Pioneering approach reduces stigma, increases access to mental health treatment
Middlebury–Mental health conditions such as anxiety, depression and substance use disorder are among the most common and disabling health conditions worldwide. And yet, according to the University of Washington, 50% of individuals who are referred to mental health specialists by their primary care doctor never follow through on that referral. And among the other half who go to the first appointment, many do not continue past the initial visit.
It’s a sad statistic that Dr. Natasha Withers, a primary care doctor at Porter Medical Center in Middlebury, has often seen play out among her patients.
“There’s probably two reasons why that happens,” Withers explained. The first stems from a huge shortage of psychiatric specialty care in Vermont. “There’s such a long wait time that the patient gives up or changes their mind about wanting to see the psychiatrist.” The second speaks to the stigma surrounding mental health care. “When someone comes into a primary care practice, no one knows why they’re there. But if they walk into a psychiatrist’s office, everyone knows why they’re there. That can be a huge deterrent.”
Fortunately, Withers and others working within the UVM Health Network are working on a solution: integrating mental health services into primary care. It’s a new model that will be coming to Porter Medical Center in the fall of 2021, with the hope of eventually rolling it out to all 37 primary health care sites within the Network.
Under this approach, the primary care practice will have its own on-site psychiatrist and therapist, who are available to meet with patients, as well as to consult with the primary care physicians behind the scenes. As Dr. Withers explains, “I can say, this patient is going to see you in a month, but until then, what can I do to help them?”
Dr. Sara Pawlowski is a UVM Health Network psychiatrist who has spent time in several Chittenden County primary health care practices over the last year, as several practices have started to implement parts of the mental health integration. She says that this indirect consultation, in particular, is a direct remedy for Vermont’s shortage of psychiatric specialists. “It allows for the primary health care provider to receive in-house continuous education on psychiatric medications and treatments. This empowers them with more knowledge that can ultimately reach, and benefit, more patients [than was possible through referrals alone].”
It’s a model that has a long history and a proven track record. According to Dr. Pawlowski, the University of Washington’s AIMS Center – which stands for Advancing Integrated Mental Health Solutions – has implemented this approach for more than 30 years, reporting data in over 80 randomized controlled clinical trials that have shown its effectiveness for patient outcomes, for provider and patient satisfaction, and through demonstrated health-care system cost-savings. The reason it hasn’t been implemented more widely, she said, is because the startup costs involved in reorganizing a primary health care practice in this way – which involves hiring more specialists and care managers – can be prohibitive.
And yet, making this type of shift – to enable the delivery of more efficient and proactive health care for the entire population – is a key component of the UVM Health Network’s Strategic Plan, and therefore a very worthwhile investment, said Ron Hallman, a spokesperson for Porter Medical Center. “As we move from the fee-for-service model to one of population health, we’re able to create more value for patients.”
As both Drs. Withers and Pawlowski explained, integrating mental health care into the primary health care practice realizes a key benefit of the population health approach: being able to review health care use data from all patients in a practice, and use evidence-based relationships among various diagnoses to identify the people who may be more likely to suffer from a mental health condition. This, says Dr. Withers, is the most innovative part of the integration.
“For instance, if someone keeps coming to me with diabetes that’s uncontrolled, even after I’ve explained the steps they need to take to get things under control, they’re probably not engaging [in their diabetes treatment] because there are other things going on,” she said. Knowing that uncontrolled diabetes is closely linked to major depression, and having that patient flagged as an at-risk individual, helps prompt the provider to ask further questions. “And, even better, having mental health specialists right down the hall helps create a safe space for that patient to open up about their barriers to better health, whether it’s ‘actually, I can’t afford my medicines,’ or ‘actually, I’m so depressed that I don’t even want to think about my diabetes.’”
According to Withers, “In the moment that the patient accepts help, it’s great to be able to say, ‘okay, let me bring in the psychiatrist or the therapist to make an introduction.’” Also, allowing the subsequent referral visits to happen within the anonymity of the primary care office removes the stigma. “Giving people the privacy they need to utilize these services is really empowering.”
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Embedding mental health specialists in the primary care office addresses Vermont’s psychiatric provider shortage and creates “safe spaces” for patients to receive mental health treatment. Porter Medical Center is on the leading edge of this innovative transition.
“In the moment that the patient accepts help, it’s great to be able to say, ‘okay, let me bring in the psychiatrist or the therapist to make an introduction.’” And then, giving people the privacy they need to utilize these services is really empowering.”
-Dr. Natasha Withers, Porter Medical Center
About The University of Vermont Health Network
The University of Vermont Health Network is an academic health system that is comprised of six affiliate hospitals, a multi-specialty medical group, and a home health agency. We serve the residents of Vermont and northern New York with a shared mission: working together, we improve people’s lives. Our partners include:
- The University of Vermont Medical Center
- The University of Vermont Health Network Medical Group
- The University of Vermont Health Network – Alice Hyde Medical Center
- The University of Vermont Health Network – Central Vermont Medical Center
- The University of Vermont Health Network – Champlain Valley Physicians Hospital
- The University of Vermont Health Network – Elizabethtown Community Hospital
- The University of Vermont Health Network – Porter Medical Center
- The University of Vermont Health Network – Home Health and Hospice
Our 4,000 health care professionals are driven to provide high quality, cost-efficient care as close to home as possible. Strengthened by our academic connection to the University of Vermont, each of our hospitals remains committed to its local community by providing compassionate, personal care shaped by the latest medical advances and delivered by highly skilled experts.