Melanie Cole, MS (Host): Welcome to UAB MedCast. I'm Melanie Cole, and joining me today is Dr. Christina Pierpaoli Parker. She's a licensed clinical psychologist and Assistant Professor at UAB Medicine, and she's here to share the benefits of integrating Behavioral and Mental Health into Primary and Specialty Care clinics.

Dr. Pierpaoli Parker, thank you so much for joining us today. I'd like you to start by letting other providers know what Behavioral Medicine really is and why it's so important to integrate this Behavioral Medicine into primary and specialty care clinics.

Dr Christina Pierpaoli Parker: Well, first of all, what a pleasure and privilege. Thanks so much for the opportunity to disseminate this important information. So, great first question. What is behavioral medicine? I have two broad conceptualizations of this. The first is the application of clinical, psychological, cognitive, and behavioral science to prevent, treat, manage, and rehabilitate disease across the lifespan. But another conceptualization is this idea of using an interdisciplinary approach to Medicine that respects and targets the biopsychosocial components of health, so the biological features, the psychological features, so the stuff that goes on inside of you, and the environmental components of health to optimize our health spans and our lifespans. In other words, not just to increase the number of years we're alive, but to increase the number of years we are alive and well starting in childhood.

So, why is this a good idea, right? Why integrate behavioral medicine into primary and specialty care clinics, or more broadly, into medical spaces? Well, several reasons. But number one, medical conditions contain significant psychological comorbidity. What do I mean? I mean, behavior centrally undergirds the development, the prevention, the treatment, and management of preventable diseases and health conditions, right? So, heart disease, diabetes and obesity, cancer, pain, chronic pulmonary disease, mood disorders and suicide, chronic liver disease and kidney disease, in which the United States alone spends upwards of $1.5 trillion, or about 75% of our annual healthcare costs. That's the first big idea, right? Behavior undergirds every part of the medical process from prevention, to onset, to management, and rehabilitation.

But here's the second big reason. The problems live in primary care. So since the 1970s, primary care has been dubbed the de facto mental health system of the United States with most patients experiencing psychiatric symptoms outside the office of a psychologist or a psychiatrist. So, said differently, most patients with psychiatric symptoms don't seek care from a mental health provider, often because they don't have access to one, because supply is low, because it's shrouded in enigma and stigma. And more importantly, in the primary care setting, 50% of patients who truly and absolutely have a mental health diagnosis are not recognized. And of those who are, a woeful 12% are properly treated. So in this way, integrating psychologists and Mental Health care providers broadly into the primary care space, into the medical space, also democratizes access to evidence-based mental health treatment, and also normalizes behavioral health as a part of physical health. I mean, it goes without saying that there is no health without mental health. There is no mind-body problem. The mind and the brain are of the body.

But, actually, there are a few other reasons. So, when we actually look at the research on collaborative and integrated care and ask this question of, "Well, what do patients think? What's the patient perspective?" Patients actually prefer it. Most express a preference for receiving their mental health care in a familiar place and from people with whom they've long established rapport. But finally, up to 75% of patients get lost in referral to mental health settings, whereas 90% of patients receive mental health care when it is integrated into the medical setting. Why? Because of the mechanics of the program, right? Integrated behavioral health benefits everyone because it offers convenience for the patient and it improves workflow for the physician by bringing mental health interventions to the patient at the time of their medical visit, which reduces logistical barriers, emotional barriers, promotes collaboration, and de-stigmatizes intervention.

And I have to say, Melanie, as a provider, as a psychologist, I understand the concept of mental load. And when patients are in distress, when they're at capacity, they truly don't have the space to do one more thing or make one more decision, including taking that well-intentioned referral from a primary care provider and executing it. Integrated behavioral health takes that burden away.

Melanie Cole, MS: Well, it certainly expands the idea of the medical home. Putting everything in one spot, which from the days of working in a silo for physicians, it does seem to be the way that we're headed, because it does make it easier for patients, when they don't have to and, as you say, it democratizes the whole healthcare setting and takes that well-intentioned referral and says, "Okay, it's right next door and it's right there in the room next door."

