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New Level of Care Can Solve Care Access Crisis
Editor’s note: This is the first in a 3-part series.
The care access crisis in our field will not be solved with new clinical ideas. While some may be helpful, the scope of the problem demands structural changes. The foundation or basic framework for our field’s care delivery—its infrastructure—needs an overhaul. A reasonable blueprint can be designed for this reconfiguration, but it will need funding, support, and leadership.
The depth of our outpatient crisis is alarming. Supply cannot meet current demands, even though factors like stigma, cost, and inconvenience suppress demand. Latent demand awaits release as these barriers are lowered, sure to overwhelm our strained system. Our focus on training new clinicians is insufficient. Without significant institutional changes, the crisis will continue.
We are failing people at both ends of the severity continuum. Too many people with severe mental illnesses and substance use disorders (SUDs) get no care or less than guidelines recommend. Yet, despite this, we have effective treatments and know what to do. The same is not true for less severe problems. We need better detection, timely access, and less intensive interventions. This is a big gap in our current infrastructure.
The B4Stage4 Philosophy
Our field draws on an analogy with cancer in addressing the severe end of the clinical spectrum. Our access crisis means too many people get no help until their disorder has progressed to a level comparable to stage 4, metastatic cancer—a stage with the poorest prognosis.
Organizations like Mental Health America have used the B4Stage4 philosophy to promote screening, prevention, and early intervention. This is compelling but needs to go further. Demanding earlier care is correct, but it must be accompanied by a more substantive demand—a care infrastructure that fits each stage.
The appropriate infrastructure exists for treating cancer at each stage. Behavioral healthcare is more complicated because behavioral conditions that might be classified as less severe than stage 1 can cause substantial suffering and dysfunction. How do we care for those people?
Should all people with stage 1 behavioral disorders receive outpatient psychotherapy? Might some benefit from less intensive services? What about problems less severe than stage 1, such as:
- People with painful depression symptoms not meeting full diagnostic criteria;
- Those with disabling levels of situational distress;
- People with unhealthy habits that exacerbate chronic medical conditions like diabetes; and
- Lonely people who isolate and neglect many aspects of their health.
While we can recommend when and how behavioral problems get addressed, in reality, we wait for people to recognize their own behavioral needs. Once ready, they unfortunately discover barriers. We could change this.
A New Level of Care
The primary care setting has the infrastructure needed for earlier detection and intervention. It is a natural setting for our services, providing comprehensive evaluations and non-stigmatized, routine care. Primary care providers (PCPs) increasingly see behavioral care as an aspect of primary care. Mind and body are understood as inseparable. This setting is ideal as the lowest tier for outpatient behavioral care.
Brief behavioral interventions in primary care will suffice for many people. Others may need to be stepped up to specialty care for traditional psychotherapy. While therapy is neither necessary nor scalable for less severe behavioral issues, it is the definitive service for the higher tier of outpatient care.
Leadership is the main asset we lack. Behavioral clinicians work on the fringes of the primary care setting today, and its potential as an initial level of outpatient behavioral care is being missed. Our integrated care models (e.g., collaborative care model) offer limited consultations and meet a fraction of existing needs. We need executives to drive a new vision of this setting—a distinct level of care.
Let us revisit our level of care (or patient placement) guidelines and articulate the features of this level of outpatient care. This setting can support therapists in providing brief interventions, combining services such as brief counseling, digital therapeutics, and measurement-based care (MBC). It will require joint management with PCPs, and yet many physicians are ready for a new type of team-based care.
Funding Essential Goals and Services
Our healthcare system funds essential health services, including behavioral care. However, our field has been on the system's periphery (e.g., separate funding and management), so it still gets questions suitable for outsiders—like how our services might save money by reducing other healthcare costs.
Easy access to behavioral care should be assured. Yet, to meet our access goals—an aspect of essential healthcare—we will need new funding. This may present challenges, but creative funding strategies can be found. In any case, success in meeting our goals should not be considered optional.
Acceptable access depends on making primary care more than a service location. Our leaders must staff and build infrastructure in this setting to make it a behavioral level of care. This is the epitome of viewing behavioral and medical care as inseparable. Millions are waiting for essential behavioral care.
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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