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Build Delivery Systems That are Data-Driven and Holistic
Psychotherapists have more in common with primary care physicians (PCPs) than either group might suspect. Both are compensated below their peers, partly because our healthcare system pays more for therapeutic procedures than therapeutic conversations. Both face potential replacement by lower skilled providers. However, a more hopeful commonality exists. Each might help improve the clinical value of the other.
Might a new business collaboration be beneficial for PCPs, therapists, and their patients? A clear path exists for this if healthcare executives are willing to seize the opportunity. The key innovation is to reconfigure healthcare delivery. This model is more business-oriented than clinical, and its features are best understood in contrast with related integration efforts.
A new working relationship between PCPs and psychotherapists is possible. It might seem obvious if not for it being obscured by the 3 common models for primary care integration today:
- The Collaborative Care Model provides medication consultations for psychiatric disorders, along with ancillary services for some of these patients.
- The Primary Care Behavioral Health (PCBH) model asks consulting therapists to improve the work of the primary care team by focusing on behavioral health issues and comorbid med-psych issues.
- Therapists co-locate in primary care offices to conduct therapy as usual.
Meet the New Team and Its Operating System
A gap in primary care waits to be filled by bold therapists willing to become full team members. They would have joint responsibility for a provider’s patient panel and would offer brief office visits like PCPs lasting up to 20 minutes. This integrated delivery system would rest on 2 premises: 1) the centrality of behavior to health; 2) the need for therapeutic conversations to change behavior.
The operating system for this reconfigured primary care setting is a measurement-based care (MBC) system that detects patients needing therapist attention and monitors clinical status over time, especially between office visits. This is an enhancement to today’s MBC, but the main components are available and many knowledgeable architects are ready to build it.
This model abandons both traditional therapy and the consulting role. It retains the largest driver of clinical outcomes according to research—the therapist—and leverages the reality that therapeutic conversations often plant seeds for later harvesting. Primary care involves unique longitudinal relationships that are well-suited to the work of therapy since behavior change often takes time.
The team’s therapists will use existing skills and not follow any type of manual-based care. Any focus on empirically supported techniques is the therapist’s choice. The goal is clinical improvement, not fidelity to a set of techniques, and results are judged as outcomes emerge from the MBC system.
This data-driven, integrated model needs executive leadership. It is the executive who assembles the pieces to create a new program better able to meet patient needs. PCPs need a therapist to address the varied behavioral impediments to a positive outcome, not just those connected with major psychiatric diagnoses. Therapists need MBC to flag needs, risks, and clinical changes they would otherwise miss.
Benefits for All Stakeholders
PCPs are struggling. Primary care funding is insufficient in comparison with global benchmarks. Retail companies are luring patients away for basic services provided by nurse practitioners and physician assistants. Results for many patients fall short due to behavioral issues. While existing collaboration models offer them limited help, this new approach meets the scale of primary care behavioral issues.
Therapists are becoming part of our healthcare system as business consolidation transforms our industry. They need a model for medical collaboration that is effective and provides a rewarding career track. Traditional services will still be an option, but this model helps therapists keep pace with a changing environment. Good careers for therapists will look very different in 20 years.
Calls for access to behavioral care have never been louder. How many people might have their needs met with brief therapeutic conversations in primary care? We do not know, but we can assume it will suffice for some. Others might benefit from adding digital therapeutic resources, and another group from adding traditional care. The rational allocation of services begins with therapists on the frontlines.
The integration of primary and behavioral care is a misnomer. These dimensions are inseparable, and yet we place them in artificially distinct categories needing integration. Patients need holistic care. To achieve this, therapists must become full-fledged healthcare providers. Behavioral care is primary care, and PCPs need them as partners to meet the pervasive behavioral challenges they encounter.
Executives are needed to make any of this happen. PCPs and therapists need data-driven, integrated settings in which they can practice more effectively. Executives can put those elements in place and bring clinicians together to reinvigorate the power of therapeutic conversations. In time the results of those conversations might surpass the outcomes of some expensive medical procedures.
Ed Jones, PhD is currently with ERJ Consulting, LLC and previously served as president at ValueOptions and chief clinical officer at PacifiCare Behavioral Health.
The views expressed in Perspectives are solely those of the author and do not necessarily reflect the views of Behavioral Healthcare Executive, the Psychiatry & Behavioral Health Learning Network, or other Network authors. Perspectives entries are not medical advice.
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