Doctor holding clipboard counsels patient.
Primary Care

Integrated Care for the Whole Person, Without Stigma

By on 11/13/2020

Matthew Behme, MD, and his colleagues in primary care had recognized for years that taking care of patients involved far more than just prescribing medicines and other typical treatments for physical diseases.

Whether it’s substance abuse, depression, motivation for change or barriers imposed by poverty, “probably one-third of my job is behavioral health,” Dr. Behme says.

All of these conditions can affect physical health, too. Yet doctors weren’t able to thoroughly address them within a traditional format of 15-minute appointments.

But thanks to a grant-funded program now in its second year, the Community Practice Center at Einstein Medical Center Philadelphia has adopted an approach that integrates behavioral health and primary care.

Managed by a licensed clinical social worker, the program features:

  • Screening of all patients for depression, anxiety and substance abuse
  • “Motivational interviewing” and counseling for anyone who encounters barriers to managing a health condition, from diabetes or heart disease to substance abuse
  • Regular follow-up by phone for many patients
  • Group therapy (now both virtual and in person), particularly for those trying to quit smoking or recovering from opioid abuse with Medication Assisted Therapy (MAT) using the prescription drug Suboxone
  • Collaboration with Emergency Department physicians who prescribe MAT and participate in group therapy
  • Part-time participation by a psychiatrist in the primary care office
  • Referral to a therapist for those who need longer-term individual treatment for depression or other mental health issues

Convenience and Reduced Stigma

All of these services, except for traditional outpatient therapy, are integrated into the primary care practice, Dr. Behme notes. This makes things easier for patients and helps them bypass the stigma that so often discourages people from accessing behavioral health care, including addiction treatment, he says.

“By having this care integrated into the office, many issues related to stigma go away,” he says. “The patients who come to our office get their physical health and their behavioral health needs taken care of in the same office where patients receive care for other chronic illnesses like diabetes or hypertension.  They sit in the same waiting room, are seen in the same offices, and receive care from the same doctors.”

The integrated behavioral health program is funded by a three-year grant – totaling $150,000 – from the van Ameringen Foundation. The foundation has a longstanding commitment to supporting innovations in mental health care in disadvantaged communities in New York City and Philadelphia, says Executive Director Hugh Hogan.

Underserved neighborhoods such as those near Einstein can experience high rates of medical conditions such as diabetes and heart disease, as well as mental illness exacerbated by violence or generational poverty, Hogan says. “That is really continuing to undermine the ability of physical health providers to do their job and help people heal.”

Wellness Education and Counseling

Clinical social worker Jacqueline O’Duor, LCSW, was hired with the grant money to help patients address any factors that may be holding them back from realizing good health. Often, her role begins when a patient is having difficulty keeping up with medications, losing weight or making lifestyle changes such as quitting smoking.

“We usually call Jacqueline our ‘wellness coach’ to further take away any stigma that’s around the term behavioral health,” Dr. Behme says. “I’ll say to a  patient, ‘We have a wellness coach in the office. She’s really good at helping people who find it hard facing the same challenges you are facing.  It would be great for the both of you to meet.'”

If the patient agrees, O’Duor comes into the room and starts a conversation. “I do education about chronic illnesses in layman’s terms,” she says. “Then, once they get that big picture, it makes it easier to understand the importance of medication and care in terms of attending appointments.”

She also asks about any aspects of everyday life that might affect the person’s ability to stay healthy.  “That could be something like not having transportation to get to appointments, not having financial stability in order to pay for medication, not having enough money for healthy food to eat in terms of managing illnesses such as diabetes and obesity. There are multiple elements of people’s lives that make it hard to manage illnesses.”

O’Duor provides referrals to an in-house nutritionist as well as community services. Patients may want to talk about anxiety, depression or managing trauma or violence in the home. She can help people accept a diagnosis, think about how the illness will affect their lives and learn how to manage it.

Coping With Health and Other Challenges

Nicole, a patient who did not want her last name used, says O’Duor has helped her cope with the often  overwhelming demands of caring for many people in her family and managing multiple medical conditions of her own.

“I’m very comfortable with telling her everything that I’m dealing with mentally, physically and emotionally,” she says. “Medication can’t fix everything. Mentally, you have to prepare your own self for whatever you’re going to go through.”

For people who want to make a change, such as lose weight or quit tobacco or opioids, O’Duor begins with motivational interviewing to assess whether they are truly ready.

“If people are ready to change, then we come up with a game plan and including supports that may help them. If they aren’t ready, we continue to be available to engage with the understanding that making life changes is difficult. And if they’ve already made the change, we provide the support to help people keep from falling back to where they were before.”

Most appointments are short – 15 to 30 minutes. Follow-up may include regular phone calls by O’Duor, group therapy and sometimes individual visits to manage chronic health concerns. For those recovering from addictions in particular, the frequent contacts help to prevent relapse.

Supporting People to Make Changes

If someone is ready to make only a small change, “it gives them the confidence to be able to move forward and make additional changes to improve health,” O’Duor says. “It feels really good to see people have the confidence to take that control of their lives.”

Joe, 58, a patient in the MAT program, says Einstein has made a huge difference for him since he came here three years ago. “He and Jackie call me just to check on me, just to say hi,” he says. “They really care. They’re wonderful people.”

He has stayed off heroin and received both emotional support and help with health problems he had neglected. “Dr. Behme got my blood pressure under control, and I got a colonoscopy,” he says.

“One day, almost two years ago, I was keeled over with pain. Before, I would always run to heroin. So I called Dr. Behme and he told me to get the emergency room right away. I had a complete blockage with my gallstones, and he saved my life that night.”

The integrated behavioral health model also helps doctors, including residents, learn more about managing patients with mental health issues, Dr. Behme says.

He’s now recruiting a second licensed clinical social worker to help expand the program. At some point, Dr. Behme says, he would like to add another “hub” – ideally in the Northeast – for patients who need behavioral health care, especially those recovering from addictions.

It’s too early to know the results at Einstein, but the experience of programs elsewhere suggests that integrated care can lead to improvements in patients’ health and even in the cost of care, Dr. Behme says. Generally, the effectiveness of programs such as this are measured on a five- to 10-year timeline, he says.

Take a patient with diabetes, for example, Dr. Behme says. “By stopping even one patient from going down the wrong road, you can be saving hundreds of thousands of dollars. If you just look at the repeated hospitalizations and the complications that can occur, it’s difficult to overstate the financial impact.”

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