Watch the AMA's daily COVID-19 update, with insights from AMA leaders and experts about the pandemic.


In today’s COVID-19 update, experts discuss the Behavioral Health Initiative (BHI) Collaborative and how to integrate behavioral health into your practice, an issue that takes on new urgency with COVID-19.

Speakers

  • Kathy Blake, MD, MPH, vice president, health care quality, American Medical Association
  • Kristin Kroeger, chief of policy programs and partnerships, the office of the CEO and medical director, American Psychiatric Association
  • Amy Mullins, MD, medical director of quality and science, American Academy of Family Physicians

Unger: Hello, this is the American Medical Association's COVID-19 update. Today we're discussing integrating behavioral health into your practice, an issue that takes on new urgency with COVID-19. I'm joined today by Dr. Kathy Blake, vice president of health care quality at the American Medical Association from Santa Fe, New Mexico. Kristin Kroeger, chief of policy programs and partnerships, the office of the CEO and medical director, American Psychiatric Association in Washington, DC and Dr. Amy Mullins, medical director of quality and science at the American Academy of Family Physicians in Leawood, Kansas. I'm Todd Unger, AMA's chief experience officer in Chicago. Dr. Blake, let's begin with you. Will you talk about the need to integrate behavioral health into practice? Was it there long before COVID and can you explain why it's so important right now?

Dr. Blake: Right. So it has been there for a very long time and many different efforts have been applied to try and provide adequate, in fact, high quality behavioral health care to patients. And we first became very aware of this with a value-based care external advisory group that we convened at AMA a couple of years ago, and somewhat to our surprise, the attendees at that group, be they large employers, health plans, family medicine clinics, federally qualified health clinics, they told us one and the same, that if we did not address the behavioral health needs of patients and do so adequately and universally, that we would never get to value based care. So for us, that was a wake up call

Unger: When you, can I talk to you a little bit about, you've done a lot of digging and research into this. Can you talk about what you learned from the RAND study about this issue?

Dr. Blake: Yes. So our next step was to say, let's do the research and let's talk to a wide range of practices that had integrated behavioral health care into what we might call total patient care, whole person care. And what they told us is about their successes and their challenges. Their successes were greater satisfaction on the part of the clinicians, as well as the patients. Better outcomes, but they also told us that there were a number of challenges, such things as having enough access to individuals, psychiatrists and others who had the expertise that was needed. Overcoming stigma amongst patients, their families and sometimes amongst clinicians. Being very fearful about getting the billing and coding correctly done and being able to sustain it on a long-term basis. So is at that point that we said within the Federation of Medicine, the various specialty societies, there is tremendous expertise, experience, programs. And so that's when we brought individuals from American Psychiatric Association, Family Physicians, other organizations together.

Unger: That's a great segue. Ms. Kroeger, like so many things that we're seeing right now, these are problems that existed before the pandemic and have been exacerbated by it. So why don't you talk a little bit about why focusing on behavioral health is particularly important right now?

Kroeger: Sure. Thank you, Todd. COVID-19 has really only increased the importance of integrating behavioral health into primary care practices. Prior to COVID a large portion of Americans were affected by mental health and substance use disorders. And they're really still not receiving the care they need, and now with COVID, it's really only exasperated those problems. So the mental health toll on coronavirus really has been shown to increase the need. There's stress, there's isolation and trauma from what is going on today.

Kaiser Family Foundation survey came out a few months ago that more than a half of Americans felt that mental health has deteriorated during the pandemic. And CDC has really said that they found this really disproportionately impacts Black and Hispanic communities. The American Psychiatric Association did our own survey in late March. So about a month into the pandemic, and more than one third of Americans, 36% say coronavirus has seriously impacted their mental health and most, almost 60% feel coronavirus is having a serious impact on their day to day lives.

So what we're seeing here is most adults are concerned that the coronavirus will have a serious negative impact on their finances. That was 60% of respondents and almost half were worried about running out of food, medicine and supplies. So their everyday lives are significantly being affected. So now since access to psychiatrists and other mental health professionals is extremely difficult sometimes, considerations for integrating behavioral health care into primary care practice business models are being widely examined. And in parallel, looking at the physicians need to address their own mental health and wellbeing. So the integration of behavioral and physical health care is more important now than ever and leading forward for both patients and physicians.

Unger: Can I ask you a simple question, just so that our viewers out there understand. When you talk about integrating behavioral health into the model, what's that mean specifically in terms of a change that you're going to see?

