Primary Care and Behavioral Health Integration

August 14, 2014

Alice Washington from California Institute of Mental Illness

In this episode of Mental Health Matters, we break down what the integration of physical and behavioral health care means for doctors and patients. Guests are Dr. Karen Linkins of the Integrated Behvavioral Health Project and Alice Washington from the California Institute of Mental Health. 

MHM - Primary Care and Behavioral Health Integration


 Hi, welcome to Mental Health Matters. I am Shannon Eliot.

Today we will be looking at the concept of integrating physical and behavioral health care. Dr. Karen Linkins is the project director of the Integrated Behavioral Health Project, an initiative to accelerate the integration of behavioral health services and primary care in California. Dr. Linkins leads projects involving the creation and evaluation of integrated care systems at the federal, state and local level.

Alice Washington is an associate at the California Institute for Mental Health. She’s recovered from mental illness and views herself as a survivor of public mental health services. Alice is passionate about including the voices of people with mental health issues in trainings, policy and research. Welcome Karen and welcome Alice. Thank you so much for joining me today.

Karen, can you tell us what integrated care is and how it differs from how health care has been delivered in the past?

>>Sure. You know integrated care is a service delivery approach that brings together medical and behavioral health services and by behavioral health we mean both mental health and substance use services. And the whole idea is to really get to the issue of integrating the mind and the body because with physical health care we focus on the body. With mental health care we focus on the mind but it’s really important to integrate the two and to see people as a whole person and that’s really the focus of integrated care. What sets it apart from usual care is that integration and the whole framing of the individual who is seeking care as the whole person and the provider sees the whole person as they develop a treatment plan.

>>Seems logical.


>>Alice, why is the primary behavioral care collaboration in particular so important? What are the benefits to come out of that?

>>So I think the integration of primary care of mental health and substance use is very important for clients. For years we have been treated kind of having our body separated from our body and so the collaboration is important because we have found that over the years people have developed physical health issues that are leading to premature death. For instance with me, I have diabetes because of psychotropic medications and I am obese from them so collaboration for me is a life and death situation. I need to be aware of my self-management plan and not to be treated differently because of physical health and mental health and often times in mental health we encounter a lot of stigma. When I go into primary care I don’t encounter a lot of stigma. They are more focused on recovery, wellness and resiliency for me so collaboration and integration is very important.

>> I think that Alice brings up a really important point about the stigma piece, because there are so many people, you know, with mild to moderate conditions who are afraid to seek care for what they’re recognizing maybe as depression. They don’t feel quite right and so they are likely to go to their primary care physician. And so when there is capacity on that side of things, it makes it so much easier for those people to get care, because they can get diagnosed and then get recommended treatment or you know, maybe it’s a medication that they need, but it’s an easier way to access services.

>> And if it’s easier for them they are probably more likely to go and come back and maintain their health. How important is integrated care when it comes to monitoring behavioral health treatments? That’s probably something that a lot of people think about.

>> It’s really critical. I mean its in terms of monitoring both you know, both behavioral health treatments but also physical health treatments because typically in primary care if the mental health condition is not recognized then and it goes untreated it actually has a negative impact on certain conditions like cardiovascular disease, depression; I mean, I’m sorry, cardiovascular disease, diabetes; those types of diagnoses where those conditions typically are accompanied by depression and so individuals aren’t going to get well or they aren’t going to manage their diseases as effectively as if both are being treated. And then on the behavioral health side, one of the biggest problems, and Alice alluded to this earlier; individual with mental illness die on average twenty-five years earlier than the general population and a lot of that has to do with the fact that we’ve made amazing advancements in psychotropic treatments you know for different mental health conditions. However, they also have side effect profiles that actually lead to major physical health complications and so if the behavioral health providers don’t recognize that then they may think that they’re doing a great job because, hey, this person is doing so much better. They’re happy. They’re like living their life but they could have untreated diabetes which ultimately will kill them and that’s why you have that disparity in terms of you know, the age at which people die.

