Patients in Chicago who have been identified by their primary care physician as requiring mental health counseling can wait a year or more before they see a specialist, according to Dr. Joanne May, director of Behavioral Health Services at Advocate Illinois Masonic Medical Center.
That's why the state's largest healthcare system recently began embedding behavioral health specialists in its primary care practices. The system's flagship hospital also runs a walk-in mental health clinic open six days a week for patients in crisis. Care is provided on a first-come, first-served basis.
The average wait time at the facility has been reduced to 30 minutes, May said. Patients are getting same-day assessment and treatment.
“When people are in crisis they might not be able to wait for an appointment that is two months down the road or even 14 months down the road,” May said.
But Advocate Health Care, which like most systems across the country is grappling with huge unmet mental health needs among its clientele, has run into a major stumbling block. There aren't enough psychiatrists and counselors to meet the burgeoning demand for services.
The shortage is projected to grow acute over the next decade, according to a recent analysis by the U.S. Health Resources & Services Administration. The nation needs to add 10,000 providers to each of seven separate mental healthcare professions by 2025 to meet the expected growth in demand.
The widening gap between demand and the supply of available behavioral healthcare providers is being driven by a greater emphasis on addressing mental health issues within primary care settings. While the fate of plans sold under the Affordable Care Act, which must include mental health and substance abuse treatment as one of the 10 essential benefits, is up in the air, the final rules for the 2008 Mental Health Parity and Addiction Equity Act, which covers all plans, established the same deductibles, copayments and limits on visits for mental health as offered for other medical and surgical services.
Those reforms brought the promise of comprehensive care for behavioral health problems. But they also highlighted how unprepared the healthcare system is for meeting the increased demand.
Integrating behavioral health services within primary care settings is now seen as key to serving the rising number of patients seeking care. Mental health screenings during a primary care visit can identify patients suffering from stress, anxiety and depression. Quick referrals and appointments with specialists can prevent more severe health issues down the road.
“There is an increasing understanding that all healthcare has a behavioral health component,” said Mara Laderman, a senior research associate at the Institute for Healthcare Improvement. “Patients are increasingly expecting that they will be able to get all of their needs met in one place, and that place is generally within primary care.”
Locating behavioral health screening and referrals within a primary care setting also addresses the second major roadblock to expanding this crucial service: patient reluctance to admit they have a problem. While reforms like the mental health parity law and expanded health insurance coverage have reduced financial barriers to accessing care, there is still a social stigma attached to being branded a substance abuser or someone with a psychiatric disorder.
“It's something that they might talk to their primary care provider about, but the stigma they might feel walking through a community mental health center's doors prevents a lot of people from seeking out specialty behavioral healthcare,” Laderman said. “When behavioral healthcare is integrated into primary care, then it removes that barrier.”
The long-term effects of mental illness are well known. The average behavioral health patient's lifespan is reduced by about 10 years, according to a 2015 study in JAMA Psychiatry, largely due to the higher risk of suicide and a reduced ability to manage chronic conditions like diabetes and heart disease.
Yet at most healthcare practices across the country – including those at most hospital systems – there isn't a system for handling patients in a primary care setting like the one being pioneered by Illinois Masonic. Once patients are identified with having a mental health issue, most primary care providers have limited options in making referrals.
The problem is compounded by the fact the vast majority of mental health cases are deemed mild-to-moderate, which means they do not require extensive periods of psychotherapy. They can often be treated in one or two counseling sessions along with proper monitoring.
But primary care physicians often do not have the time or training needed to conduct short interventions. If they refer patients to a behavioral health specialist, it can result in long wait times for an appointment while the condition festers or worsens. Longer wait times increase the likelihood of a patient delaying or postponing treatment, and are associated with a higher rate of missed appointments, according to a 2015 report by the Institute of Medicine.
Delayed treatment in turn increases use of other healthcare services and raises the overall costs of care, the report found. For many patients, the downward spiral eventually results in a crisis that lands them either in a hospital emergency room or the criminal justice system.
It's a scenario that is occurring in hospitals and jails across the country. Only 41% of adults with a mental illness received treatment over the past year, according to the National Alliance on Mental Illness, with around 63% of those with serious mental illness getting services over the same period.
The gap in behavioral healthcare resources in primary care settings is also a major concern in rural communities, where 60% of individuals live in a mental health professional shortage area, according to HRSA.
With expectations that current number of behavioral healthcare professional in the U.S. will remain relatively unchanged over the next decade, some providers are investigating whether technology can play a role in providing mild-to-moderate patients with the mental health services. The goal is to use their scarce behavioral healthcare resources more efficiently.
Next: We look at some of the new tools available to primary care providers for remote screening and treatment of mental and behavioral health issues.
