Diverting from ER and focusing on pain and addiction – how do you get buy-in from primary care docs?
True integrated care in a true collaborative space — not just a consult — is still a foreign concept to a lot of clinicians. San José Clinic is a unique environment that serves uninsured patients who face numerous challenges, particularly with social determinants of health — folks who may not make it back for follow-up care in a timely manner. For this reason, they aim to help patients with as many issues as possible within one visit. “Every clinician, every specialist is 100% willing to do whatever it takes in that visit to make it happen,” says the Clinic’s President and CEO, Paule Anne Lewis.
But it’s not like that in all primary care practices, clinics, or even every emergency department. How do you build a system of truly collaborative care? How do you get the buy-in from primary care providers to integrate their practices?
It looks different in every setting; there’s no one-size-fits-all formulary, says University of Washington psychiatrist Jürgen Unützer. For Unützer, his work in promoting collaborative care began after he moved to the University of Washington and started working in a primary care clinic. “When I moved to the University of Washington . . . I thought I knew everything there is to know about mental health,” he says. But his mentor told him, “If you really want to learn about what it looks like in most of the rest of the world, you should hang out in a primary care clinic.”
For one day a week, Unützer would see patients in a family medicine clinic, and another day each week, he would see patients in an internal medicine clinic. “There’s a lot of mental illness here, and it doesn’t come the same way it comes into a psychiatrist’s office,” Unützer realized. He gained a much better understanding of what the other health care workers in those clinics were up against.
“Then you can start thinking about, what are solutions that might really work for them?” says Unützer. “We’ve tried a whole bunch of stuff that, frankly, didn’t work. We like to talk about the stuff we publish and the stuff that works, but for every one of those, we tried five or six things that didn’t work.” One thing Unützer found is that if you want to integrate mental health services into primary care, your best advocate for this is the primary care provider, with them seeing the value of care integration and spreading the word.
“It’s not me making the business case so much,” says Unützer. “It’s really the primary care docs in the clinics that didn’t have [collaborative care].” These providers might point to the need for integrated behavioral health and addiction services in their clinic so that they can do their work better, or even threaten to leave if specialists aren’t brought in.
“I’ve seen some really interesting things on getting the buy-in from a recruiting perspective,” adds Corey Waller, Senior Medical Director for Education and Policy at Camden Coalition of Healthcare Providers’ National Center for Complex Health and Social Needs.
In rural America, it’s difficult to recruit physicians, specialists, nurse practitioners, behavioral health–trained nurses, and so on. To attract those who would normally never work in rural communities, hospitals are building new clinics and teams. “I’m going to give you all these tools — I’m going to have a mental health provider, I’m going to have someone you can consult with pain,” describes Waller. “I’ve seen that work really well as a tool to bring in some of the best people at all levels of care, because all of this is a team sport.”
“For physicians, our job is really changing. We’re not just seeing patients all day anymore,” says Waller. “Our role is only to see the sickest and then to run teams of people who see patients. That’s where the future of being a doctor is going, which is super scary since we have no training in it.”
From the NEJM Catalyst event Expanding the Bounds of Care Delivery: Integrating Mental, Social, and Physical Health, held at Vanderbilt University Medical Center, January 25, 2018.