>> And that’s a good point because we’re talking about a third of an average life span.

>> Yes.

>> That’s very significant.

>> Well, actually in certain Alameda Counties they actually did their own analysis and they found that their populations were dying on average around the age of forty-one which is pretty horrible.

>> So I wanted to say that around the experience of actually accessing care, primary care, as a person of color I feel more comfortable in primary care because they don’t have that stigma associated with mental illness. I experience less racism in my life, but I experience a lot of stigma due to mental illness in my life ,so being in primary care is comfortable for me to get the care.

>>When implemented, what does integration look like and how is it operationalized?

>> Well, you know, in California we typically see four different types of models. So you have behavioral health with primary care being integrated into it. You have primary care with behavioral health being integrated into it, and then you also see coordination across those types of agencies. So that would be like a primary care clinic coordinating with a behavioral health clinic and they typically are doing things like coordinating referrals and even medical records and that kind of thing. And then there’s the fourth area that is very important in rural areas that include; that really includes the whole technology of telemedicine and so that’s, it’s kind of a different kind of integration but we still consider that especially with the telepsychiatry and that sort of thing. It’s a way of bringing in capacity to those areas where you see workforce discrepancies in terms of what’s needed.

>>Would you say it is a little bit of a newer development?

>> You know, it’s actually been going on for quite some time. I think that what’s different is that we haven’t necessarily seen it as integration. It was a physician meeting a psych consult or something like that, but now it’s actually seen as a broader component of the treatment and so case managers and a broader treatment team would have awareness of those consultations and have access to them.

>> What considerations need to be made for special groups like children, older adults and cultural communities?

>> Well I think that Alice alluded to the stigma that we see with the vulnerable populations and you know, and for so many of these populations whether it’s kids or older adults or people of color, the experience in traditional mental health settings can be very off-putting and lots of times you know, there are certain cultural groups where mental health is not even really a concept. It’s a different kind of concept. It is not understood the way we understand it in our western terms. So primary care is such an important place for access because it really is kind of understand that that’s a component of their lives.

>> Karen, how would you say health care reform has supported integrated health?

>> Well it’s really interesting. There is a fundamental concept in health reform that I’m not sure everybody knows about. It’s called the triple aim and it’s really getting at the notion behind why we want to do health reform. The triple aim seeks to increase population health, increase patient or client experience, improve patient or client experience, and then decrease cost. And the whole idea behind that is that that can happen if we first of all measure it and track it and pay attention to it. And then second of all, reach efficiencies in the way that we do service delivery so that it can actually affect those areas. So you know for example, everybody hears about decreasing the cost of health care but you really can’t do that if you don’t pay attention to; do we have better health outcomes? Because if people are not getting well and they’re getting sicker they’re going to use the emergency departments or more expensive services so there needs to be attention to that. And then there’s the whole piece about the patient or the client experience that’s critical because you know, without attention to that that’s really about quality improvement and because if people don’t want to seek care then they’re not going to and so then they you know, they remain sick and you know, the bad outcomes happen.

>>Would you say we have the infrastructure for this? Are we prepared for this?

>> I think so and I think that you know, increasingly in California in the federally qualified health centers as well as on the behavioral health side within the counties there’s such a growing recognition and actually already a recognition that there needs to be care integration and care coordination that there’s a lot of attention on it. It’s really an issue right now of just you know, continuing to be; continuing to grow it and I think some of the components that are missing, that have been missing that people are starting to recognize are they really center on involving the client and putting the client at the center of care and also involving peers to really make sure that the experience that’s occurring isn’t just driven by the professionals. It’s really responsive to the need of the community and to the needs of the individuals who are seeking the care.

>>Alice, why are you excited about integrated health care?

