December 2019, Volume XXXIII, No 9
Behavioral health consultants
A valuable new member of the care team
ntegrated care, as defined by the Substance Abuse and Mental Health Services Administration (SAMHSA), is “The care that results from a practice team of primary care and behavioral health clinicians working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population.” The goals of behavioral health integration within the medical and dental settings are to increase access to behavioral health services, help primary care providers and dentists manage behavioral health conditions that arise during patient appointments, and provide whole person-centered care.
Primary care: the front line
Behavioral health problems are common within primary and dental care. Primary care is often the first place a patient will go when they have mental health symptoms, and primary care providers are often the first to identify that their patient has a potential mental health issue. The National Alliance on Mental Illness (NAMI) suggests that patients may feel stigma or shame in seeking a mental health counselor, but feel comfortable in raising concerns with a trusted primary care physician during the course of a routine visit or annual physical, both of which often include screening with PHQ-9s or similar patient health questionnaires. The Centers for Disease Control and Prevention (CDC) estimates that one-fifth of primary care visits address mental health concerns, often resulting in a prescription for psychiatric medications or a referral—although patients often fail to follow through on referrals.
Studies show that 50% of Americans will have a diagnosable mental health disorder in their lifetime. Only 29% of those people seek out specialty mental health services, and 21% are treated in primary care. Many mild to moderate mental health diagnoses, such as anxiety and depression, can be managed within the primary care setting. Fifty-nine percent of those with a diagnosable mental health disorder receive no treatment at all. For those who want specialty behavioral health care, the wait times can be long—up to three or more months for psychiatry or psychotherapy. With these lengthy wait times, it is imperative that primary care providers feel equipped to manage multiple mental health symptoms.
Primary care is often the first place a patient will go when they have mental health symptoms.
In the dental department, patients may present with a multitude of mental health conditions that make it difficult for the dental staff to complete treatment. Not only is there the typical anxiety that many people have when visiting the dentist, but there are patients that have had traumatic experiences that make being in this vulnerable position (lying back, mouth open, hands/tools in the mouth) difficult. There is a perceived loss of control and potential for triggering trauma responses, which could include yelling at the dentist in an effort to regain control. Dentists may have someone present after a sexual or physical assault that damaged their mouth/teeth or perhaps a sexually transmitted disease in the mouth due to an assault. Additionally, substance use can cause oral cancers or teeth that break or fall out. Delta Dental reports that people with mental health concerns may have poor oral health due to limited motivation for performing self-care activities, like brushing teeth. Depression can also cause people to have unhealthy diets, and conditions like canker sores, teeth grinding, temporomandibular disorders, and dry mouth related to certain types of medications.
Another area of concern that presents in primary and dental care is the behavioral components of medical conditions—for example, the patient with diabetes who does not test their blood sugar. These situations can be frustrating for a primary care provider. The patient may be labeled as noncompliant with medical treatment, when in fact there might be barriers, either socially or mentally, that inhibit a patient’s ability to follow through on the recommendations. There is a high correlation between chronic diseases and behavioral health concerns.
All these issues are likely well-known to primary and dental care providers. Providers may feel ill-equipped to manage such complex conditions during their short office visits.
Integrating a behavioral health provider into the medical and dental departments can help address these concerns without adding to the medical or dental provider’s workload.
Backing up the front line
Behavioral Health Consultants (BHCs) are behavioral health providers who serve as medical or dental team members. The embedded BHC can assess, diagnose, and treat mental health conditions and work with patients on behavioral concerns, all while staying within the medical department—and, since oral health can affect overall health, dental departments. The BHC can provide diagnostic clarification on behavioral health concerns to the primary care provider and work with the medical and dental providers on an integrated plan of care, which might include medication management and/or returning for follow-up visits. This approach reduces the need for patients to visit multiple facilities, since referrals can be made inhouse.
The scope of the BHC practice is a population management approach. They share the patient panel and plan of care with the medical provider. Their goal is to provide small changes in large numbers of patients. They are also able to respond to crisis mental health situations that could derail a medical provider’s schedule due to the multiple care coordination needs. The BHC can help determine if a patient is safe to leave the clinic, develop safety plans, and arrange transport to the hospital if it is unsafe for the patient to leave the clinic.
The mantra for the BHC is “There are no wrong referrals.” The BHC accepts all referrals, which could range from very specific to very vague. Referrals could be for typical psychological complaints such as mood disorders and substance use, or for multiple medical conditions such as headaches, insomnia, chronic pain, and chronic diseases. Additionally, the BHC could help with socio-emotional problems like domestic violence, bereavement, or marital problems, along with parenting or behavioral problems in children. The list of possible reasons for referral is endless, and certainly all medical clinics have patients come in with many if not all of the above concerns.
One-fifth of primary care visits address mental health concerns.
Within the scope of this population management approach, visits with a BHC mimic those of primary care. A BHC will see a patient for 15–30 minutes per visit and work to target one specific patient need. Just as the medical and dental providers have to wade through lengthy problem lists to determine the course of the visit, so does the BHC. If the visit is about diabetic management and is with an uncontrolled diabetic patient, then the BHC works with the patient on behavioral changes to improve their condition. This type of intervention is called a Health and Behavior Assessment/Intervention, and there is a list of billable CPT codes for the BHC to use for this type of visit. There is potential, though, that the BHC may see the patient and learn that significant mental health concerns pose a barrier to managing diabetes. If so, they may instead do brief psychotherapy or a brief diagnostic assessment to determine the mental health diagnosis.
Interventions, outcomes, and barriers
A BHC could perform many interventions. For hypertension, a BHC might teach the patient relaxation skills, problem-solve barriers to an improved diet, work on motivation to increase physical activity, and explore barriers to medication adherence. For chronic pain, interventions might help the patient shift the focus from pain avoidance to pain acceptance, develop skills for pain management like pacing activities, and clarify their values so that they may focus more on what they value than the amount of pain they are experiencing. Core interventions include motivational interviewing, cognitive behavioral therapy, psychoeducation, and goal setting.
The benefits of an integrated approach to patient care are many. The first is that medical and dental providers will have someone to refer to in these challenging situations. They can hand off the patient to the BHC and then continue on to their next patient. This team-based approach will help to improve care outcomes as the providers are able to address medical and mental health conditions in an interdisciplinary approach. This approach also helps with the reduction of cost of care as we can catch and treat conditions before they turn into emergency situations requiring an expensive emergency department visit or hospitalization.
While the concept of integrated care has been discussed for many years, organizations are just now working to implement these ideas. Barriers to implementation often come from the administration level regarding the question of “How to pay for it?” The BHC is a clinical-level staff member who may not be in the organization’s budget. The recommendation would be to look at the big picture of what value integrated care can bring to the clinic. There is an increase in patient and provider satisfaction, an increased use of primary care, and improved patient outcomes. In addition, there is reduced emergency department utilization, reduced hospital admissions, and a reduction in specialty referrals, all of which are costly services for the organization. BHCs are often able to bill for their services, which can help cover the expenses of hiring a provider.
Behavioral health integration is a rapidly growing field. Medical and dental providers are increasingly utilizing behavioral health consultants to manage complex mental health and behavioral concerns, and patient outcomes are improving. Patients are more readily able to access mental health services and are satisfied with the whole-person care approach.
© Minnesota Physician Publishing · All Rights Reserved. 2019
Jeni Kolstad, MSW, LICSW, is a Licensed Clinical Social Worker with a master’s degree in social work. She also has a certificate in nonprofit leadership. She practices as a behavioral health provider at Open Door Health Center in Mankato and is the organization’s Behavioral Health Integration Coordinator.