Mental health conditions such as anxiety, depression and substance use disorder are among the most common — and disabling — health conditions worldwide. Yet, according to the University of Washington, 50 percent of individuals who are referred to mental health specialists by their primary care doctor never follow through on that referral. And among those who do go to the first appointment, many do not continue past the initial visit.

It’s a sad statistic that Natasha Withers, DO, a primary care doctor at UVM Health Network – Porter Medical Center in Middlebury, has often seen play out among her patients.

“There’s probably two reasons why that happens,” Dr. Withers explains. The first stems from a huge shortage of psychiatric specialty care in Vermont. “There’s such a long wait time that the patient gives up or changes their mind about wanting to see the psychiatrist.” The second speaks to the stigma surrounding mental health care. “When someone comes into a primary care practice, no one knows why they’re there. But if they walk into a psychiatrist’s office, everyone knows why they’re there. That can be a huge deterrent.”

Removing Barriers to Care

Dr. Withers and others within the UVM Health Network are working on a solution: integrating mental health services into primary care. It’s a new model that will be coming to Porter Medical Center in the fall of 2021, with the hope of eventually rolling it out to all 37 primary health care sites within the UVM Health Network. 

With this approach, the primary care practice will have its own on-site psychiatrist and therapist available to both meet with patients and consult with the primary care physicians behind the scenes.

Sara Pawlowski, MD, is a UVM Health Network psychiatrist who has spent time in several Chittenden County primary health care practices over the last year, as they have begun to implement the mental health integration. She says that this indirect consultation, in particular, is a direct remedy for the region’s shortage of psychiatric specialists. “It allows for the primary health care provider to receive in-house continuous education on psychiatric medications and treatments. This empowers them with more knowledge that can ultimately reach, and benefit, more patients [than was possible through referrals alone].”

Better Care, Better Outcomes

It’s a model that has a long history and a proven track record. According to Dr. Pawlowski, the University of Washington’s AIMS Center – which stands for Advancing Integrated Mental Health Solutions – has implemented this approach for more than 30 years, reporting data in more than 80 randomized, controlled clinical trials that have shown its effectiveness for patient outcomes and provider and patient satisfaction as well as health care system cost-savings. The reason it hasn’t been implemented more widely, Dr. Pawlowski says, is because the startup costs involved in reorganizing a primary health care practice in this way – which involves hiring more specialists and care managers – can be prohibitive.

Yet, this shift to enable the delivery of more efficient and proactive health care for the entire population is a key component of the UVM Health Network’s Strategic Plan, says Ron Hallman, a spokesperson for Porter Medical Center. “As we move from the fee-for-service model to one of population health, we’re able to create more value for patients. It’s a very worthwhile investment,” Hallman says.

Treating the Brain and the Body

As both Drs. Withers and Pawlowski explain, integrating mental health care into the primary care practice allows providers to review health-care-use data and diagnoses from all patients to identify who in their practice may be more likely to suffer from a mental health condition. This population-health-based approach, says Dr. Withers, is the most innovative part of the integration.

“For instance, if someone keeps coming to me with diabetes that’s uncontrolled, even after I’ve explained the steps they need to take to get things under control, they’re probably not engaging [in their diabetes treatment] because there are other things going on,” she says. Knowing that uncontrolled diabetes is closely linked to major depression, and having that patient flagged as an at-risk individual, helps prompt the provider to ask further questions. “And, even better, having mental health specialists right down the hall helps create a safe space for that patient to open up about their barriers to better health, whether it’s, ‘actually, I can’t afford my medicines,’ or ‘actually, I’m so depressed that I don’t even want to think about my diabetes.’”

According to Dr. Withers, “In the moment that the patient accepts help, it’s great to be able to say, ‘Okay, let me bring in the psychiatrist or the therapist to make an introduction.’” Also, allowing the subsequent referral visits to happen within the anonymity of the primary care office removes the stigma. “Giving people the privacy they need to utilize these services is really empowering.”

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