>>Well, I think one component of the triple aim is the understanding the experience of the client. I think with that type of focus we have the possibility and the potential to decrease stigma and to improve health outcomes. With my experience of integrated care I have a health home but I am my primary care coordinator and some people may say that I need a care coordinator to help with my diabetic care but I do have a team. But my being my own care coordinator allows me to focus in on my self-management plan. It allows me the opportunity to be involved in my outcomes and not have someone sort of directing me or case managing me and letting me know what I need to do in terms of that self-management plan. I hope in the future as the affordable care act is implemented we can have self-management go into substance use services; go into mental health services because I think because physical health does have that self- management component for the clients. I think clients may feel better if they learn self-management in mental health and substance use. It’s primarily medical model focused, but I think one of the important things is although it’s medical model, it’s medical model because it’s physical health and I think people should not push back at that concept because we need to pay attention to the whole body as we mentioned earlier as oppose to just focusing on the mind separate from the body.

>> What would each of you say the implications are of integration for both patient and doctor?

>> The implication for integration for both client and doctor is the accountability. For so long in our mental health system there has been a lack of accountability and I think this has really affected the client experience. So with accountability we can focus in on improving the client experience. With accountability, I think we can focus in on improving the client experience and their outcomes so that people don’t fall into crisis and so on.

>> Well then I would say from the standpoint of when you asked about doctors, I would say, I would broaden that to be the health care professionals as well as the behavioral health professionals. I think that it’s absolutely imperative that they have a team and that they are actually seeing the client as part of the team to achieve the goals that they have as professionals. You know, because they all have been trained and they actually want to have good outcomes, but they are not going to be able to achieve those outcomes individually and so for example, for a physician the whole idea of integrated care actually gives leverage in terms of you know, the prescription. Here’s your prescription. Well if they don’t actually pay attention to the fact that the client is homeless or doesn’t have stable housing or has you know, social conditions at home where they don’t have a refrigerator for their prescription, that’s a problem. So the person, the individual, is not going to pick up their prescription. They’re not going to take the prescription as prescribed and that kind of thing.  And that’s where and so the health outcome is not going to be great. And with integrated care there’s more likelihood that the prescribing physician is going to have an awareness of the person’s social context and you know, their living situation and then can prescribe appropriately.

>> I think one of the most important implications is that doctors will be able to focus in on wellness, recovery, and resiliency in this new system of integrated care.

>>How do doctors feel about the trend towards integrated care?

>> In my experience with the physicians that we’ve worked with and also with the clinics that we’ve worked with, they’ve been very open to it because you know they are under such time constraints the way that our health care system works. I mean you go to the doctor and you know, you get ten minutes, maybe fifteen minutes and that’s not very much time to be dealing with individuals and you know all of their issues and so what I was saying before in terms of the promotion of better health outcomes, it’s really predicated on having a more robust whole person centered approach. And by having integrated care and by having a care team that includes behavioral health specialist and that sort of thing and peers they are going to be able to achieve those outcomes better and they can feel better about…

>>Alice, as someone who has faced both a mental and a physical health condition, what challenges have you faced in the past in receiving health care?

>>What has happened is, being in primary care I had a physician who did not have a team. He discovered that I had diabetes but he wasn’t able to explain it in a way that I could understand it and so I was left; my diabetes was left untreated for a couple of years. And the real issue there was the doctor wasn’t trained in behavioral health care. He didn’t know how to work with people who had mental illness, but I had a nurse practitioner who was trained in behavioral health care and she was able to find a physician who understood mental illness. And so he took me aside and sat me down and he moved the monitor and he said, “Look, this means you have diabetes and we need to take care of it because the consequences is death”. And so I look at the people who are dying prematurely early who are in just a one way system of care of mental health without that focus on physical health and I think they’re dying early because of that just that one focus on the mind as opposed to the rest of the body. So I was able to connect with a doctor who understood behavioral health services and I know that as we do the affordable care act primary care doctors may not have that skill. I mean, I only found one doctor but how many other doctors don’t have that skill?

>>How do you see the challenges that you had and that you face being solved with integrated care?   

