The Role of Behavioral Health in Optimizing Care for Complex Patients in the Primary Care Setting

Never before has so much been asked of primary care. Primary care providers are increasingly encountering heavy workloads, serving a large volume of patients in shorter visit times. At the same time, there is a growing emphasis on healthcare delivery models that meet the “triple aim” (patient satisfaction, improvedhealthoutcomes,andlower cost).Inthe context of these demands, patient complexity in the primary care setting is high, with roughly one in four primary care patients presenting with multi-morbidity 1 and up to half meeting criteria for a psychiatric disorder. 2 As such, emerging primary care models must address the significant impact of behavioral health complications on both the complexity and intensity of care. Integrating behavioral health providers (e.g., psychiatrists, psychologists, social workers) into primary care teams can enhance provider responsiveness to patients with complex clinical presentations and improve patient/family outcomes and satisfaction. This approach may also lower stress and increase professional quality of life for primary care physicians, associated specialty care providers, physician’s assistants, nurse practitioners, nurses, and other members of the healthcare team. A key role for behavioral health providers in the primary care setting is to identify and treat psychiatric conditions. Because primary care providers typically have little training in assessing and managing psychiatric conditions, they understandably may experience discomfort in working with some patients with psychiatric comorbidities. In addition to the challenges associated with treatment of psychiatric disorders, unidentified or untreated mental illness can impact overall care, and may be associated with multiple visits for medically unexplained, yet debilitating, somatic symptoms. Such visits can be frustrating for both patients and their care teams, and provider-rated “difficult” encounters are more likely to occur both with patients who have mental health diagnoses and with patients describing multiple somatic complaints. 3 Behavioral health providers can support their primary care colleagues in managing the behavioral complications of mental health conditions to optimize provider- patient relationships, patient and family engagement in care, and treatment outcomes. They can offer accessible and prompt follow-up treatment when psychiatric conditions are identified, either within the primary care setting itself or via facilitated referral to specialty behavioral health treatment resources outside the primary care practice. They can also provide telephone sessions or utilize telemedicine for patients with limited transportation access to clinic offices. Behavioral health providers can also support the efforts of the primary care team to facilitate health-enhancing behaviors, address behaviors associated with health risk, and improve pain management and pain-related outcomes by focusing on non-pharmacologic coping strategies. Primary care providers spend a significant portion of their clinical time managing chronic medical conditions, largely through pharmacotherapy.