But that is where the comparison ends.

Models of care and practices

There has been an array of models and practices developed and seemingly folded into the prospect of integrated behavioral health – practice models such as IMPACT, Motivational Interviewing, or SBIRT (Screening, Brief Interventions, Referral to Treatment).

These models sound impressive with catchy acronyms or titles, and many psychologists may think these surely must be well-researched and thought-through. On examination, these practices are rather simple and rely on just a few procedures.

IMPACT (Improving Mood – Promoting Access to Collaborative Treatment) involves a register, a PHQ-9 (Patient Health Questionnaire) administered regularly and the implementation of a physician extender – a physician extender such as a bachelor’s level nurse, according to recent developments, not an independently licensed behavioral provider.

SBIRT is just that, a step-wise model described by the acronym. Although basic, it is interesting that most of these models require their own cottage industry certification training.

Like the practice models above, Motivational Interviewing (MI) has been discussed with enthusiasm in the integrated community, although it is a somewhat more complex procedurally. At the center of MI is the concept of ambivalence.

There are repeated references to this concept as well as approach and avoidance dynamics. Many in behavioral healthcare know the body of literature on ambivalence and approach-avoidance conflicts is considerable. Yet the authors present as though they invented these concepts, without addressing seminal works, let alone the work of many others before.

Systems theory, which largely made its impact in family therapy, was also threaded throughout, and again references were lacking.

Omissions are understandable at times, but neglecting whole bodies of work is a different matter. The omissions described suggest a cavalier truncation of important works that are pillars in behavioral health. At the core of MI is the notion of changing versus sustaining behaviors and with these omissions those considerations are, at the very least, incomplete.

Screeners

The vast majority of psychologists have years of training with the proper use of psychological instruments and/or tests and are aware of the standards involved. Most have likewise been exposed to the fundamentals of research design. Those measures, even the most minimal, come with manuals explaining the purpose, research, sample, reliability and validity.

When psychologists first hear measures described with the acronyms GAD-7 and PHQ-9, they may assume the same level of rigor. I did, and went looking for a manual. Instead, each was in the public domain – a curious development given how these measures were used across healthcare settings.

The GAD-7 (Generalized Anxiety Disorder – Seven), was labelled seven because it has seven questions, unlike those of psychological instruments, where the numbers describe the iteration of the instrument. There was a six-page article describing the screener’s development with a sample of 591.

The PHQ-9 was developed similarly and had a set of articles that described its forerunner and more recent use as a screener for depression.
While most psychologists will look for the manual describing a measure, providers in other fields do not necessarily know to do this. Most healthcare providers have limited training in behavioral health and tend to simply accept the face validity of the instrument and attend to cutoff scores.

Perspective

Psychologists are encouraged to become knowledgeable about integrated care and to welcome one more modality with the cautions noted above. We need to dialogue with other healthcare providers to clarify the application and limitations involved with integrated care.

We need to engage, describing the depths and breadth of our scholarship as well as the differences between screening tools and psychological instruments. For behavioral healthcare to maintain its integrity, integrated care’s potential and limitations need to be folded into the bandwidth of our field and recognized for its unique contribution and potential dangers.

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Michael R. Bütz, Ph.D., is a clinical psychologist with Aspen Practice, P.C., and St. Vincent Healthcare in Billings, Mont. His email address is: michael.butz@sclhealth.org.

 

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