>> Well, I think as Karen alluded earlier, a team is very important. As I have managed my diabetes, I started with my primary care doctor and my nurse practitioner and now I have a psychiatrist and I have a diabetic nurse and I have a cardiac nurse all due to the affordable care act because they are working in the area of prevention. They are preventing stroke, heart attack and so on with me and so….. Can you clarify the question again?     

>> How do you see the challenges that you had and that you face being solved with integrated care?

>> So again, having this team is important, and I work with them probably every three of so months with labs my diabetes has improved. At one point I was in the mental health part of my work and they thought it was an eating disorder and I started eating the wrong way and there were consequences to that. And so I had to go back to primary care and have my plan reset. And then I had to unfortunately ignore some parts of mental health because the down side is, mental health may not understand physical health and physical health may not understand behavioral health services so there are two sides of the coin where these two fields need to come together in a collaborative fashion; in an understanding fashion where they can learn to inform each other so that they can take care of that client because the consequences and the challenges I felt was the lack of knowledge on both sides; the primary care not understanding behavioral health services and mental health not understanding physical health services. So, I got caught in the middle and oftentimes I’d have to walk that middle to get to my good quality of life ,my good outcomes.

>> Well what Alice is talking about is really important because the… you can hear in what she’s describing a scenario where a lot of the burden is on her as the individual with you know, diabetes and a mental health condition and she ends up being the person who has to help coordinate between the two sides and that’s okay and that’s where a lot of misinformation and information can just get dropped. And so it’s a scenario where the behavioral health side, there needs to be a recognition that the treatment may actually come into conflict with conditions that are on the physical health side and vice versa.

>> So Alice, some patients have reported feeling stigmatized by their providers. Why should stigma matter to all providers and if the patient is feeling stigmatized what should they do?

>> Well stigma promotes bad outcomes. Stigma promotes less quality of life. Stigma promotes death. The advice that I would give to clients is to not go into primary care in order to address physical health issues with a mindset that I’m gonna get stigmatized and I’m gonna get hurt like I did in the mental health system. I think it’s important for us to take care of that internal stigma that has resulted from mental health care and sort of use it to our advantage and help the doctors on both sides; mental health and physical health side understand that we’ve been traumatized by care. We’ve been traumatized by stigma. And really being compassionate when that person walks through your door for a whole health sort of appointment with you and to understand that that person may not believe in you because they’ve been hurt so much and they think it’s a medical model but I think the opportunity is to help them understand it’s a wellness model.

>>What advice would each of you give to patients who might have both mental and physical health symptoms?

>> I would say, have high expectations for your providers and be open and clear about what your needs are and also understand that you have some responsibility in it. You know, as Alice has been describing, there is the self-care component of this which is really critical. There’s no quick fix but it does; there’s actually a lot of empowerment that individuals can have in working with their primary care physicians and their behavioral health team and they should not discount that.

>> And to wrap us up, what advice would you give to doctors?

>> Have an open door an open mind and an open heart because the reason why we don’t come through your door is because we’re afraid of being hurt and that’s a result of the stigma and discrimination we have experienced over the years either through to ethnic racial considerations or even mental illness or substance use itself. So open your door. Open your heart. Open your mind because you know, we’ve seen what has happened when our doors are closed to folks who need help.

>>Well thank you Karen and thank you Alice for your expertise and for joining me today. The best of luck to the both of you.

>>Thank you.

>>Thank you.

>>You can learn more about the Integrated Behavioral Health Project at The Mental Health Primary Care and Substance Use Interagency Toolkit is an in depth guide on integrated care and how everyone involved in the process can work together more efficiently. You can download it on the CalMHSA website at or at the Integrated Behavioral Health Project website at

If you are a primary care doctor you can get a primer on how to better interact with patients with mental health challenges by watching a short video titled “Bridging the Gap”. You can find it at

The Center for American Progress released a report called, “Mental Health Care Services and Primary Care” tackling the issues in the context of healthcare reform. It considers various issues in mental health care and suggests options for reform. You can find it at

Thank you so much for watching. We’ll see you next time.