Practicing Behavioral Care in an Integrated Setting: PCORI Project Ramps Up

July 22, 2016 by Carolyn Shapiro

Jen Lavoie’s daughter began showing symptoms of Crohn’s disease at age nine, but most of her clinicians found nothing wrong with her, and one suggested the girl’s gastrointestinal discomfort was “all in her head,” a symptom of stress.

(From left to right) Constance van Eeghen, Dr.P.H., , Benjamin Littenberg, M.D., and Rodger Kessler, Ph.D. (Photo: COM Design & Photography)

Jen Lavoie’s daughter began showing symptoms of Crohn’s disease at age nine, but most of her clinicians found nothing wrong with her, and one suggested the girl’s gastrointestinal discomfort was “all in her head,” a symptom of stress. If her daughter had had the option to meet with a mental health provider in the same office – even see a specialist on the spot – that might have helped settle the question and led to a diagnosis more quickly.

A recently-launched study led by the University of Vermont College of Medicine aims to determine the benefits of blending primary care and behavioral health practices. The project will study patient outcomes for primary physicians who fully integrate behavioral care and compare them with practices that “co-locate” a behavioral provider under the same roof but stop short of coordinating the two areas. (Read the project announcement here.)

That’s music to Lavoie’s ears. The Huntington resident knew a specialist could help diagnose her daughter’s physical problem, but found the burden of finding a psychologist on her own and waiting for an appointment to get her daughter evaluated daunting.

“Someone needed to step in from the behavioral health side,” Lavoie says, adding that her daughter “needed to be heard.”

The ease – or difficulty – of connecting a patient’s primary care with behavioral health treatment is crucial for patients who suffer from medical disorders, such as heart disease or diabetes that are exacerbated by issues like alcohol abuse or depression. With her experience handling her own family’s challenges, Lavoie was asked to serve as a patient co-investigator on the study.

The five-year project, led by UVM College of Medicine researchers, including Benjamin Littenberg, M.D., Henry and Carleen Tufo chair in general internal medicine, Rodger Kessler, Ph.D., associate professor of family medicine, and Constance Van Eeghen, Dr.P.H., assistant professor of medicine, will include about 40 physician practices nationwide and about 3,000 patients. To qualify for inclusion, a practice must commit to integrating behavioral health and must hire or already have a behavioral provider on site.

Currently, the project is rolling out an educational component, mostly in the form of an online interactive training program for the staff in each practice. “It’s reshaping clinical expectations of what is the job” of treating behavioral health, says van Eeghen. Old presumptions “are all put into question in terms of what we could do differently,” she says.

The key difference is in the actual practice of behavioral care in an integrated setting. During a traditional visit with a psychologist, for example, a patient would explore the causes of their problems, perhaps family difficulties or deeply held emotional hang-ups.

With integrated behavioral health, the focus would shift from the reasons for the problems to solutions for managing those problems. “It’s more about what’s happening in the future, as opposed to untangling the threads that brought you here in the first place,” Littenberg says. “It’s practical, it’s short-term and it’s brief.”

This mode of care requires specific clinical training that few professionals have, Littenberg says, so the grant will provide a “crash course” for each office’s existing staff. To help a person with diabetes who has a phobia of needles and refuses to inject insulin, for example, a practitioner could learn some targeted techniques – “tricks of the trade,” he says.

The educational component also addresses the need for institutional change, which often meets resistance in workplaces, van Eeghen says. To ease those obstacles, she suggests, a staff member could take charge facilitating a team to redesign back-office operations, figuring out a patient-centered way to manage care that also works for the practice. “So they can ensure that these ideas, which are lovely ideas, are done in a way that makes sense for people in that community,” she says.

While the researchers grapple with this big question – whether patients do better with a more integrated system – each redesign team in a practice has to decide how the system will work. Does the doctor click a button on a computer? Does the patient have to go back to the front desk for an appointment? Or does the doctor walk the patient down the hall to the behavioral provider and introduce them – which van Eeghen calls “the warm hand-off”?

“If the scheduling system doesn’t have an appointment type for behavioral health, then the whole thing grinds to a halt,” Littenberg says.

van Eeghen, an expert in quality improvement and organizational management for medical settings, has studied the “lean” manufacturing process – which emphasizes customer satisfaction with minimal waste – and applies it to healthcare. Research staff will coach resdesign teams to adopt “best-of-breed” tactics for the PCORI project, but each site decide how todesign its own system.

Half of the practices will be randomly assigned to switch to an integrated protocol, and half will have a co-located behavioral specialist. Patients who participate will complete several surveys about their health and success in taking care of themselves.

“Patients come with us every step of the way,” van Eeghen says.

Lavoie and Littenberg’s wife are both fiber artists who became friends. He suggested Lavoie as one of three patient co-investigators on the grant, because he knew of her struggles with her daughter’s illness, which was ultimately diagnosed as Crohn’s disease when she was 15.

Following the diagnosis, Lavoie would have liked the opportunity to see a behavioral health professional right down the hallway in the doctor’s office – mostly to address how the family was coping.

“At that point, we all needed to be asked, ‘Are you feeling good?’ And, if not, ‘What do you need?’ ” Lavoie says.

Despite her disappointment in past experiences, Lavoie has embraced the opportunity to have a voice in the study. Her job is to help translate the team’s goals and instructions to the patient participants. She’s trying to learn as much as she can and calls out the scientists when they use language she doesn’t understand.

“This patient-centered research,” Lavoie says, “it’s really kind of cracking open the system and saying: ‘Don’t forget that you’re here for the patient’s pain, but the patients are also giving you something and teaching you something.’”


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