Improving Health Outcomes Through Integration

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Traditionally, when a person visits their primary care physician the concentration has been on their physical health, generally on the ailment that was identified by the individual. As the healthcare landscape in New York is changing, so is your typical primary care appointment.

The work being done in Project 3ai, Integration of Behavioral Health and Primary Care Services, is transforming primary care culture, infrastructure, and workflows in order to deliver appropriate care to patients when they need it most. Through the support of Care Compass Network’s Project 3ai, Lourdes Ascension is seeing major success.

Lourdes Ascension chose to integrate a Licensed Master Social Worker (LMSW) or a Licensed Clinical Social Worker (LCSW) into the primary care setting, as well as adopted evidence-based Patient Health Questionnaires (PHQ) 2 and 9 for the primary care team to screen and monitor their patients’ mental health wellness during appointments.

Lourdes is also implementing the Collaborative Care Model (IMPACT), an evidence-based treatment model, at several of their primary care clinics. This model has been shown to be more effective than usual care in the treatment of depression, anxiety, and co-morbid medical conditions such as Diabetes and Cancer.

Prior to integrating a social worker into a primary care setting, if a patient was presenting with a mental health issue, a separate appointment at another location would have to be made, often times resulting in the person having to wait weeks or sometimes even months, to be seen by a social worker or another behavioral health professional that could help them address their mental health needs. Behavioral health integration removes that extra step, providing the patient with easy access to someone who can help them immediately while visiting their primary care physician.

The PHQ2 and PHQ9 assessments quickly help the physician understand whether or not their patient is experiencing any symptoms of depression and/or mental health distress such as suicidal ideation. The PHQ2 is a two-question screening that rates each question on a scale of 0-3. If the score is a 3 or higher it is considered a positive screen which then triggers the PHQ9, a nine-question assessment that enables the physician to further diagnose, monitor, and measure the severity of the patient’s depression. Clinical guidelines were created and adopted by Care Compass Network’s Clinical Governance Committee, which is made up of physicians and behavioral health professionals across the Southern Tier, to help standardize the appropriate interventions depending on the PHQ9 score. According to the New York State Department of Health’s DSRIP (Delivery System Reform Incentive Payment) specification manual for Screening for Clinical Depression and Follow-up Care, a score of 5 or higher on the PHQ9 assessment is considered positive.

Having a LMSW or LCSW in the primary care setting transforms and optimizes the way care is provided, breaking down barriers and stigma for both the patient and the physician. A warm handoff between the physician and social worker can happen immediately while the patient is in the exam room, removing silos that were present in the past. This integrated care model removes a multitude of Social Determinants of Health (SDoH) factors such as transportation, food insecurity, housing instability, etc. With the patient in a place they are familiar with and comfortable, they are more apt to feel secure with their medical care and open to utilizing additional resources.

“Working collaboratively with the primary care physicians via warm handoffs has shown to have a positive effect on our patients while enhancing the working relationship between two different disciplines,” shares one social worker at the Lourdes Main Street Binghamton location. ” I feel the physicians appreciate the help from social workers and are finally seeing the need for this interaction to occur in order to ensure the highest quality of care to all of our patients.”

Lourdes Ascension first piloted the integration of LMSWs and LCSWs at their Robinson Main Street location in Binghamton, NY. The administration at Lourdes saw the incredible benefits to both the patients and the providers, and have since integrated social workers into 13 of their primary care sites.

Mindy Barnes, LMSW, began as a primary care network social worker in august 2019. She met with the team prior to transitioning into her role and recalled that “They [clinicians] could not have been more receptive to bringing on a social worker.” Barnes feels that this was due to the strengths of the office environment as a place where “holistic, patient-centered care comes naturally to them.” Importantly, Barnes points to the operations manager of the office who “recognizes the connection between patients’ physical health and their use of the health care systems, to their mental health and determinants.” It was a combination of these factors that made integrating a social worker into the office “an easy and welcomed transition,” as Barnes puts it.

Having a physician champion a part of the implementation team and in the senior leadership role, clearly makes the integration of social workers into the primary care setting more successful. And why not? Having a social worker on the care team in the physician’s office ensures that they have someone right there to provide immediate assistance to a patient who needs behavioral health interventions and services. It’s helping mitigate physician burnout and the stress that many providers are feeling and suffering from.

