Program addresses patients' medical as well as mental and emotional issues

Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient, with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith.

Some health organizations and medical practices across the country are integrating primary and behavioral health care.

We'll talk about why with Upstate psychologist Brian Rieger. He's an assistant professor in the department of psychiatry, and he's director of the Integrated Behavioral Health Care Program at Upstate.

Welcome back to "The Informed Patient," Dr. Rieger.

Brian Rieger, PhD: Hi, Amber. Thanks. Glad to be back.

Host Amber Smith: Why are health systems and primary care practices moving toward integrating behavioral health services into primary care?

Brian Rieger, PhD: There's a shortage of mental health services available, specialty mental health, and what many people don't realize is primary care providers actually provide overall more mental health care to patients than the specialty mental health care services available, or about the same, but actually slightly more.

However, primary care providers certainly try to do this because their patients need help, but they don't have a lot of training or education necessarily in behavioral health issues. So part of the goal of integrating behavioral health professionals is not only to give access to patients to a mental health professional right in their doctor's office, but also to be a consultant to the primary care providers when they are treating issues like depression or anxiety in their patients, and so many of them are doing that. They're doing it because, again, they kind of have to do it. Primary care is kind of the last stop, or the first stop in some ways, but when there's nothing else available, you go into your doctor, and you say, "Hey, I need help." Primary care providers want to be able to do what they can.

So we're there to try to support them. So it's increasing access. It's sort of bolstering the primary care mental health services by working alongside primary care providers.

And another thing is that because so many of the issues that come into a primary care provider's office may seem like they're medical but may end up have something to do with sort of a mental health issue. Those can take a lot of time.

And so the research has shown that by better addressing those issues and by having resources available in the primary care provider's office to help, we can actually lower the demands on the primary care providers, because we're better addressing those needs, and so people don't sort of keep coming back with the same unaddressed mental health issue. So it actually helps reduce the demands on the primary care providers, even as we bolster their ability to address those concerns.

Host Amber Smith: So it sounds like there's a benefit not only to the patients, because for the patient, they come to their doctor, and they're able to actually get the care they need, whether it's with the physician or also with a behavioral health person that's there or that their doctor can set them up with quickly.

But there's also benefits to the medical providers because they have a way to take care of these patients that they really didn't have before?

Brian Rieger, PhD: Yeah, and actually reviewing some of the models of integrated care, there are some health systems, private health systems, that don't even worry about billing for those behavioral health services because the increased satisfaction, work satisfaction, that their primary care providers have because they feel better able to help their patients and feel like they have that resource available, it actually helps them to recruit and keep their primary care providers, which is a very expensive proposition.

Here at Upstate, we are hoping to do both. If people have their insurance, there's no reason why we shouldn't be billing for that service if we can, and we do that.

But certainly, I think if you talk to the primary care providers, I think they do appreciate that. Why do you become a primary care provider? You want to help the patients who come to see you, and if you feel like you're not as capable in that area, or you can't connect people with the resources, it's frustrating.

So yes, I think you've tuned in to that very well. The idea is it helps the patient, it helps the providers, and, hopefully, it makes our health care system more efficient overall.

Host Amber Smith: Is there a particular population of patients who are more likely to have both medical and behavioral health needs?

Does it break down by age or gender or socioeconomic (status)?

Brian Rieger, PhD: I think that's a very interesting question, and I don't have a database answer for you.

Having been now director of this integrated care program for a year and a half, and working in three different clinics myself, it's hard to see a medical condition that doesn't have a behavioral component to it. And likewise, I think for those of us who are trained in mental health and not being a physician, I think it's also actually helping us to understand the extent to which medical factors influence people's mental state, not only directly, such as if your thyroid is off, or your blood pressure's causing you to have headaches, that then are making it hard to do what you need to do in your life, and you're not feeling good. That can be depressing, but also indirectly coping with a medical condition.

So one nice thing is that when I'm not seeing a patient in my consultation room, I'm sitting right next to the medical staff and the nursing staff, and we're always having conversations about our patients, and I think we're always learning from each other about this intersection.

So, for example, children: One of the most common presenting complaints to a pediatrician is stomach problems. Well, stomach problems, when they present in the pediatric clinic, are one of those things where there's very often a component of anxiety or stress or an eating issue, and sorting that out can be difficult if you're just a mental health professional working in isolation, or you're just a pediatrician.

But when you've both seen the patient and can talk to each other, you can build your confidence (to say): "You know what? We're really feeling like at this point, we think this is mostly stress related. So no, I don't think we're going to order any more workups for the tummy. We're going to have them get connected with some mental health treatment and see where we get there."

