Integrated Behavioral Health in Rural Communities

Introduction to Integrated Behavioral Health

Integrated behavioral health involves collaboration among a primary care physician, medical specialists, and a coordinated care team to deliver the best possible care for each patient. This is important when viewed from multiple dimensions. For instance, a client who requires specialized care for a condition or disease may need a team of healthcare professionals to ensure that all essential tasks are completed. Integrating primary care therefore helps patients in rural communities manage their health by learning to incorporate new solutions into their everyday lives. Beyond individual care coordination, healthcare facilities and clinics also work together to coordinate services for people in need (Chaple, 2015).

Framework for Integrated Behavioral Health in Rural Communities

Regardless of the advancements and positive changes in the support, treatment, and understanding of mental illness in rural communities, the need for improvement in the rural healthcare system cannot be understated. Researchers acknowledge that, even though progress has been made in rural behavioral healthcare, most people with mental health conditions remain disadvantaged and are not receiving adequate care. In many cases, mental health disorders are just as disabling as heart disease or cancer in terms of premature death and lost productivity. A study conducted in 2006 found that people with the most serious mental illnesses die approximately 30 years earlier than the average American. When left unaddressed, adults with mental disorders tend to experience relationship difficulties, lost productivity, increased stress, and negative effects on child-rearing.

A comprehensive care structure must promote mental health integration that treats patients at the point of care where they feel most comfortable, using a patient-centered approach to intervention. Integration is also crucial for positively addressing healthcare disparities in rural populations (Acevedo-Garcia et al., 2012).

Medical-Provided Behavioral Healthcare Model

Medical-provided behavioral healthcare is a delivery framework in which medical providers are directly engaged in behavioral health service provision. Physicians, for example, can take practical steps to address behavioral health problems. These steps may include helping patients use a daily diary to plan activities, discussing an exercise schedule with patients experiencing depression, or having a nurse follow up with a patient by telephone to ensure medical compliance (Bao, Casalino, & Pincus, 2013).

Under this framework, a consultation-liaison approach is often used. The primary caregiver delivers behavioral health services while a psychiatrist provides consultative support. The goal is to improve the capacity of the primary healthcare provider to treat patients with behavioral health problems within a primary care setting. As the sole consultant, the psychiatrist may see patients alongside the physician or offer guidance by telephone, but does not co-manage the patient directly (Chaple, 2015).

When primary care providers are assessing a behavioral health issue, they use evidence-based screening instruments. One widely used tool is the Patient Health Questionnaire (PHQ-9), which is frequently used to identify patients with depression. The questionnaire contains nine items that can typically be completed within two minutes. The physician then confirms the symptom picture by talking with other providers, discussing findings with the patient, or reviewing PHQ-9 scores, and subsequently applies brief treatment algorithms. This practice is commonly known as Screening and Brief Intervention (SBI). In many medical facilities, depression screening has been incorporated as a routine component of care for patients with chronic diseases. The process begins with a brief two-question screen using the first two items of the PHQ-9. An increasing number of primary care practices are also screening for a range of additional concerns, including substance abuse, panic disorder, and bipolar disorder. For children and adolescents, many practices use the Pediatric Symptom Checklist as a broad behavioral health screening tool (Gee & Payne-Sturges, 2004).

Brief intervention guidelines have been developed for a variety of behavioral health problems commonly encountered in primary care. In many cases, the primary care physician can deliver these interventions directly. The American Academy of Family Physicians (AAFP) has developed algorithms for several disorders. Additionally, the Substance Abuse and Mental Health Services Administration (SAMHSA) is implementing Screening, Brief Intervention, Referral, and Treatment (SBIRT) programs. These interventions are considered effective in reducing the severity of mental health disorders, decreasing hospitalizations, and lowering the number of unnecessary emergency department visits (Bao, Casalino, & Pincus, 2013).

References

Acevedo-Garcia, D. et al. (2012). Integrating social epidemiology into immigrant health research: A cross-national framework. Social Science & Medicine, 75(12), 2060–2068.

Bao, Y., Casalino, L. P., & Pincus, H. A. (2013). Behavioral health and health care reform models: Patient-centered medical home, health home, and accountable care organization. The Journal of Behavioral Health Services & Research, 40(1), 121–132.

Chaple, M. (2015). A technical assistance framework to facilitate the delivery of integrated behavioral health services in federally qualified health centers (FQHCs). Journal of Substance Abuse Treatment, 60, 62–69.

Gee, G. C., & Payne-Sturges, D. C. (2004). Environmental health disparities: A framework integrating psychosocial and environmental concepts. Environmental Health Perspectives, 112(17), 1645–1653.