Kroeger: So what you're going to see is the patient receiving mental health care within the primary care office. That can be by a psychiatrist or other mental health professionals or a combination in a team-based care approach. So they receive their mental health needs in the primary care office addressing the physical health and mental health needs at the same time.

Unger: Okay. Dr. Mullins, can you talk about what you're seeing in your practice?

Dr. Mullins: Sure. And I agree with everything that has been said. And I think that one of the things that we need to really emphasize is that if behavioral health needs are not met, then physical health needs are even more difficult to meet. So it's really hard to control a patient's diabetes or high blood pressure if we're not addressing the behavioral health needs first. So that's why this conversation is so important and it's so paramount that we really emphasize the need to do this and to address these needs upfront. And one of the things we saw as the pandemic began, is we saw primary care offices and really offices all across the country, really pivot. And they pivoted overnight to offering many services, but a lot of behavioral health services via telehealth. And it was something that they had not really been compensated or paid to do in the past.

And it was one of the silver linings that we saw, if we can find a silver lining amongst the last nine months, let's try to look for one and find one, but that's one that we could see was practices were being paid to deliver tele-health in ways that they hadn't been before. And one of the services they delivered was behavioral health services to their patients, and they were able to experiment and try some things that they hadn't had the ability to do before. And I think that that may be a kickstart to really more practices trying to integrate behavioral health into their practice and deliver the behavioral health services their patients need and meet them where they are in ways that they hadn't been able to in the past.

Unger: And on the flip side of that, of course, are what our health care providers are going through right now. Physicians and their teams, obviously under a great deal of stress. Can you talk about that angle?

Dr. Mullins: It's been a huge problem and it's not just the physicians, it's their staff, and it's trying to take care of their team, take care of their patients, take care of everyone's mental wellbeing has been really difficult. And as a lot of practices shifted to online only or virtual care, those teams got broken up or they got to work in ways that were unusual or different for them, and they had to really change the way they were interacting with each other and interacting with their patients. But they've really found their footing. But I think that the stress is still there because change is hard and we had to change overnight. So it wasn't like, let's talk about the change, let's plan for the change. Let's do some short PTSA cycles and see how we can incorporate this change slowly and in the best way, it was, we need to change and we need to change tomorrow. So it was really hard and we're still seeing some effects from that.

Unger: And that's so important because we have a long road ahead of us still. And that's a good segue into talking. Dr. Blake, can you tell us about the collaborative that was formed to address many of these issues and how it aims to help practices within behavioral health integration?

Dr. Blake: Sure, I'd be glad to. And I think you've already gotten a sense, Todd, of how this is an all in, multi-specialty team-based effort, that there is not a single organization that can do this by themselves, and they have different perspectives. And so the members of the collaborative, are the American Academy of Family Physicians, the American Psychiatric Association, the American Academy of Pediatrics, very focused on what the long-term consequences of COVID will be for children and for their parents. Also, the American College of Obstetrics and Gynecology, their interest is already well-established in terms of maternal health and particularly the risk of postpartum depression and wanting to be sure that moms who may be more isolated than ever before are able to get their needs met.

The American College of Physicians, so the internal medicine specialty, American Osteopathic Association and American Academy of Child and Adolescent Psychiatry. So hopefully that gives our listeners a sense of the depth of the commitment. This is a true collaborative. We don't want to reinvent the wheel and what we realized is that there are resources and experience that we can start to compile to be able to deliver this care holistically.

Unger: Dr. Blake, what specifically will the collective do to help physician practices understand how to implement this?

Dr. Blake: So it's really a four-part strategy. And the first of those is a series of webinars that have already started. And I think we'll be providing some links to the behavioral health website on the AMA platform. The other societies are providing those to their members, these are all free of charge, addressing some of the tough issues. How do you overcome stigma? How do you bill appropriately so that you are compensated for the care that you're delivering, but compensated appropriately. Health IT is a big factor, and as Dr. Mullins said, we're really interested in how do we get that best result from virtual care? Because yes, it's different. We're going to be doing it for quite a while. Most people think when things go back to the new normal that we'll have a hybrid, so that's important to know about. So a whole series of programs that are geared towards someone in practice, these are not theoretical, these are real world programs for the practicing clinicians.

Unger: Will you be putting together some kind of a playbook, so to speak, with a real how to guide or how will this come together?

Dr. Blake: Yes. One of the things that we heard loud and clear from the RAND study participants and also from a round table with our colleagues from the various specialties, is that there is a ton, a wealth of guide books, play books, materials that you can go to, but the smaller to medium-sized practices that are just starting to think about doing this, they wanted a curated compendium so they could look to it and say, this is the chapter I need. And so that's what we've been developing and plan to release by the end of the year with the collaborative.