One of the interesting things in behavioral medicine that I found is how it engages the multidisciplinary teams to treat these patients. When you're speaking about this care model and you're going to tell us what that care model looks like as an integrated care model, I'd like you to speak about all the people that are involved. I am an exercise physiologist and I have seen that as we integrate nutrition and exercise and therapy and mental health, for which there is an epidemic and a lack of providers, that we put this all together for patients. It's a much more comprehensive approach.

Dr Christina Pierpaoli Parker: Absolutely. And I want to clarify that there are myriad models for integrated and collaborative health, depending on the healthcare system, the care setting, and other contextual factors. But just as a general concept, when we think about integrated care, what exactly does that mean? And from my perspective, as a psychologist, it means a systematic strategy for treating behavioral health conditions in medical settings. So in other words, collaborative care models integrate behavioral health providers, sometimes psychologists, sometimes psychiatrists, sometimes social workers, sometimes all of the above in the best case scenario into the medical team and ecosystem, to assist in assessing, intervening, treating, and facilitating physicians care recommendations. So, there's significant variability within and across integrated care models and within integrated teams. Some models include social workers and psychiatrists and psychologists. Some models are even more expansive than that, right? And this is the ideal. This is the holy grail of medicine where eventually there's the primary care provider, there's the psychologist, there's the psychiatrist, there's the caseworker, and nutritionist, and physiologist. And I think the VA has done an excellent job of modeling this in part because they have the resources to do it, though other healthcare systems have lagged because of the systemic barriers, including costs, which we'll address in a moment, to execute this.

But from my perspective as a clinical psychologist, integrated care has five core components. It includes a focus on population-based care, so promoting the health of communities, not just people. It includes measurement-based care, which is the systematic evaluation of symptoms throughout the patient's care narrative to inform treatment planning. So in other words, we are using validated evidence-based measures and symptom inventories at the onset, duration, and conclusion of treatment to measure targeted outcomes. You came in for insomnia. How are you doing on your insomnia? You came in for depression. How are you doing on your depression? And using those data to inform care planning and treatment.

The third is collaborative care management, whereby all members of this ecosystem, however the system has designed it, are communicating impressions and recommendations in real time. In other words, after we see patients, we are communicating our findings, proposing solutions right there and then to promote expedited, continuous, high quality care. We're also using psychiatric consultation, whereby as a psychologist, I am taking my impressions and recommendations and stepping up the care as needed, depending on complexity and severity to involve Psychopharm and Psychiatry.

And finally, using brief evidence-based psychotherapy. In other words, inviting patients to return to clinic to give them a brief evidence-based course of solutions-focused, skills-dense intervention to help target and manage the factors in their life perpetuating their core presentation. So, skills to help manage some of the cognitive and behavioral components that are perpetuating their disease states.

So, how do we make this the standard of care? Philosophically and psychologically, healthcare providers and systems must internalize the idea that integrated care is the holy grail of medicine. It means better care and higher levels of patient-centered involvement, which results in improved health outcomes, reduced need and demand for medical resources, as well as reduced provider burnout. Updating Medical and doctoral education in this tradition, so didactics as well as applied training in these models, including specialized rotations, residencies, and fellowships, can facilitate this in combination with revamping billing codes to capture this work.

But finally, doing it, right? Doing it and recognizing that the high upfront implementation burdens will be mitigated by the long term healthcare savings and benefits. Everyone says it can't be done until it is. And as I mentioned earlier, Melanie, there are different models of this. So if it would be helpful, I'm happy to explain how UAB's model looks.

Melanie Cole, MS: I would love for you to give us a brief overview of how that model looks as we wrap up and how we can make this integrated model the standard of care.

Dr Christina Pierpaoli Parker: I'd like to briefly discuss the integrated behavioral medicine model available at UAB, which has since scaled to three sites. So, unlike traditional outpatient mental health providers who adhere to hour-long appointments, IBM's practitioners typically see patients in an initial targeted 30-minute intake appointment followed by a brief time limited 30-minute appointment to deliver a course of cognitive behavioral therapy for whatever that chief concern is, whether it's anxiety, depression, insomnia.

