Promising ideas should periodically be re-evaluated. A demotion in enthusiasm may be due. Take primary care integration. Expectations have been great for its many versions over the years. However, a fairly limited scope has delivered modest benefits. It may be time for a transformative approach. A bold model will be described here after highlighting the limitations of current approaches.
When two complex entities like primary care and behavioral care are integrated, how much should either change? Sometimes integration just means coordination, and coordination suggests little change. For example, we coordinate care to avoid duplicative or conflicting interventions. There could be some change in plans based on an information exchange, but only occasionally.
Collaboration may lead to treatment plan changes more frequently, as when a psychiatrist advises a PCP on medication. Ideally, the PCP may become better at prescribing psychotropics based on this contact. This is essentially hands-on training. The much studied and praised collaborative care model does not aim to change the PCP so much as sharpen existing tools.
The patient-centered health home frequently includes a psychotherapist in its version of primary care. They commonly work within the setting as opposed to being external and coordinating remotely. Little else changes in that the PCP and therapist exchange clinical information and use their specific skill sets. PCPs enjoy the convenience of having a therapist nearby, but the work of each is still the same.
While research has shown clinical improvement, none of these models fundamentally changes primary care or behavioral care. Those aspects of care found to be improving—prescribing for depression, resolving some behavioral comorbidities for chronic medical patients, referrals to programs for weight loss—reflect the circumscribed issues targeted. The goals are positive but modest.
What is a more transformative model? It starts with a big problem. Ask PCPs why they are not better managing the chronic medical conditions associated with 75% of total healthcare costs. They will tell you that health behaviors are the big problem, the root problem. Referring outliers to diet and exercise programs has been inadequate to address both the depth and the scope of the problem.
Ask psychotherapists what prevents many people from getting help. They will point to the impediment of stigma. It is not just that mental illness and addiction are stigmatized, but the very act of discussing painful issues in therapy is stigmatized. Our celebrity culture may include shocking self-disclosure by the famous, but this does not change the social stigma related to disclosing vulnerability and weakness.
A new configuration for primary care can solve both problems, starting with a new type of clinician, the primary care therapist. Behavior change for health behaviors and common psychological problems becomes the orienting focus. Shame and stigma could ultimately die in the light of primary care. PCPs can expand their medical work by joining a team dedicated to some potent but elusive root causes.
What types of new learning will this team need? Therapists should no longer be in private offices conducting extended sessions. Brief patient encounters in the exam room are needed to screen, counsel, and refer patients to digital resources and outside therapists as needed. PCPs will use their trusted relationship to encourage patients in small, repetitive ways to change behavior.
This model may sound like other versions of primary care integration, but it changes the focus and tactics of primary care. It changes the experience of care as PCPs grasp how behavior change is often a challenging personal struggle rather than a simple rational decision. Therapists will need to find the flexibility and creativity to devise new ways to have an impact during brief therapeutic contacts.
This model is not beholden to the DSM. Psychiatrists may rely on it as they collaborate with PCPs on pharmacology, but this leaves much of a primary care practice untouched. Therapists can still address the many problems listed in the DSM, many of them in the early stages. Yet therapists will also see how the universe of behavior change far exceeds the DSM. Taking meds as prescribed is one big example.
The cost implications are big. Should this model broadly impact health behaviors, comorbidities, and medication nonadherence, a dramatic reduction in healthcare costs is likely. This new model changes the team, focus, and tools. Can goals be achieved? Can PCPs and therapists rethink how they work? We do not know, but we know current efforts are not slowing the growth in healthcare costs.
This model is a fundamental change. Consulting to primary care does not change primary care. Doing traditional therapy in a different setting does not change therapy. PCPs and therapists can change. They can seize every opportunity for behavior change and find personal solutions for each patient. We need a fresh start. The first step is for PCPs and therapists to change how they define their work.
Ed Jones, PhD, is senior vice president for the Institute for Health and Productivity Management.