If I could go back in time to the private internal medicine and pediatric practice that I left eight years ago, I’d do many things differently. This is particularly true when it comes to the integration of behavioral and physical health in my office practice. First of all, I would redecorate. And, I would go to more parties. As odd as it may sound, both would have helped me provide my patients a better connection to behavioral and mental health care.
New Dr. Bestermann’s Review Notes can be found at the end of this story.
Looking back, I recognized that my staid doctor’s office was emblematic of a profession that—often inadvertently—closes the door on conversations about mental health. And when those discussions did occur, I wasn’t plugged into a local network of behavioral health specialists I could ask to help care for those patients.
Why integrate behavioral and physical health care?
Truly integrating physical and behavioral health care creates opportunities to drive better outcomes and lower costs in ways we’re not yet fully realizing. Consider this:
Outpatient mental health services and inpatient psychiatric care make up less than 5% of a typical health plan’s medical expenses.
But, behavioral health as a comorbidity is a massive driver of other medical expenses. For example, depression co-occurs in 17% of cardiovascular cases, 27% of patients with diabetes, and 42% of cancer patients. And injuries related to suicide, homicide, and accidents are 2 to 6 times higher for people with a history of mental illness.
Whole-person (and lower-cost) care must start with the head if it is to have an optimal impact on the body. I see that now, from my position within a health services company whose integrated care teams round daily at the conference table rather than at the bedside. They do this to surface and address both clinical and behavioral care needs.
Advanced integrated “behavioral + physical” care delivery networks like the ones that Evolent Health (where I work) and our health plan partners create are still not widespread. However, the good news is that clinicians who haven’t yet been brought into an integrated network can take steps to create better connections even outside of a formal structure.
When a patient’s walls are closing in, a physician’s walls can open them up
My hallways were such an opportunity to create a safe space for my patients to open up about more than their physical needs. My exam room walls were canvases to paint myself as an ally in caring for their lives, not just their bodies.
Instead, I had what most of us have: Anatomy posters. Diplomas. Those hotel-neutral florals that no one actually sees.
What a miss to invite conversations about the behavioral and social issues that might have been impeding my patients’ path to better health. These issues range from taking their medication or getting to their appointments, participating in risky behaviors, or masking the real reason behind a new bruise.
And instead of just saying “take this medication to get your hypertension under control,” I’d probe more about stressors that might complicate that hypertension, taking a more proactive approach to invite my patient’s whole self to treatment.
Inviting conversations matters
Inviting conversations matters: In one 2007 study of domestic violence screening in emergency departments, where many victims seek care after encounters, one practitioner elicited a story of abuse just by mentioning the word “stress” and following up on a patient comment.
Yet only 6% of people who sought out a shelter for relief from domestic abuse learned about the shelter from a health care provider. That’s the same percentage who learned about the resource from a flyer they may have seen on the back of a bathroom stall. It’s far lower than the 25% who learned about the resource from police, after their situation had already escalated to requiring legal intervention.
In another tragic example, research suggests that young men who join gangs consistently exhibit developmental characteristics that progress from “deep-seated frustrations in early childhood” to antisocial personality disorder, typically rooted in disrupted home lives. These behavioral “hints” offer incredible opportunities to reach out to treat a depressed, neglected child before we have to treat a gunshot wound. This type of behavioral treatment is definitely in our lane, too.
Office decor: a symptom of lack of integration of behavioral and physical health care
Primary care office décor is just one of the symptoms of the lack of connection between behavioral and physical health care, despite a lot of rhetoric about “integration.” As an industry, we’ve finally started to incentivize primary care and other clinician use of the GAD-7, PHQ-9, and SBIRT anxiety and depression and substance abuse screening questionnaires. However, this is still inconsistent across health plans and practices. Furthermore, it is barely a start toward the behavioral health integration that we need.
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So, I would have converted my passive landscape scenes into decidedly active invitations to engage:
A photo of a young man alone at a street corner.
A nontraditional family playing together.
A doctor reaching out to a homeless person at a bus stop.
A domestic abuse hotline poster.
I would have invited those conversations, via my environment and my actions. But having those conversations would have gotten me only so far without someone to refer my patients to.
Related Content: Why We Need to Unlock the Full Potential of Primary Care
Training and office practice reinforce the separation of behavioral and physical health care
Young physicians growing their practices face a twofold issue in building behavioral health capabilities: Most have limited exposure to behavioral health care in medical school. And once in practice, they have limited exposure to behavioral health practitioners.
I think I had a total of two months of rounding with psychiatrists in medical school, one inpatient and one outpatient. I did learn a lot, but I don’t recall, in those rounds, that the psychiatrist ever asked someone with depression about their diabetes. Nor did endocrinologists ask patients about their depression.