Host Amber Smith: It seems in recent years that we've heard about more and more demand for mental health care. Does that tie back to the pandemic, when a lot of providers left the profession, but also people were under a great deal of stress? Does it tie back to that?

Brian Rieger, PhD: Yes. Again, I can say both anecdotally and (using) some mental health data, there have been some changes in the way some mental health data is collected that coincided with the pandemic. That created a little bit of an artifact in terms of, for example, the increased suicide rate. But even before that, for example, the suicide rate has increased steadily over the last 15 years, well before the pandemic, and I think my own experience and what most of the providers would say is that, yeah, we're we're still sort of dealing with the stress and disruption in people's lives and the lack of care, frankly. People who didn't want to go to the doctor didn't feel comfortable with the doctor or couldn't get in because the system was overwhelmed, and so they didn't get proper care.

So, yeah, absolutely I would say that.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith.

I'm talking with Brian Rieger about integrating behavioral health into primary care. Dr. Rieger is a psychologist and assistant professor in the department of psychiatry, and he's director of the Integrated Behavioral Health Care Program at Upstate.

So what is the vision at Upstate for integrating behavioral health with primary care, and how are you going about changing the culture and the infrastructure so that that becomes the norm?

Brian Rieger, PhD: This is what we're really trying to do: Get away from the idea that mental health and physical health are separate.

Many years ago, the head of the World Health Organization, it's a very famous quote, and it's quite old at this point, he said, "There is no physical health without mental health."

But mental health care, and sort of our medical care, has been siloed and partitioned within the health care system, even often right down to our insurance. Often, you carve out your mental health insurance, and it's separate from your medical care insurance. So it's just one example of how the system has sort of put these things in different buckets, but a person is one person, not two buckets.

And so I think part of this is recognizing that mental health care is not something a primary care provider should just be sort of farming out to the mental health system. It should be integral to the way a primary care provider thinks about their patient and recognizing that issues like substance abuse or anxiety or depression or trauma are part and parcel of the care of this patient.

And no one expects primary care providers, by the way, to become psychologists or psychiatrists. But rather, the vision is to put resources in place to support primary care providers' efforts to treat their patients.

And that's a very important point I want to make, and I make it in meetings all the time when I talk about the vision of integrated care. We're not there to take mental health off the hands of the primary care providers. We're there to support the primary care team better meeting the health needs of its patients, including their mental health needs.

And that's how I talk about it. And I am very happy to say, by the way, that not only have the primary care providers and clinics here at Upstate embraced this vision, but they really work hard to help us create an integrated care model. We're far from where we want to be; this is new. But I think there's a lot of agreement on where we want to try and get to.

Host Amber Smith: Do you think, because some patients, there's a bit of a stigma (to) mental health care, do you think that presenting it as part of a package does a lot to get rid of that stigma?

Brian Rieger, PhD: It's precisely one of the reasons why primary care providers become the front line for mental health conditions, because a person is much more likely to go to see their doctor and ask for a doctor's visit because they don't feel well, versus, and probably lots of people have said, "Well, I think you're depressed. You should call a mental health guy."

Well, they're just much less likely to do that, and frankly, even when a primary care provider has a conversation with a patient, encourages them to seek help in a mental health clinic, there's still a reluctance to do that.

So going back to your very first question, we're right there in the clinic to meet patients, and I can tell you several patients I've worked with where I feel like my job has been to give them a little good experience about what it's like to work with a mental health provider and then help to persuade them that "Look, here in the primary care clinic, we're sort of limited in how much we can do for you because we have so many patients, just like the primary care provider, we're treating a population. But I think you found this work helpful, and I can guarantee you that there are providers in the community who could pick up where we're leaving off here today and keep you going."

And I think because they've kind of almost had an introduction to what it's like, hopefully a good experience with our team, we found that some people who may have been reluctant are now willing to engage more.

Host Amber Smith: Well, that's encouraging. So let me understand from the patient's point of view how this works.

If they come to their primary care provider for their checkup, say, and it comes to light that maybe there's some symptoms of depression, the primary care provider may suggest that they stop in and see a behavioral health care person before they leave?

Brian Rieger, PhD: Let's talk through that. That's a good starting point.

So we have a patient in front of you and, again, part of our goal with integrated care is to improve the screening and detection of things like depression in the primary care clinic. And that's one of the things we talk about in our work groups. So we have integrated care work groups in each of the clinics that have all the different disciplines. So nursing and the administrative side and the provider, the physical providers, and the physical health providers, mental health providers. So in those work groups we talk about these things.

So let's say a patient comes in, they've been given a depression screening tool, and that raises a red flag that there's a concern about depression. So the goal would be for that provider, that primary care provider, to have a conversation. And then there's several different ways that can go. They might decide that maybe it's a good idea to start some medication, and they can go ahead and do that, and they might offer, let's say, "And you know, I think you might benefit from some counseling."

