BY, MSN, RN, CCM
Behavioral healthcare in the United States falls perilously short of being a functional, effective system. Mental health and substance use disorders (MH/SUD) are universally categorized as behavioral health disorders, and this label will be used throughout this article (Knutson, 2021). Currently, available services are underfunded, delivered in silos, inconsistently available and difficult to access due to unclear direction (Knutson, 2021). As a result, all stakeholders – patients, families, caregivers, providers, systems, employers and payers – are negatively impacted.
The prevalence of behavioral disorders has risen and is expected to continue to rise due to COVID-19. Suicide rates have increased 33% since 1999, with suicide being the second leading cause of death for young adults between the ages of 10 and 34 years (Knutson, 2021). Essentially ignored during the pandemic, drug overdoses were reported at 21.6/100,000 in 2019, with a 4% increase since then (Knutson, 2021).
Health disparities and an antiquated system serve as significant barriers to accessing care. One solution is the integration of behavioral health with medical care. Behavioral services are often delivered outside traditional healthcare systems like primary care or other medical specialties. Most behavioral care and treatment are delivered by independent practitioners who cannot meet the demand for care, use different documentation and health record systems, are separately reimbursed, and there is little evidence or accountability for outcomes (Knutson, 2021). These all impact the individual’s ability to access care.
The solution involves addressing the system’s flaws, which include inadequate care delivery, workforce shortages, lack of outcome measurement and payment methodologies. Care that is delivered in an urgent or emergent setting could be avoided if screening for behavioral issues was the standard or routine in outpatient settings. If outpatient services are available, they may be inconvenient for the patient with limited office hours or geographical distance. Treatment or management for behavioral health is not incorporated into daily life, like eating a healthy diet or getting regular exercise. Failures in diagnostics and monitoring often result in worsening symptoms and delays in care, indicating the need to integrate behavioral healthcare into the lives of all patients and become a routine part of medical visits. If adopted, these practices hold promise for better engagement in behavioral healthcare.
Shortages in behavioral health professionals have been and continue to be a concern, especially in rural areas, for racial and ethnic populations, youth and the elderly (Knutson, 2021). Despite incentives to promote healthcare professions as a career choice, many areas remain underserved, as does diversity in the workforce to serve specific populations or geographical locations.
Behavioral health outcomes are not sufficiently measured, so evidence of quality or improvement is unknown. The only outcomes potentially measured are medication refills and reduced inpatient admissions. Patient-reported outcome measures (PROMs) are an underutilized measure, as are scales like the Patient Health Questionnaire-9 (PHQ-9), which evaluates depressive symptoms, and the General Anxiety Disorder-7 (GAD-7), which evaluates anxiety. PROMs indicate the patient’s satisfaction with care and treatment and self-reported improvement or decline. The PHQ-9 and GAD-7 are available in the public domain and are fairly simple to use. Improvement is measured through scores, which can monitor for worsening symptoms or demonstrate improvement over time.
Many behavioral health providers have stopped accepting insurance due to utilization restrictions and low reimbursement. This means a patient must pay out-of-pocket to receive care or go without because of inability to pay. Because behavioral healthcare is not prioritized like physical healthcare, organizations budget differently. As a result, care can be delivered in multiple settings that are funded differently and without care coordination (Knutson, 2021). Payment systems blended across federal and state systems can drive more effective and coordinated care (Knutson, 2021). Commercial payers typically take their cues from federal and state mandates and regulations.
