Although studies show that people needing behavioral and mental health services, such as treatment for substance addiction or therapy for depression, often turn to their primary care doctors for help, medical providers generally are not trained to assist them and are often unsure about where these patients should be referred.
But a growing movement toward integrated healthcare—in which physicians and mental health professionals collaborate as a team to diagnose and treat patients—is slowly shifting the traditional healthcare model and opening more doors for social workers who are better able to fill the service gap.
Consider for example, social work care managers, Amy Prentice, MSW ’09, and Rayhaan Adams, MSW ’13, both of whom work for UNC Family Medicine in Chapel Hill. Both also know that on any given day, physicians in their practice might call on the colleagues to help an aging patient in need of food assistance locate the nearest food pantry; consult with a father who is managing diabetes and trying to stop smoking; or discuss counseling options with a pregnant teen mom who has been screened for anxiety.
Regardless of what they encounter, the goal, the UNC School of Social Work graduates agreed, is to help patients easily access both the physical and mental health services they need and if possible, all in one setting.
“This primary care office is a one-stop shop,” Prentice explained. “So, in addition to medical care, we offer ancillary services, including nutrition, physical therapy, sports medicine, acupuncture, financial counseling, social work, therapy, psychiatry and substance abuse counseling. The idea is that a patient can come here and access all of the services that they need. They don’t have to receive fragmented care across several different offices or systems.”
Moreover, embedding mental health experts in primary care clinics and practices helps to break stigmas and barriers associated with mental healthcare, added Adams.
“It helps because we’re in a setting that is comfortable for most patients and as a result, they’re more willing to bring these difficult subjects up in an exam room,” he said. “And as a result, that provider is more willing to discuss potential mental health concerns because they know they have clinicians who are part of their healthcare team who can come in and support the patient’s plan and provide them with appropriate levels of care.”
Such a scenario illustrates exactly how integrated healthcare is supposed to work and why supporters, especially within the field of social work, are excited about the future of prevention medicine. The School of Social Work’s UNC-PrimeCare program offers a glimpse into that future. The $1.4 million federally funded initiative was created last year to rigorously prepare MSW students to work in primary care settings as behavioral and mental healthcare specialists. Because there remains a shortage of experts serving adolescent and young adults, the initiative targets 18- to 25-year-olds specifically, but generally aims to increase the number of professionals working in integrated health settings.
UNC’s School of Social Work was one of more than 30 social work schools tapped to create an integrated healthcare education program and received the second largest grant to support the initiative. The first 10 students graduated from UNC-PrimeCare in May, and another 21 second-year concentration students are enrolled for the 2015-2016 academic year.
Students receive a $10,000 stipend to help fund their education and field placements: all are required to complete internships in primary care practices, clinics or other medical settings. Overall, the program aims to train a total of 85 MSW students over the next three years, increasing the School’s number of behavioral health graduates by threefold.
The federal grants that schools of social work have received to help educate and train behavioral health specialists are, in part, a result of the Affordable Care Act’s efforts to reform the nation’s healthcare system. Distinguished Professor Mark W. Fraser sees social work’s role in this wave of reform as “the most exciting thing happening in the profession.” Fraser, associate dean for research, recently co-authored a discussion paper on the topic that was published by the National Academy of Medicine and adopted as a Grand Challenge for Social Work.
The paper, “Unleashing the Power of Prevention,” challenges the nation to consider how promoting programs and interventions that have shown success in curbing behavioral health problems, such as substance abuse, delinquent conduct and violent behavior, can improve the country’s overall physical health and mental well-being.
Further, the paper supports the merger of behavioral health with primary care and suggests that such integration can ultimately save billions of dollars in avoidable long-term healthcare costs. More specifically, Fraser and his co-authors see integrated healthcare as a solution for reducing the “incidence and prevalence of behavioral health problems,” especially among young people by 20 percent over the next decade.
“What’s so exciting about what’s happening is that we are going to change the way healthcare has been provided in this country for the last 30 years, and a huge part of that change will focus on the power of prevention,” Fraser said. “So many of our current structures are oriented toward dealing with problems such as addiction or intimate partner violence or child maltreatment after the fact—after they have taken hold of a person’s life. But we have decades of intervention research that shows that we can deal with these problems and save money if we identify them early. Because we have a much better understanding of the etiology and the causes of problems, we now have the ability to deliver powerful prevention programs and maybe catch people before they come into the healthcare system.”