The patient says, "All right, well, I'm not so keen on that."

(The provider then says) "All right, well, why don't we start with the medication, and we'll see where we get with that."

And so that might be one outcome. Another thing, you might have a similar conversation with other patients that might say, "I'm not so keen on medication" or "Is there anything I can do for myself?"

"Well, we do have our integrated care staff. If one of our psychologists or social workers are available, would you be willing just to meet with them today?" And they could explain what we have to offer right here in the clinic and see if you'd be interested in an appointment."

We call that a warm handoff, and the reason that's important is because the patient trusts that PCP (primary care provider) already. So by bringing us into the room and introducing us, he's pulling us into that trust circle, and that goes a long way to breaking down that reluctance to open up to, or even seek help from, a mental health provider.

We're going to explain what we do, we're going to offer, "Maybe, if you're willing, we could have you set up an appointment to come to see me, and we could dive in a little deeper to find out what's going on and see what you really need." So that would be kind of the warm handoff.

Or if one of us is not available because we're tied up with our own patients, they might just place a referral, and then our care manager would contact that patient and do sort of the same thing over the phone: "Hey, here's what we have to offer. You know, your doctor referred you because they're concerned about some depression, and would you like to come in and see one of our folks?"

Or, sometimes people, maybe they've already had treatment, and we know we need really to connect them with more significant treatment, so that care manager will jump right to helping connect them with the resources in the community.

And the reason that's important, again, is rather than just giving them a list of providers and saying, "Here, go make some phone calls."

I mean, it's really hard to access mental health care, not just in Syracuse, but in the country. There's a shortage of providers. They have waiting lists. There's forms that need to be filled out. So it's kind of a barrier.

So what our care manager does in those cases is really trying to facilitate, support and work with the patient to get them connected to that community-based service. So we kind of have a menu of options, and we try to meet the patient with whatever item on that menu seems to be appealing to their appetite that day.

Host Amber Smith: And then I like how you described it's like a team. So if this patient has side effects from the medicine or is having other issues that pop up, the team kind of discusses that? Are you able to facilitate back to the physician?

Brian Rieger, PhD: Not only are we able to, it's our job to communicate back to the primary care provider.

And I might see a patient, say, they were reluctant to try medication. I've seen them for three visits, and I've spent some time talking about the benefits of different treatment options, and they'd actually like to give it a try, so I told them I'd let you know. They're not scheduled to see you for another three months, but I told them you might want to bring them in sooner and have that conversation.

And so I will either literally go find the provider and have that conversation face to face, or in Epic. There are all sorts of ways within our electronic medical record, which we use here at Upstate -- Epic -- that we can communicate. We can message each other, there's a sort of instant chat function, like texting, through the medical records. So we have all sorts of ways to communicate.

And that's one thing, Amber, I will say that we've started on both sides to learn the best ways to communicate with each other and to learn what issues we should be bringing forward more quickly versus what can wait till we sort of bump into each other and catch up. And that's part of, again, us all learning together how to do this.

Host Amber Smith: Are you aware of other health systems in Central New York where this sort of integration is becoming common?

Brian Rieger, PhD: Yeah. Actually the University of Rochester is ahead of us on this a little bit.

They have developed an integrated care system. And when we put our system together, I think we have a number of physicians that we have trained who work at the University of Rochester, so we have some connections. And so when I was hired as director, my goal was to sort of try to get this thing off the ground a little bit, working with my colleagues in psychiatry Dr. (Seetha) Ramanathan, our medical director, Dr. (Thomas) Schwarz, the chair there, they had already had conversations with Rochester before

now, I will tell you one of the things that I've learned, and the VA (Veterans Affairs system), by the way, has been doing this longer than anybody, and the national headquarters for integrated care in the VA system is in Syracuse, so I've accessed those resources as well. But I will tell you, anybody who works at Upstate knows that Upstate is a different animal from a private hospital like the U of R or from the VA. We have our own culture, we have our own rules, or New York state sort of thing.

So we've been able to learn from those systems, but really we've sort of learned where they've had the greatest gains. And we've tried to figure out how do we learn, how do we take that and make it work within our system? And that's been, I think, the challenge for us.

Host Amber Smith: Well, it's really interesting, and I'm appreciative of you taking time to tell us about it. Thank you so much.

Brian Rieger, PhD: Sure.

Host Amber Smith: My guest has been psychologist Brian Rieger. He's an assistant professor in the department of psychiatry, and he's also the director of the Integrated Behavioral Health Care Program at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air."

"The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe.

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