Note: This transcript has been created with a combination of machine ears and human eyes. There may be small differences between this document and the audio version, which is one of many reasons we encourage you to listen to the episode!
Note: This episode includes mentions of suicide.
Robert: I took like a step back because there’s…too much going on.
Dr. Eboni Winford: Like what?
Robert: With the virus. It worries me sometimes. Will I survive if I was to get it? Yeah, I’m not trying to get it.
EW: It’s scary.
EW: It’s scary.
DG: A lot of us are feeling scared…about our health, our jobs, our families…
The number of adults reporting symptoms of anxiety or depression has tripled since last year. Calls to some crisis lines have octupled…overdoses are up, too.
Research shows many people in distress don’t go on to get treated or even diagnosed. But for those who do, about half will turn to the doctors and nurses they already know.
EW: Primary care is the de facto mental health system.
DG: Today, meeting this rising tide…by reimagining what mental health looks like inside the doctor’s office.
From the Annenberg Studio at the University of Pennsylvania, I’m Dan Gorenstein and this is Tradeoffs.
It may sound strange to put much faith in primary care to meet our mental health needs. These practices, what New Yorker writer Atul Gawande calls “medical general stores,” often are overburdened, and now with COVID, are getting crushed financially.
But the reason to think primary care practices may be able to respond to this demand for mental health care…is because some…already do.
It’s an approach often called “integrated care” and compared to your usual check-up, visiting an integrated clinic can feel like peering through the looking glass.
EW: Good morning, sunshine. We’re doing things a little bit differently today, I’m recording our patient’s journey through the clinics so you can just check on them like you normally do. We’ll be good.
DG: This is East Knox, one of the 24 primary care clinics run by Cherokee Health Systems, a large safety-net provider in eastern Tennessee. Cherokee, a pioneer in this field, is considered a national leader.
EW: Alright, we’re getting started.
DG: That’s Dr. Eboni Winford.
EW: You can sit where you want to. Like we normally do.
DG: Eboni’s patient “Robert” sits down. He’s asked that we not use his last name. The 53-year old has diabetes, depression, arthritis, two artificial hips and multiple sclerosis. He’s here to get his meds checked, and what Robert calls a “tune-up.”
Robert: I’ve been dealing in Cherokee going on I think about 12 years.
DG: Robert and Eboni have worked together for about half that time and agreed to let us listen in on their visit.
EW: Okay, so how has your mood been since we met last week?
Robert: Still dealing with depression, just feelin, you know…I can’t go over to my momma’s that much no more, really. We talk on the phone but you know, she’s into social distancing big. So I got to respect that. But, you know, it really hurts a lot–doesn’t really hurt–but it’s kind of sad, you know. I don’t get to pop up like I want to and all that.
EW: And you know, we’ve talked about how like the more we try to avoid or distract ourselves from things…
Robert: You gotta take that mask off sometime. You can’t wear a mask all the time, it will kill you it’ll wear you down.
DG: Robert is talking about wearing a figurative mask, not the COVID kind.
EW: It really will, emotionally, physically, all that, trying to pretend like everything is okay.
Robert: Trying to act like you okay but you ain’t.
EW: Yeah. What’s the plan for the week?
Sfx: Knock on the door
EW: Come on in.
Nurse: Here you go. Your hydroxyzine is not in here. Have you picked it up?
DG: That’s the nurse, Sheila, here with Robert’s meds for the week.
Robert: I went over there and they said it wasn’t filled yet.
Nurse: Okay, I’ll call and ask. Alright. See you!
Sfx: Door closes
EW: What about like your diabetes and stuff? How have your numbers been?
Robert: I don’t feel bad until like 350 or something then I know cause I feel my feet.
EW: What’s the lowest it was?
Robert: One time it was 68
EW: That’s pretty low, sir.
DG: Robert and Eboni talk for a few minutes more.
EW: We will see you next week.
Robert: I’ll see you later
DG: So what exactly was that visit? A check-up? An exam? A therapy session That is precisely the point…it’s all of those…at the same time.
What we just heard is integrated care in action and many see it as critical to meeting the needs of this moment…needs that people like Dr. Parinda Khatri, Cherokee’s chief clinical officee, don’t think we can meet just doing things the old way.