But another distinctive feature of this service includes same-day appointments. And this is really where the return on investment comes in, in which patients receive mental and behavioral healthcare services acutely at the same-day of their medical appointment, either out of urgency or convenience. So in other words, if you go to your PCP and you're experiencing insomnia or sleepiness, that provider knocks on my door or one of my residents doors and says, "Hey, we've got a patient for you in room five." And we go in and we do our assessment and provide intervention and then create a treatment plan that includes a brief course of behavioral health, if indicated. And if it isn't, no problem. Our providers serve as ambassadors throughout the health system so we can get you to the care that you need. And that's that stepped care approach where if we believe that our particular clinic isn't indicated for your presentation, we work to get you to a higher level of care.

The final and most important feature of this includes that collaborative component whereby not only can the IBM's provider deliver care in a down-the-hall manner, but we can work with other medical and behavioral health providers, including psychiatrists or nephrologists or oncologists or primary care providers to discuss and implement a bespoke treatment plan the time of care. And what we have found, not only in the existing literature, but in our ongoing scholarship, is that this model, which we've scaled again in a Nephrology clinic, Primary Care clinic, and Concierge Medicine clinic has reduced noncompliance with treatment, mitigated the stigma associated with seeking mental and behavioral health services, and increased how quickly people can get seen, which reduces gridlock to the healthcare system.

I think one of the things that has made this model successful is that we really try to adopt the same optics of a traditional medical visit. So, all patients are triaged in the same way as they would be for their medical appointments. And this is to normalize behavioral health as a part of routine care, reduce barriers to initiating treatment, and increase uptake. And as part of the workflow, we communicate those impressions and recommendations in real time, whether it's face-to-face to that provider or using our behind-the-scenes infrastructure to communicate that.

Last few ideas. So, what does the evidence say about the effectiveness? What can it treat and how do we make it a standard of care? So, this model is aptly suited to target the behavioral and psychological features of acute and complex health conditions like adjustment, depression, mood and anxiety disorders, nicotine dependence, and mild to moderate substance misuse, insomnia and related sleep disorders, headaches and GI problems, diabetes and metabolic conditions, chronic pain as well as hypertension and related cardiovascular disease. And when we look at the effectiveness, several randomized clinical trials have demonstrated integrated care increases access to mental health care and is more effective and cost efficient than the current standard of care. But said differently, there are at least three levels on which this model is effectiveness. So clinically, broadly defined, our model and the models available in the literature have shown not only to increase access, but to materially improve mental and physical health outcomes in a durable way, including anxiety and depressive symptoms, as well as disease burden associated with chronic kidney disease, cancer, and cardiovascular disease no change in healthcare costs.

And even more hearteningly, our own data, so our data from ongoing QI studies or quality control studies of the Integrated Behavioral Medicine service, demonstrate that patients get better and stay better quickly and durably. So, in other words, at three, six, and 12-month outcome studies, our patients are reporting maintained decreases in anxiety, depressive, and insomnia symptoms.

But systematically, we have found also, again, we being broadly and more proximally in our clinics, that integrated care reduces wait times, it increases access, and it promotes early detection and intervention, which has potential to reduce downstream healthcare costs and burdens on the system itself and providers.

And finally, socioculturally, we have found that this model decreases stigma, increases awareness of mental health issues, not only for patients, but also providers. So, it becomes the self-reinforcing process whereby when psychologists and Mental Health care providers are integrated into the system, it also refines physicians' detection and screening of these issues.

Melanie Cole, MS: What an informative episode. Thank you so much, doctor, for joining us today. This was so educational and enlightening, and it's such an interesting topic about integrating behavioral and mental health into Primary and Specialty Care clinics. Thank you for sharing your expertise and stories with us today. And for more information, please visit our website at uabmedicine.org/physician. That concludes this episode of UAB Medcast. I'm Melanie Cole. Thanks so much for joining us today.