Marrying Behavioral Health And Primary Care

Bridging the divide between two disciplines helps to eliminate one-sided diagnoses that mask multiple comorbidities.

“There is no clear-cut demarcation where behavioral health comorbidities start and where physical comorbidities end,” said Joseph Conigliaro, MD, chief of general internal medicine for Northwell Health.

Such an overlap causes issues on both sides of the spectrum, such as uncontrolled behavioral health issues that make it difficult for people to comply with care guidelines for chronic conditions.

“Someone living with diabetes and severe depression may lack the motivation or energy to do things required for wellness, such as checking their sugar levels or counting carbohydrates,” said Nancy LaVine, MD, associate chief of clinical affairs of general internal medicine at Northwell Health. “Managing other diseases becomes overwhelming when a behavioral health condition isn’t controlled.”

On the other hand, whereas someone may find psychiatric care helpful for depression, the psychiatrist may focus on treating behavioral health issues without adequately considering comorbidities, leaving a gap in care.

Situations like these call for integrated health channels.

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Routine depression screening

A first step is a screening initiative that better equips primary care physicians to flag behavioral health issues, particularly depression. Since depression presents differently depending on each person, doctors use a sensitive global screening process — the PHQ-2 form — to check for underlying symptoms.

“We ask two standard questions, using neutral language,” Dr. LaVine said. “It’s like checking for blood pressure, a common practice that isn’t alarming to patients.”

Doctors ask about sleep habits and home life, and screen for alcohol, drug and tobacco use. Responses determine if further evaluation for a depressive disorder is necessary.

Northwell’s larger primary care offices — those with six or more physicians — now include behavioral health counselors, licensed social workers and health coaches on staff, so the teams can address behavioral health comorbidities in-house.

“For instance, health coaches offer motivational interviews on-site for those who struggle with substance abuse,” Dr. Conigliaro said. And counselors address behavioral health disorders.

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Following the DSRIP model

Northwell began this system on a small scale prior to 2014, when New York State instituted the Delivery System Reform Incentive Payment (DSRIP) program to standardize the process and support it through federal grants.

Similar to the DSRIP model, reverse integration brings internists to inpatient psychiatric units to address medical needs on site.

“For some people, it’s all we can do to connect them to psychiatric care, so this setup addresses both types of health concerns without disrupting the system,” Dr. Conigliaro said, adding that it further engages patients in their own care.

Coordinating behavioral health and primary care within a team bypasses obstacles to care, fosters relationships between clinicians and patients, increases engagement and improves outcomes. It’s a community-driven health model that meets a real need: addressing the whole person in one setting.

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An adult behavioral health crisis center opens

If Drs. LaVine and Conigliaro see someone dealing with a new or worsening behavioral health condition that needs rapid intervention, they refer to the walk-in Zucker Hillside Hospital Adult Behavioral Health Crisis Center. The urgent care facility can be the right medium of care delivery for those who don’t need emergency medicine but require immediate attention.

“For those in treatment who may be dealing with heightened anxiety or a diagnosis beyond my scope of care,” Dr. LaVine said, “the center connects them with an appropriate provider.”

When traveling to a primary care location isn’t possible, Dr. Conigliaro uses telehealth to consult directly with a psychiatrist, who conducts an interview virtually before connecting someone with services such as care coordination, crisis psychotherapy, diagnostic evaluations, medication management, referrals and connection to follow-up care. The Crisis Center team accesses primary care records and adds notes for referring providers to keep care full-circle.

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