Many areas of the U.S. lack integrated behavioral health in primary care

A Graham Center Policy One-Pager in the June issue of American Family Physician overlaid the geographic locations of integrated behavioral health clinics in primary care over a color-coded map of U.S. counties’ percentages of residents reporting poor mental health. In an ideal world, these clinics, which are associated with better health outcomes, higher patient satisfaction, and lower costs, would cluster in regions with greater mental health distress. Unfortunately, the Graham Center analysis found that the opposite was frequently the case, with such clinics “notably lacking in … rural Kentucky, Louisiana, Tennessee, and West Virginia.”

What factors could account for this apparent mismatch between integrated behavioral health supply and demand? A recent Health Affairs Forefront article noted that obstacles to widespread adoption include an ongoing debate about the need for high fidelity to the evidence-based Collaborative Care Model, which can be difficult to implement, and inadequate fee-for-service payment relative to costs of practice re-design and ongoing services. Successful efforts to improve behavioral health integration in Rocky Mountain Health Plans, Blue Cross Blue Shield of Michigan, Rhode Island, and Minnesota have relied on multiple approaches customized to primary care structures and community needs.

A 2022 study in the Journal of General Internal Medicine examined characteristics of integrated behavioral health associated with primary care clinician confidence in managing depression in a network of community health centers (CHCs) in 10 mid-western states. Primary care clinicians reported more confidence when their CHCs had depression tracking systems; when they were satisfied with the accuracy of depression screening; when they had access to behavioral health treatment plans; and when they cared for more patients with depression. In contrast, clinicians working at CHCs with more patients living below the poverty line had lower confidence in prescribing antidepressants, while those at CHCs with more Black patients had lower confidence in diagnosing depression.

Integrated behavioral health clinics may or may not provide treatment for persons with opioid use disorder or other substance use disorders, even though these commonly co-occur with mental health problems. In a Substack post, Ben Miller explained that shared vulnerability, dual diagnosis, and bidirectional influence support pairing mental health and addiction treatment. Obstacles to concurrent treatment in primary and specialty care settings include societal stigma, diagnostic classification systems, health system fragmentation, and different treatment philosophies.

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This post first appeared on the AFP Community Blog.

Housing matters for good health

What does a "renter's utopia" in Vienna have to do with optimal treatment of asthma?

Francesca Mari's recent New York Times Magazine article about public housing in the capital city of Austria features images of beautiful, well-maintained apartment buildings with rooftop swimming pools, lots of green foliage and attractive playgrounds. 80 percent of the city's residents qualify for public housing, a staggeringly high percentage that might imply to an American that the vast majority of people living there are poor. Actually, Vienna makes its plentiful supply of municipal housing (which they call "social housing") available to a large portion of the middle class, and tenants cannot be turned out no matter how much their incomes increase after signing the initial rental contract.

To American eyes, the whole Viennese setup can appear fancifully socialistic. But set that aside, and what’s mind-boggling is how social housing gives the economic lives of Viennese an entirely different shape. ... Imagine having to think about [housing expenses] to the same degree that you think about your restaurant choices or streaming-service subscriptions. Imagine, too, where the rest of your income might go, if you spent much less of it on housing. Vienna invites us to envision a world in which homeownership isn’t the only way to secure a certain future — and what our lives might look like as a result.

In contrast, wrote Mari, one of several "fatal" compromises to the real estate industry in the Housing Act of 1937, restricted eligibility for public housing in the U.S. to "those so poor that they could never secure decent housing in the private market." These units were deliberately underfunded and poorly constructed. As millions of past and current residents of American urban housing projects could testify, "America's public housing was designed to fail: to be unappealing to anyone who could afford to rent."

Which brings me to patients with asthma who live in American public housing projects or neighborhoods in similar states of disrepair. In West Philadelphia, the Children's Hospital of Philadelphia (CHOP) partnered with community organizations to implement Community Asthma Prevention Program Plus, a program that performed home inspections of CHOP patients with asthma and completed repairs to 97 homes that were deemed likely to benefit these patients, including carpet removal, roof and plumbing repairs, improving ventilation, and eradicating mold.