So, we come into our own practices with a lack of integrated training. And then we’re coached to network on our own with those who can refer patients to us.
In building my practice, I sought out cardiologists, obstetricians, and other clinicians who could contribute to my patient panel. I also joined formal society meet-and-greets, which were a great way to build my relationships.
But I don’t think I once attended a networking event that intentionally brought together local primary care practitioners with local psychiatrists, social workers, and other behavioral health guides and clinicians. When I started in practice, I didn’t know any.
My patients taught me about the gap in care
It was my patients themselves who helped me build a personal network of trusted behavioral health practitioners. They told me who they were seeing, and they showed me a gap in my own Rolodex that I then worked to close.
Going back in time, I’d have asked my medical school to sponsor more interaction among new hospitalists, internists, pediatricians, and behavioral health clinicians. I think health systems in larger cities should do this regularly for people at all career stages.
It would be a great boon to those who recently relocated to a new city and need to build personal lists of trusted providers across specialties, including behavioral health. And, it would create connectivity that currently does not exist outside of formally integrated behavioral + physical care delivery networks.
What true behavioral and physical health care integration looks like
I left private practice in part because I felt rushed all the time and realized I wasn’t providing the integrated care I truly believed best for my patients. I sought to affect health care in a broader sense.
Today, in my role supporting health plans, I can take in the big picture that was often hard to see from within the private practice. For example, I’m on a multi-specialty team that comes together a couple of times each week to discuss complex patient cases. We challenge and inform one another on approaches to treatment. From our vantage point, the interrelated nature of physical and behavioral health comes into sharp focus.
Our clinicians bring a list of hospitalized patients with red flags—perhaps a patient with diabetic ketoacidosis who is refusing medication and has a remote history of bipolar disorder. The clinician notices that the patient doesn’t have a psychiatrist assigned, suggesting a gap in care management. Discharging that patient without intervention is highly likely to result in a rebound.
But with our integrated care team, a case manager will hear the patient’s story at the same time as a behavioral health expert, with a medical doctor in the room to weigh in on what post-discharge follow-up should look like.
The patient will likely be put in a complex care program and followed for a couple of months, with a care manager assigned to help the patient make and keep appointments and receive guidance on any needed social services.
Integrated care like this can put a spiral of bad health back on course by convening multiple minds to treat a life, not just a body.
The bottom line
It wasn’t until I gave up my private practice in 2013 and joined a formal integrated care team that I truly saw how behavioral and physical care can inform one another, the gaps in my own training and networking, and what I could have done differently in my private practice to act more like an integrated care provider.
The good news is, even though integrated delivery networks are still young and not all practitioners have access yet to formal team structures, there are actions that any family practitioner can take immediately to build better connectivity now between behavioral and physical care.
Medical Reviewer Notes by Dr. Bestermann
This article makes a significant point that should be addressed. Patients do not receive the behavioral health interventions that they need nearly often enough. That said, the point must be made that this is part of a much bigger problem. We cannot fix behavioral health adequately without a broader solution.
Today more than ever, primary care doctors in a fee-for-service financing model are governed by the tyranny of the urgent, and they are burning out like never before. They are trapped in a system that sets them up for failure. Asking them to add more attention to mental health issues just stretches the rubber band a bit further.
Chronic disease drives most health care costs, and mental health comorbidities make progress much more difficult. However, just exhorting primary care to pay more attention to mental health won’t accomplish a thing except to frustrate primary care providers. Progress requires a comprehensive solution— new science, new systems, and new payment models.
Here is an example of what I am talking about. Adverse childhood experiences create epigenetic changes and increase cortisol levels which activate the same receptor as aldosterone. Aldosterone is a critical driver of metabolic syndrome and its consequences. These changes adversely impact physical and mental health later in life.
We are not translating the science showing physical and mental illness have the same roots. We will not succeed until we have primary care teams that are designed to manage the whole patient with chronic disease using treatments that protect cells and organs.
Tiffany Hall, M.D., CHCQM
Tiffany Hall, M.D., CHCQM, is board-certified by the American Board of Internal Medicine and American Board of Quality and Utilization Review (ABQUARP) and a member of the American College of Physician Executives.
Dr. Hall earned her M.D. from the University of Tennessee Health Science Center, is a Magna Cum Laude graduate from Fisk University, and will complete a Master of Business Administration (MBA) from Louisiana State University in the fall of 2021.
For 11 years, Dr. Hall was a partner in an internal medicine and pediatric private practice. She has also served as the co-owner of a certified readmission prevention homecare agency and as a medical director for multiple health plans.
Since 2020, Dr. Hall has served as the Senior Medical Director of Utilization Management at Evolent Health. She works with an integrated team to provide holistic care across physical and behavioral healthcare.
She enjoys running, travel, and family time with her husband and three children in her spare time.