The Value of Integrating Behavioral and Physical Health

00;00;00;19 - 00;00;31;23
Tom Haederle
The wrap up of the American Hospital Association's 2024 Community Health Improvement Week reminds us once again that overall health does not fit neatly into buckets: One for physical health and a separate one for behavioral. Mind and body are intertwined, and today's caregivers not only recognize that reality, they design comprehensive treatment regimens around it.

00;00;31;25 - 00;01;03;02
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. Dr. Jerry Halverson is a consult liaison psychiatrist with Rogers Behavioral Health. That's a provider of specialized mental health and addiction treatment with locations around the country. As we hear in this podcast hosted by the AHA's Rebecca Chickey, senior director for Behavioral Health, Dr. Halvorson is a big believer in the integration of physical and behavioral health services for simple reason: it works.

00;01;03;04 - 00;01;15;11
Tom Haederle
It makes for better patient outcomes, and also for payers like Medicare who are providing reimbursement for integrated care. Not only that, it improves clinician satisfaction levels as well. Let's give a listen.

00;01;15;14 - 00;02;06;00
Rebecca Chickey
It is my honor, as Tom indicated, to be here today with Dr. Jerry Halverson - who just to reiterate this because it's important to the nature and the content of this podcast - is a board certified adult psychiatrist as well as a subspecialty in consultation liaison psychiatry. And the reason I mention that, because today's podcast is all about the value of integrating physical and behavioral health, I think consultation liaison psychiatry, which has existed for many, many decades, was really the first step forward in terms of treating the whole person, addressing an individual's psychiatric needs or substance use disorder treatment needs, while they were also being treated for a "other physical illness."

00;02;06;02 - 00;02;18;07
Rebecca Chickey
So, Jerry, my first question to you is is that true? And can you tell us a little bit about what led you to make sure that you had that extra additional training in psychiatry and the coming of CL?

00;02;18;09 - 00;02;39;29
Jerry Halverson, M.D.
Well, first, thank you for having me here. I think what you said is accurate. Having behavioral health available to treat behavioral health issues in other medical settings is important. There was a time, I think, where we tried to split the two or cleave the behavioral health off and have the behavioral health kind of taken care of elsewhere.

00;02;40;01 - 00;03;05;27
Jerry Halverson, M.D.
Unfortunately, I think that was to our patients detriment and frankly, to our medical outcomes detriment. I think what we've seen over the years is if we take behavioral health out of the rest of the medical care, what happens is that the behavioral health oftentimes doesn't get addressed. It gets ignored by the patient. And when it doesn't get treated, then we see poor outcomes.

00;03;05;27 - 00;03;34;29
Jerry Halverson, M.D.
We see people that have heart attacks and depression, have a much higher mortality rate than people that have heart attacks that that don't have depression. I've always been interested in, obviously, I went to medical school. I've always been interested in the medical piece. I had a great residency experience where we had consult liaison, where we took care of psychiatric issues and really complex medical situations.

00;03;34;29 - 00;04;09;05
Jerry Halverson, M.D.
And being there, being able to help, the patient kind of negotiate the experience and help the medical teams understand where their patients are coming from and, better able to negotiate the psychiatric aspects of what presenting at the bedside has always been something that's been really fun for me. And as we've found, as time has gone on, that kind of understanding, addressing both of those at the same time does nothing but help the patient do better and make it less likely that they're going to need to come back to the hospital.

00;04;09;07 - 00;04;34;14
Rebecca Chickey
So at the heart of what you just described is the ability for integration to do multiple things at once, I think, and I'd like you to do a little bit of a deeper dive on each of these if you would. In part, what you were describing is that integration allows improved patient outcomes. Integration also allows and encourages improved workforce satisfaction.

00;04;34;16 - 00;04;53;22
Rebecca Chickey
And it can also at the same time improve patient satisfaction. So if you can speak to, in your experience, how you have seen and where you have seen improved outcomes and improved patient and clinician satisfaction when integrated care is being provided.