Parinda Khatri: In many cases people stay in therapy for years and years and it can be useful for a lot of people. But we also have to recognize that there are many people suffering and they don’t necessarily want this traditional specialty therapy model.
DG: Lots of people shy away from seeking out that type of care…worried about the stigma it carries…others can’t get it even if they want it. Half of U.S. counties lack a single psychologist or psychiatrist. Cherokee’s solution, something they’ve worked at for nearly 40 years, is to reimagine mental health care.
Bye-bye hour-long visits, couches and questions about your mother.
Hello to speed…
EW: I see patients in about 20 minutes or so.
DG: … to collaboration….
EW: At the beginning of every morning, the team gets together to discuss the patients that are on the schedule.
DG: …to responsiveness…
EW: Nine times out of ten, I can see you today.
DG: …and to flexibility…
EW: Everything’s interruptible, like nothing’s sacred space. Right. Like there’s always a knock on the door,
DG: Eboni is a psychologist but Cherokee calls her a behavioral health consultant or BHC. And she is in the middle of everything…like, literally.
EW: The interesting part about where my office is, is that it’s smack dab between a series of exam rooms, medical exam rooms. My office wall is shared with an exam room. Directly in front of me are one, two, three, four exam rooms there.
DG: There’s an analogy Eboni likes to use to explain the difference between what she does at Cherokee and what her colleagues do in traditional therapy.
EW: I usually liken it to firefighter versus arson investigator. When your house is on fire. You don’t need the arson investigator to figure out how it started. You need some water, like you need a firefighter to spray that thing down and make the fire stop. After the fire is settled, you’re safe. You have a plan. You have support. Now maybe we need to figure out how the fire started, but I’m not going to come in as an arson investigator in a primary care exam room. I’m going to come in with my water hoses. Alright, you’re in crisis or you’re just having a bad day. Let’s make a plan and we can go deeper if we need to.
DG: A lot of us could benefit from a firefighter right about now. Parents and kids stressed about the fall…seniors grappling with isolation…millions out of work…worried about making rent.
An important part of Eboni’s job is teaching people how to put out these fires for themselves. Like an exercise she uses to help Robert and her other patients fend off negative thoughts like “I’m a failure” or “I’m dumb”…a concept called defusion.
EW: It’s this idea that we think that our thoughts are reality just because our brain created them. And I have him repeat to himself, “I’m a lemon. I’m a lemon. I’m a lemon.” I don’t care how many times you try to convince me you’re a lemon. You will never become a lemon, even though your brain made the thought that you’re a lemon. And he’ll come back and tell you like, “Man, I was starting to think this and I was like I ain’t a lemon!” You know, I’m like, “No, you’re not a lemon. Good job! Whatever that thought was is not true just because you had it.”
DG: This all is Cherokee’s version of integrated care. This work goes by lots of names and comes in many flavors. One of the most popular alternatives, called collaborative care, has produced the lion’s share of evidence on integration with more than 80 randomized trials.
The bottom line: integrated care works.
Its greatest impact is on patients with both mental and medical illnesses. Eboni and Robert have seen it firsthand.
EW: All these years we’ve worked together, we’ve always had this pattern. When your mood is down, what gets down?
Robert: Diabetes goes up and mood swings and just, just feel like mush.
DG: This may sound obvious, but mental and physical well-being are intertwined and research shows that mental health problems can make physical ones much harder and more expensive to manage. And that’s why integrated care has been shown to improve health for patients like Robert, and cuts costs.
The actuarial firm Milliman estimates that integrating care for patients with both medical and mental illnesses around the country could save between $40 and $70 billion in spending every year.
DG: On today’s show we’re asking the question: can primary care offices meet the nation’s growing tsunami of mental health needs? Let’s consider why there’s reason for at least some optimism.
In the 90’s, most primary care clinics had little to offer patients in crisis…no Ebonis…Most docs were left to battle their own blazes, docs like Whitney Slade.
Whitney Slade: It was an elderly woman.
DG: Back then, Whitney ran a practice 400 miles down the road from Cherokee in Memphis.
WS: She literally pulled a gun out and pointed it at herself, pulled the trigger.
DG: The chamber was empty.
