How to advance equity by integrating behavioral health

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

In today’s COVID-19 Update, Patrice A. Harris, MD, MA, psychiatrist and immediate past president of the AMA, and Melvin Oatis, MD, a child and adolescent psychiatrist, discuss ways physicians can advance health equity through the integration of behavioral health in their practice.

Watch the Behavioral Health Integration (BHI) Collaborative’s webinar in the Overcoming Obstacles series: "Advancing health equity through BHI in primary care."

Learn more at the AMA COVID-19 resource center.

Speakers

• Patrice A. Harris, MD, MA, psychiatrist and immediate past president, AMA
• Melvin Oatis, MD, child and adolescent psychiatrist

Unger: Hello, this is the American Medical Association's COVID-19 Update. Today we're talking about how physicians can advance health equity through the integration of behavioral health in their practice. I'm joined today by Dr. Patrice Harris, AMA's immediate past president, as well as a psychiatrist and former county health director in Atlanta; and Dr. Melvin Oatis, a child and adolescent psychiatrist in private practice in New York. I'm Todd Unger, AMA's chief experience officer in Chicago. Dr. Harris, integrating mental health into overall health has been a passion of yours for a number of years. Can you talk about why integrated equitable behavioral health is so important in a primary care setting?

Dr. Harris: Well, Todd, there is no health without mental health, and the good news is more and more people are recognizing that. That has not always been the case historically, but I think everyone is aware of the data, the data that shows that after surgery, if you have untreated depression, there are more complications and potentially more readmissions. We know a significant number of visits to primary care physicians are related to anxiety and depression. And I can tell you that in my practice of seeing those who have severe persistent mental illness, they often don't get the primary care that they need. So for those reasons and many more, it is so critical to make sure that we are integrating mental health into primary care.

Unger: Dr. Oatis, this has been particularly laid bare by the pandemic and making the need for behavioral health integration even more important. Can you talk about the ways that you're seeing that integrated, and why it's so important from an equity standpoint for this to happen?

Dr. Oatis: Well, oftentimes patients don't make it to a psychiatrist's office. So they're seeing their primary care physician as the person that gives them the thing that they have the greatest access to, the person they have the greatest access to. So that person needs to be knowledgeable about anxiety and depression, how it presents, because sometimes patients may just talk about being tired and not really understanding that that is one of the signs of depression or anxiety, or poor decision making or just feeling run down. And oftentimes, they may neglect that and just overlook it, and it can really have an impact upon their lives and their family's life. So in speaking to their primary care physician, they have to be able to feel comfortable in telling them that.

Unger: Dr. Harris, anything to add there?

Dr. Harris: Absolutely. This pandemic has laid bare issues around equity or inequities, certainly the need for mental health. And I will throw in, as a former public health official, our really underfunded public health infrastructure. And so if you take any of those issues, they are interconnected. Certainly we came into the pandemic with people from communities of color having less access to mental health services. And so we know that this pandemic has worsened some of these issues, and so really these issues are interrelated. And so we have to talk about mental health. We have to talk about those preexisting inequities, and going forward, we need to think about solutions that solve not only issues around overall mental health infrastructure and the need to integrate, but also making sure that we never forget the importance of equity in those conversations.

Unger: Well, Dr. Harris, physicians probably are right now, along with many people, they're really examining kind of where those inequities might exist in their practices. How do you recommend that they work toward incorporating behavioral health into their practices?

Dr. Harris: Well, here's where I'm so always actually proud of the work at the AMA, but so very proud of our recent initiatives regarding this issue. The audience hopefully is aware of our new Behavioral Health Integration Collaborative, but just a quick story about how that came about. The AMA had convened folks in the room to address issues around value-based care, but the conversation kept coming back to mental health care or the lack there of, again, another interconnection. So we have resources available, we've developed a playbook.

And so our primary care colleagues can and should take advantage of the resources there, but it starts with looking at your own practice, what's going on, maybe doing a survey of patients or even your staff about issues that are being raised by patients. And then also connecting with psychiatrists and other mental health care colleagues in the community to discuss ways of making sure that patients who present with the symptoms that Dr. Oatis discussed are getting the care that they need.

Unger: Dr. Oatis, is this a new muscle for physicians, or is it something they've been doing all along and are now kind of recognizing as more important?