00;04;53;24 - 00;05;19;11
Jerry Halverson, M.D.
Well, as far as the outcomes, it's pretty clear out there. You can look at multiple medical issues, whether I'd already mentioned cardiovascular disease, but you look at diabetes, you look at cancer, you look at HIV, you look at all sorts of other very serious medical issues. And if there is a co-morbid psychiatric concern, if there's a psychiatric concern alongside of that medical concern, if they are not getting that addressed, they are just not going to do as well.

00;05;19;16 - 00;05;40;11
Jerry Halverson, M.D.
They are going to be much more likely to have a rough course or to actually die. Mortality rates are high. So it's super important that when we have folks that have serious medical issues that we investigate and rule out psychiatric issues and take care of psychiatric issues when they exist. So we know that it's important.

00;05;40;11 - 00;05;59;14
Jerry Halverson, M.D.
And as I mentioned before, there have been times where we have taken psychiatry or behavioral health treatment and taken it outside of the medical facility, and that makes it much less likely that people are going to follow up and are going to get that aspect treated. And as I said, if they don't get that aspect treated,

00;05;59;14 - 00;06;25;06
Jerry Halverson, M.D.
they're just going to do more poorly. Now, does poorly always mean death? No, but poorly can certainly mean that this condition becomes more chronic. This condition becomes more difficult to treat. This condition becomes more disabling. But there's also, as I said, mortality. There's also, unfortunately, poorer ultimate outcomes. So patients appreciate being able to have everything taken care of in one spot.

00;06;25;09 - 00;06;53;07
Jerry Halverson, M.D.
They appreciate having all aspects of their of their illness identified and treated. And our workforce also, as far as other physicians, nursing staff... you know, sometimes when a psychiatric issue pops up and there isn't a lot of comfort with that psychiatric issue in the medical space, it becomes a piece of dissatisfaction. This is a problem patient that I don't know what to do with, and I'm frustrated with, and it makes me frustrated with my job.

00;06;53;14 - 00;07;16;20
Jerry Halverson, M.D.
Whereas if we're able to identify those issues and help the primary teams manage those psychiatric issues, not only are outcomes better, but also  everybody's happier. Obviously, if a patient is getting better, that's what the medical team wants to see. If the patient is feeling better, that's what they want. So if you're able to address that psychiatric concern, people are in a much better space.

00;07;16;23 - 00;07;44;03
Rebecca Chickey
So that's three for three. If you integrate care you can see improved outcomes. You can see improved patient satisfaction and improved workforce satisfaction. Not bad when you're looking for how to transform a delivery system and push for the triple or the, the fourth aim now. So, doing well. I want to dig a little deeper since, looking to July...

00;07;44;03 - 00;08;11;07
Rebecca Chickey
July is Minority Mental Health Month, and we know the statistics that it is difficult for anyone, in many cases, to access mental health services at the right point in time when they need it. I mean, that's a challenge that every hospital and health system across the country is trying to work on. But it is particularly difficult for historically marginalized communities.

00;08;11;09 - 00;08;32;27
Rebecca Chickey
So wondering if you could share with us your experience, your thoughts on how integrating care can reduce health care disparities for individuals of color, for individuals who may be LGBTQIA+, how does integrating care reduce the stigma and improve access to care for those marginalized patient populations?

00;08;32;29 - 00;08;53;16
Jerry Halverson, M.D.
I think that's a very important point that you bring up. And we definitely see that. I think what's been helpful is over the course of the last 25 years of my career, I've seen that behavioral health treatment from a patient perspective is much more acceptable. They want to talk about these issues. They want to have treatment for these issues, but oftentimes they don't know where to find it.

00;08;53;16 - 00;09;32;02
Jerry Halverson, M.D.
And as you've mentioned, historically marginalized populations particularly have had poor access. Well, to all medical care, I think in general. But psychiatric care in particular has been a significant concern. So having that treatment be convenient, having that treatment be accessible, having their primary care doctor bring up these issues to try to screen how else they could help this patient, makes it easier for the patients to talk about, but also makes it easier to access if you have that access where they're getting the rest of their medical care.

