Substance Use Disorder,
Opioid Use Disorder,
Medication Assisted Treatment,
Frank deGruy III, MD, MSFM, Woodward Chisholm Professor and Chair of Family Medicine at the University of Colorado, shares his expertise on the emerging educational issues for training primary care providers in integrated behavioral health (IBH), the most promising innovations, and tips for new IBH educational programs.
Dr. deGruy discusses the opportunities and challenges facing the development of IBH within primary care settings. Innovations mentioned include the use of adaptive screenings and virtual reality-based treatments to leverage technologies in the identification of and response to behavioral health issues. IBH reform requires policies that support inter-professional education and complex adaptive leadership to build on the expertise necessary for all levels of implementation.
Q:What are the emerging educational issues for training primary care providers in IBH?
FRANK: I’m going to frame my answer in three parts:
The first has to do with leadership. We need to make sure that it is not just the medical directors, department chairs, or residency directors that understand themselves as leaders. We have a misunderstanding of who the leaders are who enable this work. There is certainly a role for administrative leaders to speak the vision and repeat it often and to make sure everyone who is a stakeholder can repeat the vision, but when trying to implement IBH, it is the front line of primary care and the clinical team, that consists of the appointment schedulers, the care manager, the community health workers, and the behaviorists who all have an indispensable part to play as leaders coming up with solutions to the problems we encounter in implementing IBH. We need to reform our understanding of complex adaptive leadership. We have to train all staff, from front-line to administrative leaders, to be flexible, creative problem solvers. It turns out we need practice coaches to facilitate the transformation of practices going to IBH, and what we need them for is most often to help previously passive clinic staff become active leaders. It’s a lot of work – helping people understand in a completely different way, what kind of leadership responsibilities and roles everyone has and getting people to step up. Something interesting happens when you do that - some say they don’t like it, it’s not what they signed up for, but most staff absolutely love it, being part of the clinical problem-solving leadership team, and morale is exceptionally high.
Secondly, first generation IBH clinics mostly consisted of testing a model that wasn’t necessarily a fully integrated care model because they didn’t have access to psychiatric consultants – and yet they had patients with problems that go far beyond let's say, simple depression, and that the current model might not be able to deal with. So you have a primary care clinic, and they have primary providers, a care manager, and a behavioral clinician consultant - that’s all well and good, but that leaves 10-15% of patients that neither the primary or behaviorist are comfortable to deal with - the deep end. Those with very severe mental illness, with multi-modal treatments, and complex med regimens. We require psychiatrists or sometimes psych NP’s to cover the deep end. Just as the medical providers must organize themselves into teams that can collectively deal with most or all medical conditions, so also must the behavioral clinicians organize themselves into a team that can collectively deal with most or all of the behavioral problems. And all of these fit together into one primary care team.
Finally, the needs of patients with substance use disorder and chronic pain are so pressing that primary care providers cannot avoid taking some responsibility for that. Patients with very real care needs are in our primary care clinics, they are very difficult and complicated to deal with, and we need help to deliver MAT, and treat their co-morbid psychiatric disorders. This is a place where addiction psychiatry resources matter a lot. We are still negotiating where we take care of these patients, and who takes care of them. There is a whole level of social service wrap-arounds needed here. It requires a total redesign of the way we deliver care. We need a somewhat different approach to integration to deal with this issue.
Q: What is the most promising innovation in IBH training that has caught your attention?
FRANK: We are exploring technical solutions that actually make us much more effective:
Diagnostic instruments based on item-response theory for common mental health disorders that are more efficient and accurate than our standard tests. The CAT-MH instead of the PHQ, for example. We can use these tools to measure very subtle changes in severity in mental diagnosis. For example, someone may be using yoga as part of their self-management program for depression. They can take a pretest where their phone will ask them 4-5 questions, give them a pre-class severity score, then take the class and take a post test. You can see very subtle changes, whether the yoga is helping with the depression. These technologies will put self-management into the hands of patients in a way we can’t do right now. It's going to change the way we manage mental health diagnoses and psychological symptoms.
Setting up a clinic for veterans to use virtual reality graded exposure therapy as a mode of treatment for PTSD. With virtual reality technologies you can refine the experiences, shape the severity and nature of what you are exposing people to so carefully and subtly, that you can get to just the right therapeutic dose without triggering symptoms in a dangerous way.
Q: What are some of the most pressing challenges for educational programs?
FRANK: We have a lot of trouble finding extremely high-end behavior professionals who understand how to make teams, how to work in primary care, who understand complex adaptive systems, how to be more than just the specialist who is consulted. So we need joint training for the primary care and behaviorists - agreement on how the setting operates, and what the cockpit culture ought to be like to work across our specific spheres of expertise – it’s a culture change across the disciplines to train together.
It’s also really hard to pay for this stuff, so we have to figure out how to educate our policymakers and our financers about how hard it is to do this work under current regulations. We have to produce results that resonate with their evaluative criteria. Saves money, better health outcomes, and more rewarding for practitioners – we need to figure out how to produce these answers for decision makers.
Q: What are insights you would like to share for programs new to the field?
FRANK: First, there are lots of people and places who have succeeded, so ask for help. Don’t reinvent the wheel. Second, it almost always takes a practice coach or transformation facilitator to really get fundamental change; you just don’t have eyes to see the issue alone. So get a practice coach. Third, it takes longer, and it's harder than you think, so you have to be in it for the long run. Don’t be disappointed or discouraged by early false starts and failures. That’s normal.
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