One solution to the coordination and integration of behavioral and physical healthcare is multidisciplinary teams structured to meet the needs of a particular cohort of patients with similar conditions. Integrating behavioral healthcare in a medical setting improves the patient’s ability to access these services while receiving physical healthcare, reducing stigma and improving safety (Knutson, 2021). The recent health pandemic was responsible for the fast-tracking of telemedicine. This technology was slow in adaptation, primarily because of reimbursement. But stay-at-home orders resulted in the need for patients to access their providers even if it wasn’t in-person. Telemedicine was also implemented for MH/SUD during the pandemic with some success. Incorporating technology can help bridge the disparities of traveling to a behavioral health provider and allow providers to increase their patient census. There are still too few providers, but telemedicine can help with improving access. Another vital part of this solution is to address social drivers or the social determinants that impact access to care. Social determinants exist in both the physical and behavioral sectors, and determinants encountered may impact both. The physical social determinants of health (SDoH) are well recognized, but we are only starting to understand the social determinants of mental health (SDMH).
The World Health Organization and the Calouste Gulbenkian Foundation recognized the social determinants of mental health as economic, social and political conditions into which one is born. These could impact an individual’s mental health, especially when poverty, deficient or dangerous conditions are present (National Academies of Sciences, Engineering, and Medicine, 2020). Of concern, there is little to no integrated mental health education outside of specific mental and behavioral professional training. As part of their 2020 “Educating Health Professionals to Address Social Determinants of Mental Health” workshop, the National Academies of Science, Engineering, and Medicine (NASEM) emphasized the need for interprofessional and cross-sectional education and a team-based model of care to address this deficiency. An interprofessional environment can connect with academia to create sustainable practices (National Academies of Sciences, Engineering, and Medicine, 2020). To better understand how to address physical and mental health social determinants, the concepts of health disparities and health inequities need to be understood. These terms are often used interchangeably, but they are different concepts:
“Health disparities: are the differences in health status among distinct segments of the population, including differences that occur by gender, race or ethnicity, education or income, disability or living in various geographic regions. An example of health disparities is racial or ethnic groups that are more likely to die of diabetes complications. This applies to Black/African Americans, American Indians and Hispanics. Specific populations may have higher incidences of a particular disease or condition, but it is critical to understand that they can be preventable.
“Health inequities: are a result of systemic, avoidable, and unjust social and economic policies and practices that create barriers to opportunity. An example of health inequity is that lower life expectancy can be dependent of residential location and socioeconomic background; for example, a child born in Sierra Leone has a life expectancy of only 50 years. Another example can be found with young people who identify as gay, lesbian, bisexual, transgender or queer, who experience higher levels of bullying and sexual violence than those who identify as heterosexual” (National Academies of Sciences, Engineering, and Medicine, 2020).
Physical and mental health determinants are the “ultimate markers of mortality” (National Academies of Sciences, Engineering, and Medicine, 2020). Health choices are made based on the choices available. To truly care for patients and promote their well-being, we, as healthcare professionals, must first understand and know how to address what our patients are facing. We cannot sufficiently address illness unless we understand the conditions that influence illness. Learning to address social determinants is not as simple as attending an in-service or adding a module to a curriculum. NASEM recommends a framework that maps out a way to mainstream social determinants into a lifelong learning journey (National Academies of Sciences, Engineering, and Medicine, 2020).
Skills and knowledge are necessary but must also be put into practice — one without the other is ineffective. As healthcare professionals, we need to engage in interprofessional dialogue that allows for “hearing the voices” of the many diverse perspectives found in various communities (National Academies of Sciences, Engineering, and Medicine, 2020).
CMSA offers the opportunity to learn how to better address the physical and mental health social determinants with its Integrated Case Management program. Case managers learn to holistically work with high-risk patients addressing both physical and mental health needs by examining cause and effect. The case manager can create a care plan that prioritizes and addresses risk. A risk scoring tool is used to measure progress and can be used as an outcome measure. To learn more, visit www.cmsa.org/education/icm.
Knutson, K. H. (2021, August). A value framework for transforming behavioral health. NEJM Catalyst, 2(8). doi:10.1056/CAT.21.0037
National Academies of Sciences, Engineering, and Medicine. (2020). Educating professionals to address the social determinants of mental health: Proceedings of a workshop. Washington, DC: The National Academies Press. doi:http://doi.org/10.17226/25711