Laura Andrus, who has battled cancer and lung problems for years, told her doctor it felt like she was slipping into a depression worse than she had ever felt before.
As inconclusive medical tests piled up, offering no information about why Andrus wasn’t feeling well and whether the cancer was back or if she had an autoimmune disease, her mood deepened. Then Andrus’ doctor suggested she speak to the psychologist who works in the same Littleton family medicine practice.
After a few weeks, including a virtual visit with a psychiatrist who prescribed medication, Andrus was “feeling more positive and able to deal with life,” she said. By the time she learned a couple of months later that she had a rare lung disease, Andrus was ready to cope with it.
This is how it’s supposed to work. And what experts have been saying for years — that people should have access to mental health treatment in the same place they get medical care. Finally, at least among big hospital systems, so-called “integrated” care is becoming mainstream.
Kaiser Permanente was likely the first in Colorado to intertwine medical and mental health care, and in the past couple of years has bumped up its co-located “behavioral medicine specialists” to 30 people working in 23 primary care offices. The specialists sit in on primary care checkups, offering input on mental health and lifestyle recommendations — and the patient pays only a copay for a primary care visit.
UCHealth, meanwhile, announced in 2020 that it would spend $100 million on behavioral health, in part by putting mental health professionals in each of its 60 primary care clinics across the state. It began with three pilot clinics, in Littleton, Longmont and Colorado Springs. Two years later, 40 clinics have an embedded therapist. The plan is to have six more in place by the end of June and all 60 clinics staffed by the end of the year.
Andrus, a UCHealth patient, said she was grateful that her team — medical and mental — pored over her complicated medical history together to “get on the same page.”
“I feel strong enough mentally to deal with whatever comes,” she said. “I don’t think I could have bounced back so well or so quickly from the depression without each of them working together.”
The two-thirds of UCHealth primary care clinics that have embedded mental health professionals are staffed with therapists and counselors. As an added layer, psychiatrists are each assigned a group of primary care clinics. If an assessment by a clinic’s therapist determines a patient should see a psychiatrist, a virtual appointment is arranged.
“We have to be good at this”
Dr. Christian Lobo, a family medicine physician in UCHealth’s primary care clinic in Littleton, asks two standard questions of every patient.
“In the last two weeks, have you felt down, depressed or hopeless?”
“Have you had thoughts that you would be better off dead or of hurting yourself in some way?”
Knowing that there is a mental health professional a few doors down makes a huge difference any time the answer to either of those questions is concerning.
Lobo, who finished his residency training in 2019 and has always incorporated mental health questions into his examination routine, typically ends up asking three to five patients each week if they want to set up an appointment with the office counselor. He’s also called the counselor into his office on a few occasions when patients confided in him that they had thoughts of suicide.
“It’s helpful to have somebody then and there who has more experience talking through the nuances,” Lobo said. “I’m no counselor, but I’m a good listener. Sometimes, it’s really not enough.”
The licensed clinical social worker in his office will help assess whether the patient needs to go to emergency psychiatric treatment. They also can help come up with a safety plan for the patient, guiding them through what to do to protect themselves if they ever feel like ending their lives.
The way Lobo sees it, there is no choice but for health systems to integrate mental health care into primary care practices because, for many people, their primary care doctor is the only one they see. And they often open up to their doctor about mental health problems.
“There is really no choice except that we have to be good at this,” he said.
The new model is helping patients see mental health professionals faster; UCHealth patients can typically get a therapy appointment within a few weeks, he said. This is a huge upgrade from patients asking their insurance company for a list of therapists who are in network, then calling them only to find out they aren’t accepting patients or that the waitlist is months long.
The quick access is important particularly for patients with time-sensitive mental health issues, including grief or panic attacks, or symptoms that are making it hard for them to go to work or get along with their families, Lobo said.
Just like checking cholesterol or blood pressure, Lobo checks mental health with those first two questions, called the PHQ-2, for “patient health questionnaire.” If either answer is yes, he moves onto the more detailed PHQ-9.
Often, mental health problems arise that aren’t severe enough to show up on those questionnaires but still require a reaction, Lobo said. He’s had a few patients who have survived cancer and then get bad news — or fear bad news — on oncology tests.
“It brings up almost this kind of trauma, PTSD,” he said. “It just reawakens everything we thought we had worked through and gotten closure with.”