Unger: Ms. Kroeger, we talked about earlier in the segment about not reinventing the wheel, there's obviously a lot of expertise in this field. How do physician practices and care teams tap into that expertise?

Kroeger: Sure. Well, through this initiative, physicians are going to learn about the benefits of collaboration with psychiatrists, with other mental health professionals and how practices can be supported to provide this care, the full spectrum of medical care to improve access and outcomes for the patients. But also as you had mentioned and Dr. Mullins had mentioned, improving the satisfaction of primary care physicians by relieving the possible stress of taking care of this patient population by having guidance from psychiatrists and other mental health professionals. I mean, that is key. Primary care physicians are overwhelmed with treating their current patient population and add individuals with substance use and mental health disorders on top of that, and their stress level goes up.

So I think working together as a care team is the best way to go. And I know that American Psychiatric Association and psychiatrists, we've been working on this issue for several years now and providing education to our members. And we're so happy that the AMA has pulled all of the organizations together to do this because we need to really look to ensure early intervention and prevention of these illnesses in primary care.

Unger: Dr. Mullins, do you want to speak about any other kind of specific tools and resources that will be offered to help physicians in these efforts?

Dr. Mullins: I think that really, what we've said so far is really covering it. And I think that what people need to know is that this is going to be a one-stop shop so they're not going to have to look around and they're not going to have to try to find the best resources from all of these different organizations. We're trying to take the guesswork out of it and we're trying to curate and find a location to have all of these great resources live so clinicians can find them quickly and use them and make this an easier process. I don't want to say it's an easy process because it's not, but make the process as easy as possible for them.

Unger: Do you think that—go ahead.

Dr. Blake: Just one thing, Todd, to what Dr. Mullins has just said, which is that, for example, for our listeners, if they are thinking about what will be my priorities for my practice in 2021, one of those priorities could be that I'm going to start the journey towards integrating behavioral and mental health care into my primary care practice. And I'm going to be on a learning journey with others using the resources that we are developing. And the collaborative has also committed in 2021 to developing a user group. The user group will be practices who've said, we're going to adopt, and we're going to provide the collaborative with feedback about what worked, what didn't work, what else do we need and then be able to iterate over time so that the resources that we've identified can progressively improve.

Unger: Dr. Blake, we talked a little bit earlier about silver linings, always hard to find in this scenario, but in addition to the adoption of telehealth, which we spoke about earlier, are there any other things that you're seeing coming out of the pandemic?

Dr. Blake: There really are, because when we first started within even the AMA to raise this, to elevate this issue that our external advisory group had hammered into our minds, there was, I think, quite understandably a sense of gee, haven't we already done that? Or, is this all about substance use disorder? And it's really not, it's not a job done and it's about more than substance use disorder. So important though that may be, it's about anxiety. It's about depression. It's about being able to grow up healthy. So the silver lining with all of what's been in the press is I think people are more willing to talk about it, about their own concerns. For a physician, the awareness as was mentioned that physicians are struggling, other healthcare professionals are. That in a interesting way, the more pervasive the challenge, the more people understand it and are willing to act. And I think also because healthcare resources are so stressed right now, this idea that it's got to be all of us in it together working on it, really becomes a very powerful, very attractive approach.

Unger: Dr. Mullins, how about as it relates to primary care?

Dr. Mullins: Right. As a family physician, I would be remiss to say, the pandemic has really shown what the value that primary care it brings to the system. When the pandemic was at its worst in March, April, May, primary care really stepped up, and they moved out of their outpatient clinics and into ICUs, into urgent cares, into the ER, inpatient units. They went where they were called, and they really showed the value that primary care brings to the system. And they provided care in ways that others could not because of the holistic way that primary care physicians are trained. And I think that the pandemic has really highlighted the value that primary care brings to the system and the way that system really can't function without primary care physicians.

Unger: Well, thank you so much, Dr. Blake, Dr. Mullins and Ms. Kroeger for being here today and sharing your perspectives, for all the work that you and your organizations are doing to integrate behavioral health into physician practices. If you missed any of the Overcoming Obstacles webinar series, you would like to register for future ones or get access to the materials, visit the AMA site and search for behavioral health.

That's it for today's COVID-19 update, we'll be back with another segment soon. For information on COVID-19, you can access the AMA site, ama-assn.org/COVID-19. Thanks for being here today and please take care.


Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.

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