A physician generally has fifteen minutes with a patient and a lot of concerns can be thrown at them in that short time frame. By bridging the two worlds of physical and mental health, it builds collaboration that can get the patient help immediately, thus removing additional stress and worries on the clinicians such as wondering if they did enough for their patients. ” For the social worker to be able to come right into the exam room and act as an extra helping hand for the provider, it not only leads to a strengthened patient-provider relationship, it also takes the weight of worry off the providers’ shoulders,” shares Barnes.

There are clear cost savings and positive impacts to having a social worker integrated into the primary care office. Having social workers manage and intervene when a patient is experiencing a mental health crisis, often times, mitigates visits to the Emergency Department (ED) or to a Comprehensive Psychiatric Emergency Program (CPEP). Patients receive the help when they need it in  a less invasive and more comfortable setting. In a 2016 webinar, New York State reported that Medicaid members with a behavioral health diagnosis accounted for 53.5% of hospital admissions and 45.1% of ED visits, but not all of these are medically necessary.

Many people often don’t know what services are available to them or what kind of help they need. Having a social worker on staff to connect patients to the right level of care is beneficial. “Working in a primary care setting you come across many people who don’t know where to start when connecting to services,” shares a social worker at Lourdes Ascension. “There are many services available but are often challenging for patients to navigate.”

One social worker at Lourdes Ascension, shares a story about one of her patients that had shown up at the primary care office and was looking for help but didn’t know where to go. After spending some time with the patient, she found that they were dealing with depression and anxiety but were unsure of what to do next. They didn’t have a primary care physician, so she quickly connected them to a physician at the office and scheduled follow-up appointments to help them with their mental health. “As the office social worker, I met with [the patient] multiple times and found they needed a higher level of care than the short-term help I could provide. I was able to sit with the patient and help them fill out the necessary forms that would get them into the long-term care they needed. Working in this setting and being able to witness and connect patients to the services they need is a truly important role. Without the guidance this patient was provided, it is uncertain if they would have connected to counseling services, let alone a primary care physician,” shares the social worker.

Seventy percent of all antidepressant prescriptions in the United States are written by primary care providers and are administered without the assistance of counseling. Having a social worker on staff that works in conjunction with medications provides better care for the patient, setting them up for success. This is due to social workers not just counseling their patients on big picture, long-term goals, but they are helping them to set small self-management goals. According to SAMHSA, up to 45% of individuals who die by suicide have visited their primary care provider within a month of their death. Trained to be able to access a patient’s willingness to change (Motivational Interviewing) and navigate a patient’s feelings, social workers who are embedded in a primary care office can provide a higher level of care when those individuals are identified through evidence-based depression screenings.

Caitlin Oswald, another Lourdes Ascension Social Worker, shares an experience that brings that to light. The office she was working in had a patient that was visibly upset in the exam room, the physician turned to Caitlin to have her engage with them and see if there was something more they were experiencing. “I sat down with the patient and started discussing what was going on. The patient started to engage with me, expressing how she was feeling so overwhelmed for a variety of reasons. During this conversation the patient started to discuss other symptoms of depression. I was then able to review their PHQ9 score and further explore these symptoms they were feeling.”

At the end of the encounter, Caitlin advised her to pursue counseling for her depression and shared support services in the community. The patient declined but later called the office. “The patient shared with me that they were actually waiting at the crisis center. They reported to me that after discussing their symptoms and identifying how high they had scored on the PHQ screen and realizing how emotionally driven they had been at the office, they were finally able to accept the fact that maybe they needed some extra support to help them through all of this,” shares Oswald. “She was very thankful for our discussion as it was the first time she had explored how depression can become this vicious cycle and how this was affecting other areas of their life.” Caitlin later followed up with the patient to see how they were doing and the patient reported that they had been evaluated and will be attending sessions at the outpatient mental health services the following week.

Integrating behavioral health services into primary care settings changes the dynamic of care and the delivery of services. Not only is care more coordinated due to constant communication, but there is a better recognition of and decreased stigma of mental health conditions.

“We learned a lot from this collaborative experience,” says Mindy Barnes, who saw firsthand as she integrated into one of Lourdes’ primary care offices. “For one, it immediately became clear that we were being provided the perfect opportunity to reevaluate our current practices and reeducate ourselves on mental health policies. But something even more amazing was also happening. Everyone in the primary care office from front office staff and providers to patients, were talking about mental health in a non-stigmatizing and supportive environment.”