00;09;32;03 - 00;10;00;07
Jerry Halverson, M.D.
As I said, historically, we have carved out behavioral health and put it somewhere else. And all that that's done is made it more difficult to seek out behavioral health. And again, 15 years ago, when people didn't want to see a psychiatrist, didn't want to talk about behavioral health, maybe that wasn't as much of an obvious concern. But right now when people want that treatment and can't get it, it's just makes it much more clear what a mistake we made by not integrating behavioral health with the rest of medical care.

00;10;00;09 - 00;10;23;17
Rebecca Chickey
Thank you for that. It's good to know that integrated care can help reduce stigma and even more importantly, improve access to services, particularly for historically marginalized patient populations. But I have a question for you that I know everyone is kind of thinking about, and that is, how do you pay for this? Is it really worth it? Is there a positive return on investment?

00;10;23;20 - 00;10;27;21
Rebecca Chickey
So can you speak to that from your experience and what you've seen?

00;10;27;23 - 00;10;53;17
Jerry Halverson, M.D.
Well, there's a rich literature in how this pays off. Before I get to that, I mean, concretely, there are codes. There are CPT codes that you can use when you're integrating behavioral health care in the medical care. So CMS has understood how positive integrating behavioral health into medical care is. So they're actually paying for it is the most obvious piece.

00;10;53;19 - 00;11;22;01
Jerry Halverson, M.D.
But also it's really the outcomes. What you're going to save is not necessarily money that you realize, you're going to save in behavioral health. What it is, is your ER visits go down, your complications go down, your outcomes improve, which means they're not coming back to redo that surgery that they had because they were no longer depressed and they were able to do the rehab program that you wanted to. Out there

00;11;22;03 - 00;11;46;15
Jerry Halverson, M.D.
right now, very easy to find are many studies that show if you're giving people behavioral health care and they're utilizing and that's what we're talking about. We're talking about bringing behavioral health care to where people are so that they're more likely to utilize it. If you're able to improve, the behavioral health symptoms that people are having, your outcomes improve, and they're less likely to be going back to your emergency room.

00;11;46;20 - 00;11;59;01
Jerry Halverson, M.D.
They're less likely to be calling back their surgeon or their primary care doctor for another appointment because the psychiatric piece isn't getting in the way of their recovery like it would if it wasn't treated.

00;11;59;04 - 00;12;29;10
Rebecca Chickey
Thank you. I'm going to ask the listeners. I'm going to let them know about a resource that AHA released last fall. And if you Google "AHA Integration, the Time is Now," that four-page brief will provide some - and definitely back up - Jerry's comments here about the fact that there are a lot of studies out there that have shown that it at least breaks even, or it could have up to, 1 to 6 or a 1 to 4 return on investment.

00;12;29;12 - 00;12;53;15
Rebecca Chickey
And you didn't even mention Jerry, which I wish we could captured this in so many ways. And that is the improvement in daily living skills, the ability to go back into the workforce, the ability to support a family structure and just the overall improved outcomes of living as a human being. I don't know how you put a price on that because I think that is priceless.

00;12;53;18 - 00;12;59;18
Rebecca Chickey
But it is also something else that I think we calculate that into the return on investment.

00;12;59;21 - 00;13;21;29
Jerry Halverson, M.D.
Now, what we're talking about exists out there. There are folks dealing with depression all the time that they're living their lives and living their lives at a lower level, not being the husbands, the wives, the parents that they need to be not being able to do their job like they should. Productivity is down, but they kind of still live that life that's depressed.

00;13;21;29 - 00;13;49;19
Jerry Halverson, M.D.
And again, we had really stuck about medical outcomes and getting significant medical comorbidities better with a depression being better. But as you said, it's like from a population health quality of life perspective, functioning human being perspective, if we are somehow increasing the amount of people that get treatment for the depression or anxiety that we know exists, we know what's out there.

00;13;49;22 - 00;14;10;11
Jerry Halverson, M.D.
At least a quarter of your patients have a significant mood disorder. Very nearly the same have a significant anxiety disorder if you're talking about less than significant, but still substantial, it is double so it's out there. And if you're making it easy for people to receive that treatment these days, they'll want that treatment. That might not have been the case 20 years ago.