This movement to promote prevention science also offers rich opportunities to demonstrate how social workers and behavioral health specialists play vital roles in tackling the root issues of health inequality, said Associate Dean for Academic Affairs Lisa Zerden, who is the principal investigator for UNC-PrimeCare.
“In the literature, there is a lot of discussion about the fact that your zip code is more indicative of your health outcomes than your genetic code, and that’s attributed to many things such as water quality and neighborhood safety, clinic accessibility, transportation and all those other factors,” said Zerden who is collaborating on UNC-PrimeCare with Anne Jones, co-investigator and clinical professor. “And so, I think from the medical side of this, it’s really understanding that we need a social worker who understands that these social factors are making our job that much more difficult. As a doctor, I can do what I do medically and intervene with pharmaceuticals but at the end of the day, until I get a patient’s housing in check, or their food security in check or their transportation needs in check, my medical intervention is going to be useless or ineffective.”
Still, there are many challenges to overhauling the current healthcare model. Traditionally, doctors and behavioral health providers are trained differently. Few physicians or mental health workers are taught how to work together as members of the same team. Behavioral health workers also don’t generally learn the medical terminology commonly used in healthcare settings.
UNC-PrimeCare is helping to address some of these gaps, in part, through the program’s curriculum, which requires students to attend monthly seminars that focus on the federally mandated core competencies of integrated behavioral healthcare. These competencies are tailored toward the skills behavioral health professionals need to successfully assimilate into a primary care setting, such as the ability to conduct brief evidence-based screenings in a fast-paced environment.
“Practitioners working in these settings need to be flexible and nimble in their role and also understand the role of other professionals so they can explain these roles to patients and family members,” Jones added of some of the core competencies. “Social workers in these settings also need to be assertive—they need to be able to share information…and advocate for patients while also being professional and respectful.”
For Prentice, learning all of the jargon that the physicians, nurses and other medical staff in her primary care practice use took some adjustment. However, she and Adams said they are both fortunate that their colleagues have been willing to work with them and appreciate having social workers on the team.
“But that is one thing that social workers have to think about— what it’s like to work with an interdisciplinary team where hierarchies may exist or preconceived thoughts may exist around what a social worker does or doesn’t do or should or shouldn’t say and being able to really know your role and how to be an equal member on the team,” Prentice said. “What if you work with people who may or may not like to work with social workers, or who have never worked with a social worker before, or who think that their opinion is the only opinion that really matters? While this remains a challenge in healthcare, we’re lucky in that we work with care providers who truly regard us as equal members of the team.”
Although more primary care settings are starting to embrace integrated healthcare, many supporters see financial sustainability as the biggest barrier to full integration. Generally, doctors and behavioral health providers are paid differently. Physicians use billable codes to ensure services are paid. But how, for example, do you bill for the 15 minutes that a social worker might spend helping a new parent with limited resources locate infant clothing or a stroller?
“I think we’re starting to see some slow changes in how we reimburse for social services,” Zerden said. “But we continue to grapple with how do these mechanisms work? You can bill for running x, y, and z labs and for running x, y, and z tests, but how do you bill for a social worker’s call and making sure that a patient has access to a food pantry in their community? So we’re starting to recognize that that is something that is going to have to change.”
Long-term, someone will also have to consider how best to determine that social workers are making a difference as part of this new integrated healthcare model, Zerden and Adams agreed. Although hospitals consider readmissions as a barometer for whether the follow-up care they are providing is working and reducing overall health care costs, there are no tools currently available for measuring a social worker’s influence on the care of a patient.
“(Because) our role is so versatile, and we are involved in so many different aspects with patient care and in providing so many different resources, it’s very difficult to say, ‘Ok, the fact that I set up home health or made this referral to mental health impacted this patient at this outcome,’ ” Adams added. “We know that it’s helpful and making a difference; it’s just hard to pinpoint what exactly is causing this improvement in care. So I think the sustainability of having care management or social work in these sort of settings is something that we’re going to struggle with for a while until we can figure out the metrics behind why this is important and what sort of impact it’s having.”
On Aug. 24, the School held the first of the monthly seminars that students in our PrimeCare program must attend. A panel of health care providers spoke with the students about their individual professional training. The panel also discussed a fictional patient from their specific professional lens. Many of the students are new to working in a health care setting, and this seminar helped them better understand the roles of the many professionals with whom they’ll be interacting.