Report: New health care model will better connect patients with mental health services

The Children's Clinic of Billings in Billings, Montana (Photo by Darrell Ehrlick of the Daily Montanan)

Montana has been described as a perfect storm of circumstances that lead to an acute mental health crisis. Rural areas, unforgiving weather, lack of providers and a social stigma make getting help a challenge.

A new report by the Montana Healthcare Foundation, coupled with a project focused on mental health providers, is one solution to the dearth of mental health providers. That same report, “The Critical Role of Primary Care in Supporting Montanans with Behavioral Health Needs” details that in some cases, more than 80% of mental health treatment is done through primary care physicians, not those who specialize in behavioral health, for example, a psychiatrist.

Overall in America, it is estimated that one-in-six visits to a doctor’s office involves some some aspect of mental health, and in 2021, Montana had the second highest suicide rate in the country, according to the Centers for Disease Control and Prevention. In 2022, a look at Montana’s Medicaid numbers reveal that more 81% received some form of behavioral health support. And more than half of the Montana Medicaid members said that they received behavioral health through their primary care provider — statistics that suggest improving mental health in Montana is inextricably tied to primary care healthcare.

That’s why the Montana Healthcare Foundation is helping clinics and practices throughout the state adopted the integrated behavioral healthcare model where mental health staff are embedded or “co-located” with the providers.

The Montana Healthcare Foundation has so far provided grants and training to 68 primary care practices to support start-up costs and implementation of the model.

The idea is straightforward: Place mental health care specialists — sometimes ranging from case managers to psychiatrists — with primary healthcare practices. That makes it easier for both the patient and the other healthcare providers to access mental health services, and lessens the stigma associated with seeing mental health professionals.

The model, which has been used for more than 20 years, is gradually gaining traction and popularity. The integrated behavioral health model also helps support healthcare practices where doctors and practitioners are called upon to help with various mental health issues, even though most family care physicians have only general, not specialized training in mental health. For patients, it drops the barriers to mental health care — meaning they don’t often wait as long to see a specialist and that care can be administered in a familiar setting, not at another place.

“We’re trying to build a stronger behavioral health system, and to do that, we need to look at the foundation,” said Dr. Aaron Wernham, the chief executive of the Montana Healthcare Foundation.

He said the foundation of behavioral health is really in primary care providers because that’s where the bulk of the patients access the healthcare system.

He points out that behavioral health is really not much different than other aspects of health. For example, primary care doctors may treat some patients with diabetes or heart conditions, but need to refer patients to more specific care from a specialist in complex cases.

For providers, the model means helping patients as well as having support embedded in the practice. Danny Zimmerman, the administrator at the Children’s Clinic of Billings, said that having more support for the 11 pediatricians and practitioners at the clinic means they don’t risk burnout or uncertainty.

“This makes a huge difference because many of our providers feel the pressure to do something. They know we may not have all the skill sets, but we better than nothing, which was often the alternative,” Zimmerman said. “Now, know we have the people with the right skill sets.”

Those skills include a mental health counselor that can provide a little assistance to those whose struggles are less severe, or stabilization for people who are struggling, but can’t get into a specialist for weeks or even months.

Zimmerman said that after COVID-19, providers at the clinic started to see around a 40% increase in depression and other related issues, largely driven by social isolation. Although the risk of COVID has subsided and changed, those numbers of people identifying mental health issues as problematic has remained high.

The model is also successful because it helps triage patients to the right level of care. For example, a patient who is suffering from mild depression may not need the services of a psychiatrists, but rather a consultation with a nurse-practitioner. Conversely, doctors are able to get more severe cases of mental health into see professionals sooner, lessening the stress and harm for families.

“Traditional behavioral health settings are not going away because they’re needed for the more intensive care,” Zimmerman said. “This is absolutely the future. This isn’t replacing, it’s supplementing.”

For example, the Children’s Clinic in Billings counts nearly 12,500 patients, and an estimated 10% to 33% need some form of behavioral healthcare management. This helps get the care more directly to those patients.

“In my nine years as the administrator here, this is the most meaningful work we’ve done,” Zimmerman said. “We owe a lot of it to the Montana Healthcare Foundation because they also had the technical expertise and that brought down the barriers.”

Zimmerman said that in the Children’s Clinic the wait time to get help is sometimes days, not months.

The Montana Healthcare Foundation said that this new model works for Montana because it places the practitioners where the need is the greatest, and so are the patient interactions.

“It’s the only segment in healthcare where increased investments translates into better health outcomes,” Wernham said.

Zimmerman said the model also works because of the relationship people have with their primary care providers.

“There’s a trust issue here,” Zimmerman said, “People love their pediatricians, and fewer things are more important that their kids.”

In other cases, investing in more complex specialities may not result in longer, better outcomes.

Wernham likened it to testing for blood pressure: At one time, high blood pressure was often a silent, symptomless killer. Once doctors understood the risk of high blood pressure, doctors offices everywhere started testing and treating it. Now, routine depression and anxiety screenings are becoming as common as the blood pressure cuff in the doctor’s offices.

“Primary care is the least expensive cost, so it makes sense to do it there,” Wernham said.

The foundation points out that while 30% of the overall population gets treated for mental health issues by their primary-care providers, it only constitutes 4.5% of medical spending overall, making a little investment go a long way, Wernham said.

“It’s a very inexpensive place to bring it in,” Wernham said, as opposed to other more cost-intensive places like the emergency room. “Speaking for myself when I worked at a community health center when we began a program like this within two weeks, no one ever wanted to go back. It was a profound sense of relief that we had help and that’s because in primary care, we see patients all day long — this gave us more tools.”

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