Dr. Oatis: So the physician is not only building a muscle, but now they're paying attention to a muscle that was already there, that they may have ignored for a while. So once the patient has now come into your office, you think everything is okay because you're asking them questions about one particular thing, but you still have to expand upon that. For instance, in talking about COVID-19, you'd have to ask them specifically, "How has COVID-19 affected you and your family?" Then you may be surprised at the answers about transportation, access to care, vaccinations. You hear a lot about things in the media, but there are things that the patient hasn't shared with the physician, because they don't know if they really care about it or can actually do something about it.

But many times, physicians are uniquely situated to share all sorts of resources, such as places with food pantry, things that are beyond their offices, where they can get their vaccinations, all manner of things. Who's accepting their health insurance, where they can do other types of referrals. All these things are important and they may only have a single person, such as that health care provider, to give that to them without making it to someone else like a psychiatrist. So it's vitally important that the primary care physician become more important in expanding upon their questions to their patients.

Unger: And that's a lot of new questions. And so obviously one of the barriers or challenges, this would be around time. What are the other key challenges that a physician would face when they think about behavioral health integration?

Dr. Oatis: I think one of the things beyond the time is actually trusting that they can provide something to them, that they can really, that the patient's going to be honest about what's going on. And that really requires the physician to listen and reflect upon what's being said and feel very comfortable in re-asking the question and reflecting back what they've heard, to make sure that they're really understanding their patient. Because oftentimes, we want to be in this position of authority and recognize that that's not necessary to actually build upon trust, that there's a reflection, there's a give and take that must happen within that office and encounter.

Dr. Harris: You know, and this can seem overwhelming to our primary care colleagues, and I want to recognize that. And again, that's the reason to develop issues around team-based care. Our primary care colleagues should not feel like they have to solve this problem alone. There are opportunities for collaboration with psychiatrists and making sure that maybe others on the team in the office know these resources, right? The resources around food pantry, or where they can get fresh fruits and vegetables. So here we talk about team-based care and we talk about partnerships. That is really key for our primary care colleagues, I believe, to know.

Unger: Dr. Harris, it does seem somewhat overwhelming, because we are asking a lot more of physicians, it seems every day. You mentioned before that the AMA is doing a lot of work in the space to help physicians address these challenges. Can you talk a little bit more about those resources and that work?

Dr. Harris: Well from a broader scale, it's about time and getting reimbursed for the time spent on these issues. And so the AMA has a long history of elevating these issues and making sure that our primary care colleagues are fairly and appropriately reimbursed for the work that they do. I remember many years ago, and I don't know if Melvin remembers this, but if a primary care colleague coded for mental health services, they may or may not be reimbursed. And so the AMA has been working on that issue, and certainly along with our primary care colleagues, has addressed that issue over the long term. And in addition to the basic resources that we continue to update, we have road maps or playbooks for a practice to do their own, again, internal assessment. And then from that assessment, make sure that they are getting the tools and resources and reimbursed for the work that they do.

But at the local level, something that we did here in Georgia, we had a joint meeting with the American Academy of Family Practice, the Georgia chapter, once. And we sort of did a psychiatry 101 for our family medicine colleagues, and then our family medicine colleagues did a family medicine 101 for us as psychiatrists, because I definitely recall a time when one of my patients who had schizophrenia came into my office with a blood pressure of 180 over 150. Now, as a physician, I had to do something. That was an urgent situation that I wanted to make sure that I resolved, and not just with, "Go to the emergency department." And so those are just a few things that AMA has done, but also our state colleagues can do on the local level to support one another in this new endeavor.

Unger: It sounds like, too, that this is kind of a nexus of, you mentioned kind of a lot of the advocacy work around reimbursement. Then there's the work that the AMA has been doing on practice satisfaction and sustainability. And then the third leg of that would be around health equity. Do you see kind of that new, that convergence of all three of those areas into this one issue?

