Integrating behavioral health models in practice

A new integrated behavioral health model at Sixteenth Street Community Health Centers (SSCHC) in Milwaukee encourages closer collaborations between medical providers and mental health team members to better address the needs — and meet the goals — of patients together. The model, which evolved to its current iteration in 2012, has roots dating back to 1998.

SSCHC is a group of health clinics that cares for an underserved population. With the integrated behavioral health model, behavioral health clinicians practice on the same floor as primary care providers to immediately address mental health concerns, such as depression, anxiety, suicide avoidance, and alcohol and drug abuse, during a patient’s primary care physician visit. For a negligible cost investment, SSCHC has found it is more efficient to marry these services in the same location, and patients definitely benefit.

One way the team has gauged success for its open access comprehensive services is by the high rate of walk-ins. In a recent fiscal quarter, the social services staff reported making about 6,000 follow-up phone calls; conducting approximately 2,000 appointments; and receiving more than 3,500 walk-ins.

Integrated model

The first step in implementing the new model was to put primary care physicians and behavioral health clinicians on the same floor so that patients’ physical health and mental health concerns could be promptly addressed. After some trial and error, we began scheduling only half of the behavioral health appointments and leaving the rest open for real-time doctor referrals. We used physician schedules to identify the right time slots for scheduled appointments, providing real-time slots as the day progresses and more people are seen on site.

We keep open slots on the schedule for behavioral health clinicians so that medical teams can immediately refer patients who show signs of emotional issues, stress and other mental health concerns. With everyone on the same floor, the behavioral health team is close by to complete an assessment. Supportive social services are also available to assist patients and their families with crisis intervention, resource referral and advocacy.

A plan of care is created after each assessment to ensure patient care is coordinated. For example, the plan of care for a depressed patient might include steps for staying active: spending more time with family, a conscious effort to increase his or her social life or learning new things.

Immediacy is key for curtailing behavioral health issues. By bringing in a social worker or another member of the behavioral health team, whether it be a licensed clinical counselor, psychologist or licensed marriage and family services counselor, a patient can immediately talk about his or her situation. The main goal is to reach patients right away, let them know help is available and give them hope. Physicians are experts in treating physical wounds from trauma while the behavioral health team lends a hand in providing emotional care.

Working together

The goal of this collaboration is to align treatment for patients with mental and physical health issues, such as depression and diabetes, or attention deficit hyperactivity disorder (ADHD) and pediatric care. The team works with the whole spectrum of patients, from 3-year-olds to 87-year-olds, regarding behavior problems, family trauma and common mental health issues.

The focus is on intervention and relief during three sessions, each lasting no more than 30 minutes. Clients are more specific about their concerns and motivated to make progress during these shorter meetings. Team members help patients make lifestyle changes they can incorporate into their routines. For example, diabetic patients often receive stress management and relaxation therapy through monthly classes or group sessions that teach progressive relaxation.

In our experience, by teaching patients how to better manage stress, they are less likely to become depressed. In turn, patients with increased emotional stability are more in control of themselves and their health issues, making it easier to manage their disease.

Understanding patients

Team members try to customize appointments as much as possible and use face-to-face time with patients and their families to help address any concerns. A staff member might walk parents through their child’s ADHD questionnaire during a scheduled primary care physician visit instead of sending it home where parents can easily lose or forget about it. Concentrating on a child’s mental health concerns during a primary care visit also cultivates a conversation about what to do in the home to minimize ADHD behavior. Parents receive both medical and behavioral advice tailored to each child and his or her family’s lifestyle.

This integrated model also fosters a culture of open communication among providers and mental health specialists. However, even with mental health clinicians close at hand, physicians still need to advocate for behavioral health help and understand how some mental health issues might aggravate clinical concerns. For example, a patient diagnosed with depression and diabetes might not keep up with his or her diabetic treatment during a difficult episode.

We also have found that there is no need to “medicalize” everything. Social work concepts like playing to a patient’s strengths help identify cases where medication or formal medical treatment like therapy isn’t needed. That might mean drawing on a patient’s strengths in planning, saving and reaching out for family support. Applying those strengths in the patient’s medical care can have a positive effect on outcomes.

When an elderly patient visited one of our clinics recently, her doctor was concerned that she was depressed. He asked a social worker to talk with her before he prescribed medication. During the assessment, the patient explained that she spent a lot of time traveling across the country visiting her children and she missed her home. So instead of prescribing antidepressants, her medical team recommended that she spend more time at home. The patient took the team’s advice and is doing much better and enjoying regular activities again.

Another social work concept built into the integrated behavioral health model is the environment. Physical aspects (such as exposure to lead or access to clean water), community aspects (such as the availability and proximity of healthy food options) and the home environment (such as safety, security and loving support) all have an impact on patient health.

Other SSCHC programs, such as social services and the Parenting Resource Center, support the work of the behavioral health staff. This multidisciplinary team includes bilingual and bicultural clinicians who encourage family wellness by building bridges with patient populations that are often difficult to reach.

Reduce the stigma

A key feature of the integrated behavioral health model is that it helps reduce the stigma associated with mental health. In 2014, SSCHC conducted more than 21,000 individual mental health sessions on the shared floor compared with 18,187 the previous year.

The integrated model eliminates the fear or pressure often associated with seeing a therapist because patients are in their medical doctor’s office though they might be talking with a counselor or social worker.

Patients react more favorably to physician recommendations to see behavioral health colleagues when they are on site, and anecdotal evidence suggests that the convenience and immediacy also help with follow-up treatment.

With the help of a $1 million grant from the Aurora Health Care Better Together Fund, SSCHC plans to increase access to integrated behavioral health services for community members in the future.