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How a “warm handoff” is making mental health care a regular part of doctor visits in Boulder

It isn’t lie-on-the-couch psychiatry, but a more approachable model that gets patients focused on their whole health

Gina Manchego arrives at the Della Cava Family Medical Pavilion for treatment with her doctor on Sept. 10, 2019, in Boulder, Colorado. Boulder Community Health has integrated mental health care into 10 of its primary care clinics. (Kathryn Scott, Special to The Colorado Sun)
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Gina Manchego worried she had some rare disease. She slept only two hours each night. Her heartbeat thundered in her chest, and more days than not, her head pounded in pain.

The stay-at-home mom went to see her doctor about 20 times in one year to try to figure out what was wrong with her. She had high blood pressure, but repeated blood tests found nothing else abnormal.

Then her doctor at a Boulder Community Health primary care clinic suggested Manchego, 41, meet with one of the clinic’s behavioral health specialists. That’s when everything changed.

The heart palpitations, migraines and lack of sleep had the same root cause: Manchego’s mental health. She had such severe anxiety that it was causing physical symptoms. 

To get the mental health care that would rescue her, Manchego didn’t have to get a referral from her doctor or call for an appointment, or worry whether the therapist was accepting new patients or her insurance. She didn’t even have to drive to a mental health clinic. 

That’s because Boulder Community Health has absorbed mental health care into 10 of its primary care clinics, a model that is attracting national attention and buy-in from the insurance industry. The clinics aim for a “warm handoff,” a direct introduction from physician to mental health specialist.

Gina Manchego arrives at the Della Cava Family Medical Pavilion for treatment with her doctor on Sept. 10, 2019, in Boulder, Colorado. (Kathryn Scott, Special to The Colorado Sun)

Eight behavioral health specialists in Boulder Community Health’s primary care clinics help patients address their “whole health,” typically focusing on the early stages of depression and anxiety. Patients are not billed for a separate visit when they talk to a mental health counselor. 

Instead, much of the funding for the 5-year-old program comes from a State Innovation Model grant from the federal Centers for Medicare and Medicaid, which gave Colorado $65 million from 2015-19.

“We wanted to take the burden off of the patients,” said Betsy Duckett, director of integrated clinical services for Boulder Community Health, noting most people would choose to spend their money to “pay their bills, take care of their kids” rather than to talk to someone about their anxiety. The model, she said, is a “game-changer.”

In 2015, the first year Boulder Community Health hired mental health specialists, those therapists saw 256 patients. In 2018, that number climbed to 1,730.

More natural, less stigmatized

Before 2013, patients who came to Boulder Community Health received no routine mental health screening. Now everyone age 12 and older gets screened for depression and anxiety. Those who need it are offered a conversation with a behavioral health case manager. 

Each month, the health system runs a report to find patients who scored high on the screen. If they haven’t been in to see a behavioral health specialist or a mental health professional in the community, a staff member calls to ask them to schedule an appointment. 

“We’re actually looking for the patients now, not just waiting for them to come to us,” Duckett said. 

Boulder Community Health offers three behavioral health visits in a six-month period. For many patients, it’s enough. 

Excessive alcohol use and sleep problems are the most common issues that people need help with, according to Julie Jungman, who is the behavioral health program manager and a licensed clinical social worker. She teaches coping mechanisms, including asking patients to name five things they smell, see and feel as they are trying to fall asleep or feel a wave of anxiety during the day.

Her meetings with patients focus on “anything that involves emotions and behaviors,” which is  almost everything. Patients who are trying to lose weight. People with diabetes who are trying to manage blood-sugar levels. Patients who have high-stress jobs that lead to heavy alcohol use and trouble sleeping. 

“We hope that we can help small storms from becoming tornadoes,” Jungman said. 

By making mental health workers part of the daily flow of the clinic, mental health care feels more natural and less stigmatized, she said. Jungman often invites patients to an appointment by asking if they want to talk about techniques to manage stress, not if they want “mental health therapy.”

“People think they need to lie on a couch and focus on birth to now,” she said. “We really have a focus on the present day and that feels more accessible to patients.”

The Della Cava Family Medical Pavilion on Sept. 10, 2019, in Boulder, Colorado. (Kathryn Scott, Special to The Colorado Sun)

Some patients only need one visit: a psychology lesson about the relationship between sleep and alcohol. Alcohol makes people fall asleep more easily, but also can cause them to wake later in the night with anxiety, heart pounding and mind spinning. 

Jungman teaches those patients other ways — besides alcohol — to wind down the mind, and “maybe that is all the patient needs to take it from there,” she said. Others get a “taste or a flavor of what this service can be like and they are willing to come back again.” 

Manchego was at first unwilling to make the connection between her physical symptoms and anxiety. But when she did, she felt like she was receiving help for her “mind, body and spirit.” 

“There wasn’t a compartmentalized approach to me getting better anymore,” Manchego said, noting her case was a tough because she did not want to take anti-anxiety medication. 

Her behavioral health specialist coached her through coping techniques and coordinated visits with a sleep specialist and a neurologist to help with Manchego’s migraines. The headaches come about three times per month now, instead of three times per week. She no longer wakes up with her heart racing. She started blogging about mental health. 

Manchego said she has had anxiety almost her entire life, but about two years ago she was feeling worse than ever. It’s a relief now to know what was wrong. “My brain chemistry was off,” she said. “Anxiety takes you to a different reality. You’re living in these weird, what-if scenarios instead of being mindful of real-life occurrences. I was pretty much a big mess.” 

Boulder one of eight sites chosen for pilot project

Boulder Community Health took a step further a year ago and hired a psychiatric nurse practitioner to help manage the ever-increasing number of patients with mental health issues coming to its primary care clinics. 

The psychiatrist doesn’t actually see the patients, but reviews the medical records of up to 65 patients at a time, monitoring the prescriptions doled out by primary care physicians. The consultant regularly meets with the patients’ behavioral health specialists to offer real-time advice about dosage adjustments or new medications.

It’s designed to give patients better access to psychiatric care, and is based on the premise that it’s often a patient’s physician — not a psychiatrist — who is prescribing mental health drugs, specifically antidepressants and anti-anxiety medications. Patients get treatment faster, rather than trying to find a psychiatrist in the community, where the waitlist for an appointment is typically months long.

Boulder Community Health began the program in partnership with Medicare and now has support from Cigna, a private insurance company. Cigna is piloting the model at eight sites in the nation, including Boulder. The health system can bill for the psychiatric consultant under specialized billing codes released by the federal government in 2016, helping recoup the cost spent on the program. 

“Our hope is that we take care of the more mild to moderate folks and create more access to the psychiatric community for those who really need it,” Duckett said. 

The efforts are part of the push toward mental health parity, a law on the books for more than a decade but still not in practice. 

A hallway leads through the lobby of the Della Cava Family Medical Pavilion. Boulder Community Health has integrated mental health care into 10 of its primary care clinics. (Kathryn Scott, Special to The Colorado Sun)

Other family practice clinics in the state, including UCHealth, CU Family Medicine and St. Mary’s Medical Center in Grand Junction, have incorporated mental health care. 

Federal law mandated in 2008 that insurance companies provide the same coverage for illnesses of the brain as for physical conditions — if they offer mental health benefits. The Affordable Care Act under President Obama went further, requiring insurance companies to cover mental health care and addiction treatment beginning in 2014. 

But in practice, mental health parity does not exist throughout the country’s health care system. Insurance companies in Colorado pay mental health doctors 30 percent less than they pay other medical professionals, and consumers have to pay for out-of-network care seven times more often than they do for other medical care.


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