And during the isolating days of COVID, Lobo had multiple patients who were depressed and needed a few counseling sessions. “I’ve had younger people moving away from family for the first time. Your support system is gone,” he said. “Getting to meet new people has been very difficult. Lots of change has unmasked anxiety or depression. Something brings it over the edge where they are talking to me about it.”
Mental health workers join Kaiser doctors for appointments
Kaiser hired its first two “behavioral medicine specialists” in 2009, then poured in money pre-pandemic to bump the number to 30 in 2019. The health system also has added 20 mental health professionals within the past year, mostly in its outpatient mental health services for patients who need ongoing therapy beyond the mental health checkup at their primary care doctor.
The majority of Kaiser patients, about 70-80%, only visit their primary care doctor and do not need speciality care. This includes children coming in for pediatric visits, who also see a behavioral medicine specialist during their visit, said Amy Conley, regional director for behavioral health services for Kaiser Permanente Colorado.
Doctors can call behavioral medicine specialists into appointments whenever they are concerned that a patient might need a mental health evaluation. But the specialists proactively look for appointments to join by reading over the records of patients ahead of their scheduled medical checkups, Conley said.
If they see that a patient has a history of depression, uncontrolled diabetes, or a new cancer diagnosis, they make plans to attend the appointment, she said.
“They will actually come into the room with the primary care physician and talk with the member about chronic health concerns,” Conley said. “Or it could be something like, ‘I’m not sleeping at night due to stress from the pandemic.’
“We’re supporting our physicians to treat the entire person.”
The whole arrangement is more convenient for the patient, not to mention cheaper because they are billed only for a primary care appointment and not a mental health appointment. And, because they are seeing a mental health professional during a regular medical checkup, it erases the stigma still associated with walking into a mental health clinic, Conley said.
“Before this program, they had to call in and get an appointment with a therapist,” she said. “Now, they can conveniently come into the primary care physician who they know and trust and receive this service.”
“Behavioral health is health”
In the past two years, the UCHealth behavioral health program has tallied 40,100 therapy appointments for about 8,500 patients, said Carrie Brauninger, director of behavioral health integration for the UCHealth medical group.
Brauninger, who sees patients two days each week in Littleton, said she now meets more patients who have never before seen a mental health professional than she ever did in previous jobs, a sign that the integrated setup is reaching new patients.
“Our mission is to increase access and reduce stigma related to behavioral health, and really normalize the fact that behavioral health is health,” she said.
UCHealth set off on its behavioral health initiative in February 2020, a month before the COVID pandemic struck in Colorado. The state was short on mental health staff before the coronavirus and the shortage has become more dire since then, as more people sought treatment for anxiety and depression and as overburdened staff left the profession.
That shortage has meant it takes longer to hire for behavioral health positions, even at higher-paying systems such as UCHealth and Kaiser.
Community mental health centers in Colorado, which serve patients on Medicaid or who are uninsured and can’t afford to pay, say they have struggled the most to find staff because they typically offer lower salaries than hospital systems. And now, they’re competing to hire workers with health systems that are ramping up mental health offerings and startups that offer virtual counseling via app or computer screen.
Behavioral health workers address lifestyle changes after cancer, heart attack
Kristin Orlowski, a psychologist and manager of UCHealth’s behavioral health integration team, provides therapy to patients at a primary care clinic in Sterling Ranch, a community of colorful, two-story homes west of Highlands Ranch. When the clinic’s doctor sees a patient dealing with insomnia or depression, he tells them Orlowski is just down the hall.
Orlowski will introduce herself if she’s not with another patient, and the patient can walk out of the office with a mental health appointment on the books.
In prior jobs, Orlowski worked in private mental health clinics and community mental health care, and struggled to connect with patients’ primary care doctors to discuss the best way to provide comprehensive care. “You can’t separate physical and behavioral health,” she said.
In some cases, it’s the therapist that suspects there are medical issues causing symptoms that at first might seem like mental health issues, such as a patient who recently complained about poor concentration. It turned out the patient had a medical condition that was resulting in a shortage of oxygen to her brain.
In some cases, patients need a behavioral health specialist to help them change their eating and exercise habits after a diabetes diagnosis, or because they are feeling depressed about changing their eating and exercise habits after a heart attack, she said.
And since the psychologist and medical doctor are in the same office, and using the same electronic health records, they can see each other’s notes, catalog of symptoms and medications, and any prior diagnoses.
“Patients don’t always remember certain things about their history,” Orlowski said. “They don’t always remember all the details.”