00;14;10;17 - 00;14;17;11
Jerry Halverson, M.D.
These days, they want that treatment. So if you make it available and they get better, as you're right, you know, we're checking all the boxes there.

00;14;17;14 - 00;14;36;10
Rebecca Chickey
So as we start to close this out, I'd love for you to give me maybe your definition of what integrated care is, because there's many different approaches, as we've evolved to where we are. So if, pretend I'm a novice and, I say, what is integrated care? What does that mean? How do you staff it?

00;14;36;13 - 00;15;01;00
Jerry Halverson, M.D.
So integrated care means a lot of different things as you said. But I think at its baseline, it's bringing behavioral health expertise into the rest of the medical house, which means making it easier for patients to access the treatment. Because optimally you have a provider that's evaluating the patient, identifying with a screening tool that maybe depression is an issue.

00;15;01;00 - 00;15;21;29
Jerry Halverson, M.D.
And obviously there's a lot that primary care or other providers can do with depression. But once you get past a certain point, maybe you've tried a medication, maybe you've referred them to therapy and there's still an issue. Or maybe they don't make it to therapy because the therapy is not convenient. The therapy is across town, or they don't know what is covered under their insurance.

00;15;22;00 - 00;15;42;20
Jerry Halverson, M.D.
They don't treat it. Having somebody right down the hall, having somebody right in the area that easy for the patient to get to, that's easy for you as a clinician to find and refer to, really increases the chance that that treatment is going to happen. And we know that our treatment works. So if the treatment is happening, it's very likely going to be successful and the issues will be resolved.

00;15;42;23 - 00;15;55;02
Jerry Halverson, M.D.
But I think defining it is trying to bring behavioral health care where the medical care is being given. So it's convenient for the providers to refer and convenient for the patients to seek out.

00;15;55;05 - 00;16;08;25
Rebecca Chickey
And it sounds like that could either be someone physically down the hall from the primary care office, whether it's a social worker, a psychiatric nurse practitioner. But it also could be through telehealth. Is that correct?

00;16;08;28 - 00;16;33;02
Jerry Halverson, M.D.
They are behavioral health providers that kind of extend their bandwidth by directly intervening with cases with primary care doctor in a consultative way. Further, there are providers that oversee, like social workers or people that are following up with a full panel of patients and then they would bring issues to a higher level provider, oftentimes a psychiatrist.

00;16;33;10 - 00;16;57;16
Jerry Halverson, M.D.
And then, you would be able to help take care of those patients from a broader sense, rather than just the one on one that oftentimes psychiatry is known for. That's a way to take a psychiatrist and spread the psychiatrist over a population. And that particular model has been shown to be very effective in identifying and taking care of mental illness in more medical settings.

00;16;57;18 - 00;17;04;13
Rebecca Chickey
Well, and given the overall shortage of psychiatrists currently, compared to the demand and the need for them and

00;17;04;13 - 00;17;05;02
Jerry Halverson, M.D.
therapists. And nurse practitioners.

00;17;06;22 - 00;17;29;06
Rebecca Chickey
And then when you talk about geriatric psychiatrist or child and adolescent psychiatrist, the demand and need for their services exceeds the supply. So great to know that can also help from a workforce perspective. Dr. Halverson, thank you so much for your time, your expertise, for being able to inspire others to consider integrating physical and behavioral health.

00;17;29;08 - 00;17;53;03
Rebecca Chickey
It has so many values and positives, but I think going back to the very first one, it can improve patient outcomes. And I think that's probably why you got into medicine in the first place, is to help and assist and to improve the health of the individuals that you treat. Keep up the great work. And for our listeners, this is Rebecca Chickey, senior director of Behavioral Health at the American Hospital Association.

00;17;53;05 - 00;18;02;06
Rebecca Chickey
For more resources on the value of integrating care, go to aha.org/behavioral health. Have a great day.

00;18;02;09 - 00;18;10;19
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and write us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.