WS: And the husband said, thank God. And the first thing he did was he loaded her in the car, brought her over to my office.
DG: Whitney outlined the options…none of them good.
WS: Basically all we could do was call an ambulance, which they didn’t want to do. They didn’t want the embarrassment of an ambulance, you know, coming to get her or having the police take her away.
DG: He could prescribe antidepressants but he knew those could made things worse.
WS: So you know what? What, I ended up saying is, you know, I don’t have anybody that I can call for you right now. So I’m basically gonna have to take my finger and point, you know, the psychiatric hospital’s that way. I hope you get admitted.
DG: The psychiatric hospital eventually admitted Whitney’s patient, but in the middle of her crisis the health system came up short. 20 years later, the episode still haunts Whitney.
WS: I mean, in to a degree, it makes me feel like a failure because the best I could do was listen to this extremely dramatic story that was upending this family and say, I’m sorry.
DG: Cases like this, where patients get rushed or referred to long wait lists, still happen all across the country. But they are less common. Since the 90’s, more practices have embedded firefighters like Eboni…and earlier this year, even Whitney’s office added one.
WS: To me, it’s like a sigh of relief knowing that behavioral health is there. It’s night and day.
DG: And it’s not just in Tennessee. University of Massachusetts psychologist Sandy Blount says you find at least some practices marrying medical and mental health care in every single state in the country. Today, federal health officials back the idea…with hundreds of millions in grants…and so do major professional groups, like the American Medical Association.
Sandy Blount: I mean, this is the most conservative, biggest medical outfit out there, and they’re talking to people about how to run their practices, and behavioral health is a part of it.
DG: And that, says Sandy, is a very different conversation than back in the 90s when blazes like Whitney’s were burning.
SB: The message then was why you should do it? Now, we’re really talking about how you should do it.
DG: How you should do it? In some ways, that is a much harder conversation. Today a little less than half (44%) of practices have at least a behavioral health provider on site, according to a study published earlier this year.
Most experts suspect a much smaller fraction offer truly blended care–the kind backed by all the evidence.
To understand why integration hasn’t spread further, faster it helps to trace Cherokee’s nearly 40-year journey.
First, there was the matter of finding all those firefighters.
Parinda Khatri: If you look at our workforce and you look at our training programs, people are to a large extent still trained in silos.
DG: When Parinda joined Cherokee she remembers how often they’d strike out and end up with providers who didn’t really get primary care.
PK: So about 17 years ago, we started a psychology internship program. We started a postdoctoral fellowship program.We started working with medical residents, because we recognized, you know, we’re not going to naturally get the workforce that we need. We have to help grow the workforce that we need.
DG: That postdoctoral fellowship program is what drew Eboni to Cherokee. And once she got there, she says she had to adjust.
EW: I had to learn the primary care workflow. And that’s a huge, huge, huge growing curve because primary care is fast pace. So I shadowed medical providers just learning. How do they ask questions? When did they tag in a behavior health provider? How quickly or how slowly do they move, like that tells me where I need to be.
DG: Training programs have started to adapt. About half of the nation’s psychology programs offer students some exposure to primary care, and there are a few dozen fellowships. For physicians, the majority of family medicine residents do some training in integrated care clinics.
But even if every program embraced integrated care, Sandy says we’d still come up short.
SB: We’re never gonna meet the need with doctoral psychologists or clinical social workers or marriage and family therapy clinicians.
DG: To have any shot at meeting this moment experts say we need to think more broadly about who can do this work. Some places, even Cherokee, are adding new kinds of team members, like community health workers and peer specialists. Others are giving new skills to the workers they already have.
SB: Navigators, community health workers, case managers, all of these folks who are not clinicians but have extended contact with the patient…they can learn to use language that will activate patients to take better care of their health.
DG: It’s an idea that other countries, often out of necessity, have embraced–that with the right training and supervision, people with less formal education can still have a big impact. Of course, all this training requires money…
And money, really reimbursement, is the second hurdle to seeing this work spread.
Parinda says historically Medicare, Medicaid and private insurers have made it a bear to bill–complicated at best, impossible at worst. Some rules have started to change and Parinda’s glad for that, but there are still plenty of headaches.
PK: There have been barriers after barriers, after barriers.