That's great, but what if the home is located next to an interstate highway, factory, or power plant emitting pollutants that can't be easily remediated by a contractor? Or if these patients' asthma exacerbations are triggered by the stress of living in a violent neighborhood? The logical next step is to move to a different home. The case settlement for a 1995 lawsuit against the U.S. Department of Housing and Urban Development for discriminatory public housing practices created the Baltimore Regional Housing Partnership (BRHP), which as of October 2020 had provided housing vouchers to more than 5,200 households to move to privately-owned housing in low-poverty neighborhoods. A research team followed 123 children with persistent asthma whose families moved with BRHP's assistance from 2016 to 2020. Compared to a control group, these children experienced fewer exacerbations, fewer days with symptoms, and lower measures of stress.

Hospitals and health systems are now investing in affordable housing to improve health in many areas of the country, reasoning that being homeless or housing insecure presents a huge obstacle to attaining control of asthma, diabetes, and other chronic diseases. Health care payers are also taking notice. In an ambitious experiment, California's Medicaid program is spending $12 billion over the next 5 years on "a new kind of safety net that provides housing and other services for [145,000] people who are homeless or at risk of becoming homeless and have complicating conditions like mental illness or chronic disease." Whether the experiment will achieve its aim of moderating the program's soaring health care costs remains to be seen, but even if it doesn't, giving people access to decent housing is a worthy end in itself. Kudos to Philadelphia, Baltimore, and California for thinking outside of the health care box, but I'd rather be in Vienna: a city where grinding poverty and housing vouchers aren't necessary for persons of modest means to afford a clean and safe apartment for as long as they want to live there.

Patient portals and electronic health record transparency: pros and cons

After completing my fellowship, I considered taking a job filling in for a family physician on sabbatical who had been in solo practice for thirty-plus years. Even for these pre-electronic health record (EHR) days, his written notes were telegraphic. A typical example: "Patient doing fine. Labs normal. Continue current meds and follow up in 6 months." That was it. What he recorded in the chart was for his eyes only. No need to write an essay, or even a paragraph, when the only purpose was to jog his memory for the next time he saw the patient.

A few years later, the federal government handed tens of billions of dollars to physicians and health care organizations to convert their paper charts to digital form in exchange for requirements to use these records to measure quality of care and increase transparency of health information to patients through so-called “patient portals.” Notes became longer and more detailed. The negative effects of EHRs on physician burnout and health care team communication have been well-documented. Aside from initiatives such as OpenNotes, however, transparency was not fully implemented until last year, when the Office of the National Coordinator for Health Information Technology re-interpreted a previous rule against “information blocking” as an expectation that patients would have real-time online access to their office notes and test results rather than having to request them. With little fanfare, the floodgates opened.

In an insightful article in The New Yorker, Dr. Danielle Ofri, a general internist, admitted her newfound reluctance to list an extensive differential diagnosis for anemia in the EHR because she worried that mentioning colon cancer or a duodenal ulcer could scare the patient. After all, she observed, “my inbox was already jammed with panicked messages from people convinced that they had catastrophic illnesses, based on minuscule lab discrepancies and panic-inducing Google searches.” Comparing EHR transparency to the “C-SPAN effect,” in which live, nonfiltered television coverage of Congress made lawmakers more likely to grandstand to the camera, Ofri noted that granting patients instant access to test results has also had unintended consequences:

In one devastating stretch of twenty-four hours, two of my patients learned of their cancers’ metastatic reappearance by way of the portal. Their inboxes pinged with new test results; they read them before either their oncologist or I had even seen the scans, let alone called. … In the past, I’d do the legwork [for the evaluation] before I called the patient. Now that buffer is gone, and I am pressured to act immediately: the patient has seen the result, and further delay would be unconscionable. This timbre of rush imperils thoughtful analysis, and I worry incessantly about missteps.

In contrast to the mixed feelings of primary care clinicians and staff about patients having online access to their health records, research suggests that patients overwhelmingly prefer to see test results immediately, even though those marked as abnormal increased worry prior to discussions with health professionals. Sometimes, portals save time. Rounding on my practice’s adult inpatient service last month, I was pleasantly surprised that in several cases I could skip through the text of a recently resulted blood or imaging test finding – which the patient or their designated decision-maker had already seen on a smartphone app – and jump straight into the implications for their condition and care plan. Finally, portals allow patients to proactively correct or update medications, allergies, and problem lists outside of office visits, rather than taking up precious minutes with medical assistants or physicians in the examination room.

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This post first appeared on the AFP Community Blog.