NEW YORK – Integrating mental health care into primary care settings offers clear benefits for patients and providers. However, careful planning is key to making these models work, clinicians said at the American Psychiatric Association’s Institute on Psychiatric Services.
Among the challenges psychiatrists, social workers, and other mental health clinicians face when trying to merge their services into a primary practice are resistance to collaboration among primary care physicians and other non–mental health clinicians, stigma regarding mental health diagnoses and treatment, communications issues, and the difficulties of treating complex patients, said Dr. Orit Avni-Barron, a psychiatrist at the Gretchen S. and Edward A. Fish Center for Women’s Health at Brigham and Women’s Hospital in Boston.
Dr. Orit Avni-Barron
"When you work with people who are [primary care physicians], dermatologists, or surgeons, they don’t exactly know what mental health [services] can do for them," she said. "They expect things to be fast and to be a certain way, and we need to manage those expectations. In addition, because ours is an outpatient setting, we deal with very medically complex patients who have multiple Axis III diagnoses – a lot of medical issues – in addition to Axis I and Axis II problems," she added.
The five essential elements for effective integration of mental health services are self-definition, interdisciplinary team work, effective communication, limit setting, and education, Dr. Avni-Barron said.
‘Not Hidden in a ... Corner’
Mental health teams must clearly define their role within a practice, said Suzanne Etre, one of two clinical psychiatric social workers at the Fish Center. Given their large staff-to-patient ratio (three MDs and two social workers comprising 2.9 full-time equivalent staff), the mental health staff decided that the only practical approach was to define the service as short term by offering assessments and consultations. Staff physicians perform medical evaluations, recommend medications, and follow patients until they are stable.
Staff social workers help patients with cognitive-behavioral and solution-focused interventions, and also assist with adjustment disorders or bereavement issues. Patients with trauma or more extensive needs for psychiatric services are referred to other providers.
The mental health staff work with primary care physicians within the clinic, share expertise in patient management, and build trust through repeated interactions and scheduled team meetings so that each team member understands the capabilities and limits of the mental health service.
"We try to optimize the value of repeated interaction so that we’re not hidden in a little corner of the practice, and we repeatedly try to build that trust – them with us and us with them. It really helps us to clarify what our roles are," Ms. Etre said.
Setting Limits Key to Success
Primary care practices with a small mental health staff cannot be everything to everyone, and therefore must establish clear limits for both patients and clinicians working in the practices, said Lynn Curran, also a clinical psychiatric social worker at the Fish Center.
Mental health staff members model how to set boundaries and support the ongoing efforts of other clinicians in the practice to maintain them, she said.