Dr. Harris: There's no question. And I'm sure Melvin will talk more about this as well, but the AMA, we see health equity as an accelerator of all the work that we do. It's not sort of an afterthought. It's embedded into the work that we do. And so as we think about integrating behavioral health and primary care, equity is a foundational element here. It really will make the work easier. It will ultimately lead to better patient outcomes. If you are making sure that you are addressing issues around equity, whether or not that is making sure that the diagnoses are appropriate. Making sure that the care matches the issue, these are all issues around equity that need to be addressed at that level. And again, at the end of the day, it's about improved patient outcomes.

Unger: Well, Dr. Oatis, looking at it in the future, what does successful behavioral health integration look like, and how do you hope to see care evolving after the pandemic?

Dr. Oatis: The successful integration of behavioral health care and primary care is essential. And looking at that, looking forward to making sure that that is successful, is making sure that you continue asking questions and not make assumptions. Understanding that integral to your physical health, how you're feeling, how one is doing not only in their profession, but also how they're doing within their family, how they're doing within the community, is all very important. So being able to ask the right questions, reflect upon that with your patients and not feel like you're doing something outside of your lane or outside of something that's important, is very essential.

And the more you do it, the more comfort you'll have in having these conversations with your patients. Also, you'll see better outcomes when your patient comes in, in terms of their overall health. Their physical and mental health is improved by being able to discuss this, being able to sort of take away the stigma of asking these questions so that discussions of problems is a normal thing, the discussion of what's going on with you besides, "Hey, how are you doing?" And not that pat, "Oh, I'm fine," expecting an answer, being able to actually hear the follow-up and go into that. That's going to lead to a real successful integration of behavioral health care.

Unger: Dr. Harris, any final thoughts on what success looks like?

Dr. Harris: Yeah, I think ultimately it's our patient outcomes. That's how we should always measure success. But I think it's also our primary care colleagues' comfort with this. And also our primary care colleagues feeling supported. It is not always easy work, and we want to make sure that our primary care colleagues feel supported in doing this work, because actually, they're doing it now. They may not realize it, to the degree that they're doing it, they're doing it now. And we want to make sure that they feel supported in doing that work. And ultimately, our patients will have better outcomes.

And I really do think another piece that Dr. Oatis just mentioned was the issue around stigma. Success will be when there is less stigma and everyone is more comfortable talking about issues around substance use disorders, by the way, and depression and anxiety. And when we routinize having these discussions in our office visits, then we will, I believe, deem this work a success.

Dr. Oatis: Dr. Harris, you mentioned also that this is a team approach, so the primary care physician also knowing that they can talk to others. The psychiatrist may not be in the foreground, but in the background, that they're speaking to them by consultation by phone, if they're not able to actually send the patient there, so that they're not doing it alone. And if there's some questions that they feel that they have not asked, they can consult with someone and actually bring that into the office without the patient having to go someplace else, so that everyone wins in this discussion.

Dr. Harris: And Todd, I know you can tell two psychiatrists are excited about this, but as we think about what the COVID-19 pandemic has accelerated, it's certainly accelerated using telehealth. And now we see that payers are more willing to pay for telehealth. We can see the value. And these consultations with psychiatrists can occur through telehealth consultation. So the future is exciting. The future is bright. We'll have to continue to work on the advocacy issues, but again, there will be so many opportunities going forward, so we have meaningful integration of mental health and primary care.

Unger: Kind of new teamwork, new technology and better patient care. So it's a great combination. I want to thank you, Dr. Harris, Dr. Oatis, for being here today and sharing your perspective. If you'd like more information on this topic, you can view the full “Advancing health equity through BHI in primary care" webinar on the AMA's website. This webinar features Dr. Harris and Dr. Oatis as part of our BHI, or behavioral health integration, collaborative's Overcoming Obstacles series. We'll be back soon with another COVID-19 Update. In the meantime, for resources on COVID-19, visit ama-assn.org/COVID-19. Thanks for joining us 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.

With an increased number of people reporting worsening mental health in recent years, it is imperative that people are aware of the 988 Suicide & Crisis Lifeline (formerly known as the National Suicide Prevention Lifeline) telephone program.

People experiencing a suicidal, substance use, and/or mental health crisis, or any other kind of emotional distress can call, chat or text 988, and speak to trained crisis counselors. The national hotline is available 24 hours a day, 7 days a week.

The previous National Suicide Prevention Lifeline phone number (1-800-273-8255) will continue to be operational and route calls to 988 indefinitely.