November 14, 2018

An Interview with the Director of NCIBH

Type: News Tags: Interview, Newsletter

This month, Emily Paterson, NCIBH research coordinator, sat down with Chyke Doubeni, MD, MPH, Director of the National Center for Integrated Behavioral Health, to reflect on the progress of the NCIBH thus far and discuss current challenges to advancing the educational field for integrated behavioral health as well as to discuss the future of IBH training and education.


Emily Paterson: Thank you for taking the time to speak with me today. I’d like to start by asking you to reflect on what motivated you to work in the area of primary care training for IBH, and your beliefs about the importance for the field of primary care?

Dr. Chyke Doubeni: My motivations for this work are primarily informed by my own work as a primary care physician and the experiences of my patients due to limited access to care. Mental illness is very common. Fifty percent of people will have some form of mental health disorder in their lifetime, and yet access to help is limited. We know that having a mental health disorder is more common as people get sicker and older, and as people grow ill, the risk of mental health comorbidity gets higher. But many times these conditions are not detected, making it difficult to receive the proper treatment, and even if mental illness is detected, it is often not treated adequately. Often patients are treated with sub-optimal doses of medication and never receive behavioral therapy. Many patients who have behavioral health care needs use primary care as their main form of care, but the expertise and resources for managing behavioral health often resides outside of primary care, and primary care providers do not have access to the necessary resources or training. With all of these challenges, the model that works most effectively in this setting is the integrated behavioral health model, where behaviorists and primary care physicians work collaboratively to diagnose and treat patients and, when necessary, refer patients to psychiatrists. We know that the integrated behavioral health model is cost-effective as well as highly rated by both providers and patients. However, we need to scale up efforts to train primary care providers in this model in order to improve access to high quality care


Emily Paterson: Can you speak to the role of the NCIBH and how we as a national Center are applying our research and translating IBH evidence into practice?

Dr. Chyke Doubeni: The work of the NCIBH is driven by the perspective that current primary care training models do not adequately prepare providers to work in integrated teams providing care for patients with behavioral health needs. Training is often not enough for providers to recognize and treat mental disorders, especially within the context of the current healthcare system and care delivery pressures. We often don’t have enough time to treat complex conditions in primary care, and we often don’t have the resources to manage them. Together these issues make caring for patients with behavioral health needs very challenging. Therefore, one of our goals is to increase the ability of primary care physicians to have the training and resources needed to improve the care of the patient population.

Additionally, our country’s opioid epidemic requires action across the health system, including primary care. There are resources that have been galvanized to help manage this nationally and even internationally. There are many players in this area who are trying to do something about this. There are people working on the delivery side, the policy side, the financing side, and what’s really important is that with all that work, we still need people on the front lines who are able to detect and treat these conditions effectively. If it’s not done effectively, it will just widen the gap between those who have access and those who don’t. The goal of the Center is really to work with the community of practice – people who have the same challenges in addressing behavioral health issues in primary care settings – and increase access to training resources so that providers are equipped to identify and manage these conditions. So that’s what the National Center for Integrated Behavioral Health is really focused on doing. We want to bring people together who have the same interests and same challenges to work on this, and to bring knowledge and access to this community of providers and educators. We do this through our research and by engaging stakeholders around the country.


Emily Paterson: Can you speak to the need and importance of engaging professional organizations and societies in IBH training and education?

Dr. Chyke Doubeni: What I would emphasize is the importance of working within a community of practice, and that assumes that people in the community know, understand, and share the notion that we must nationally address primary care training needs in behavioral health models and implementation. If you think about the audience that we’re trying to target, we’re trying to address the needs of training in medical schools, nursing schools, residencies in family medicine, internal medicine, and pediatrics, and that’s a vast number of people. It is possible that over time we can reach all these stakeholders and interest groups respond to this national epidemic. It is, however, very difficult to reach each of the primary care providers that are members of these professional groups individually. So there is a structure within the communities of practice model to work with these societies nationally. That allows us to understand what their respective priorities are, what they’re doing, and what challenges they’re facing. Perhaps their challenges are the same as other groups, and so bringing them together in a new forum will allow them to begin to work on those common challenges together. We’ve heard two things repeatedly: one is stigma of addressing these conditions and two is the time and space within existing curriculum to insert these trainings. It’s going to be very hard to do this by creating an entirely new module, so we have to understand how these associations are already addressing these problems and work with them to integrate these elements of training within existing structures. We are here to help, and to understand those needs, one way to do so is to go through those organizations that have the understanding of the needs of respective professional groups and the systems already in place to address this international crisis.


Emily Paterson: Can you speak to some of the barriers and challenges programs are describing when implementing IBH training and education and some of the opportunities for overcoming these challenges?

Dr. Chyke Doubeni: Let’s talk about the curriculum component - we are fortunate that several members of our advisory board are leaders in this area and as such we have gained a lot of insight from them in terms of how we can successfully integrate these components of training into curricula. The one assumption that is often made is that, somehow, medical students, residents, nursing students, PA students, are not exposed to IBH training, yet we know that all of these types of learners have some exposure to behavioral health during their education. I think one key strategy would be to look at how behavioral health, which really touches almost all we do in medicine, is being integrated into curriculum. To me, that might be the best way to enhance the reach of training efforts. To look at behavioral health in an integrated format requires you to think about the curriculum as integrated, because this does not exist on its own. Some training occurs in an interprofessional setting, and that is a place to seek greater integration of training domains.


Emily Paterson: Let’s turn to the future of IBH and primary care. As we look towards the future, what are important areas of training and education for IBH to focus on?

Dr. Chyke Doubeni: There is a lot of focus currently on medication assisted treatment (MAT) training, which is very important but is just one part of a bigger and more challenging issue. In a future state, I see IBH becoming more accepted. We know that mental illness is as old as mankind, but we always have had this approach of carving it out as a separate thing, mostly due to payment structures. As these payment structures begin to align and payers understand how important it is to manage these conditions under the context of chronic disease care, they’ll have a greater interest in integrating these two streams of care. What I foresee in the future is that these two will come under the same structure of care, especially in the era of population health and value based care. People will understand the importance of managing them concurrently and not as separate things.

This goes beyond just training. It goes beyond just addressing opioid use disorder. It goes beyond just addressing mental health. It is also about social determinants of health. It is about holistic care of people in promoting health and wellbeing for patients and the healthcare teams. It’s therefore really important that part of our work nationally involves engaging with healthcare delivery systems at the front line of dealing with these problems. Until their incentives are aligned, and they buy in and understand the importance of managing these conditions, we will probably have less progress. It’s really important for medical schools and training institutions to understand and emphasize this as crucial to both clinical competence and effective care delivery. If you can’t manage behavioral health issues, you can’t promote wellness and health. What gets measured gets done. We need to get to the point where we have really strong outcome measures for behavioral health care as part of clinical performance measures that integrated within value based payment models.

The last point I want to make is that behavioral health disorders are very common in patients with complex medical disorders. For patients and providers in primary care often face limited resources and support to manage them. These limitations can serve as a source of burnout for primary care physicians. Managing behavioral health conditions well using a team approach and equipping trainees to manage these within integrated settings is critical to managing burnout within primary care.

Thank you again for taking the time to speak with us today. To find out more about the National Center for Integrated Behavioral Health, join our Community of Practice.

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