DG: For example, some insurers have adopted special billing codes for integrated care. Others have not.
PK: It’s really a hodgepodge. So it’s hard to transform a model where there’s so much fragmentation in how people get paid.
DG: Cherokee has been able to piece together enough of the right kinds of contracts to make their model work. But a recent study in the Annals of Internal Medicine found that only three of 30 integrated practices had positive financial returns.
Harvard economist Richard Frank says the field should assume major payment changes are not coming. But he still sees a way to make it work: build a cheaper model.
Richard Frank: The thing that is striking about Cherokee…is they’ve accomplished what we’d like to have done in many respects, but they remind me very much of having sort of a specialty boutique in a high-priced mall. And that’s not the same thing as being able to go and get comparable services or similar services at a Wal-Mart.
DG: One expensive part of this work is all the back-end functions: hiring and training new staff, reconfiguring health records, doing battle with those billing offices. Richard’s excited about a new crop of private companies that remotely rent the services and even staff required, especially for smaller, more rural practices.
RF: It opens up some new approaches that might make it easier and more economical for practices to engage in this.
DG: With COVID raging and mental health needs soaring, the case for scaling integrated care has never seemed clearer. So what will it take to spur more action? Some advocates think stories are the best bet.
EW: I think everybody just needs to meet Robert. And once they hear Robert’s story, they’re like, oh, yeah, I want to do that.
DG: When you say that, they just need to know Robert’s story…what is Robert’s story?
EW: He was a person whose house was ablaze and he walked out of the fire with just a few burns.
DG: Robert’s had a few fires, but one stands out from 2018. Eboni had been working with Robert on and off, when he needed it, for a few years by then. She’d gotten to know him and his conditions well…
EW: Like clockwork
DG: And the telltale sign that his depression was flaring up…
EW: If Robert misses an appointment, that’s when we know something’s wrong.
DG: So in the winter of 2018, when Robert missed three appointments in a row, fire alarms started clanging in Eboni’s head.
EW: I knew Robert had had suicidal ideation before and I knew that Robert had attempted suicide before. In fact, that’s how Robert and I first met. He had overdosed on a bottle of medications and that’s where my mind was going.
DG: And Robert’s mind was heading there too, especially on nights when he’d drink too much.
Robert: I didn’t know because I was really depressed, just sitting at home crying and I was mad at people. When you in depression you get mad at people even trying to help you because you get to be so used to being depressed that you don’t really want to come out. You want to be depressed. I was one click away from pushing the real button and that’s the button of no return.
EW: We’re all very, very, very worried about him. We had sent letters. We had called people we thought to call. And finally I said, you know what? I’m calling his mom.
Robert: They done ratted me out to my damn momma!
EW: We did snitch. No shame. We snitched. And I told Mom, I said, “He doesn’t even have to call. Just tell him to show up.”
DG: Two days later, he did just that.
Robert: I knew I had to come back again. I had to come. It was just fighting the progress.
DG: Eboni’s glad she knew the signs and acted on them when she did. But she’s even more glad to see the progress Robert’s made since then using his own tools to spot sparks and snuff them out.
Robert: Sometimes I get down and depressed again and I call Eboni, and tell her, “Yo I need a tune-up.” I come in and get me a tune-up.
EW: He’s good about recognizing when that cycle starting again and I think that helps prevent these infernos. So you know, if the bush outside the house burned, he’s like, “Whoops, before this burns my house, let me go get some water.” And I think he’s learned that about himself.
DG: He’s so confident, so convinced now, says Eboni, that he’s become a sort of neighborhood Smokey Bear preaching to all his friends and family…letting them know that they, too, can prevent a fire…if they’d just get some primary care.
Robert: I try to take what I learned here and help other people with it. “You really need help.” That’s what I tell ’em.
DG: And if you tell ‘em enough times, Robert’s learned, eventually people might just hear you. People like his girlfriend, who he brought to his visit today.
Robert: I’ve been trying to get her down here for a long time. She finally decided to come today.
DG: One by one…house by house…that’s the only way Robert sees to save the whole forest.
Robert: That’s the only way you gonna bring about change.
DG: I’m Dan Gorenstein, and this is Tradeoffs.