BHI: Easier access, better care, less stigma

Members of the BHI implementation team at Kaiser Permanente’s Tacoma South clinic (left to right): Clinic Chief Tania Posa, MD; Social Worker Kristy Eggen, MSW; and Administrative Assistant Karen Taylor.

Clinicians and staff at Kaiser Permanente’s Tacoma South clinic describe how Behavioral Health Integration is making a difference for patients

In 2015, Kaiser Permanente Washington launched a Behavioral Health Integration (BHI) pilot project where all adult patients started receiving screening and support for depression and alcohol or substance use as a standard part of primary care. BHI has now spread to nearly all our primary care locations, with implementation wrapping up in the final two clinics in the coming months. BHI was initiated with the support of a grant* to KPWHRI, which was focused on ensuring that we deliver outstanding care to people who drink alcohol. That study will be evaluating the proportion of patients who receive appropriate care for their level of alcohol use and alcohol-related problems. Although research is still underway, many throughout the system are already enthused about the changes they’re seeing. In this story, providers and staff from our Tacoma South clinic talk about the difference BHI is making in the lives of our patients.

What happens when patients’ behavioral health needs are addressed as a standard part of primary care? If you ask Noelle Egge, a physician assistant at our Tacoma South clinic, she’ll tell you it leads to better care and makes her job easier.

“My patients have a lot of behavioral health needs,” she explains. “Behavioral Health Integration brings these needs to the forefront and opens the door for my patients to talk about depression, drinking, and substance use. Plus, the whole team is involved, which saves me time and makes my work a lot more efficient.”

With Behavioral Health Integration (BHI), all adult patients are screened annually for depression, unhealthy drinking, and substance use at the beginning of a primary care visit. If the results indicate a need for further assessment or treatment, an onsite social worker is available to work with patients on anything from stress management to short-term treatment.

“BHI screening gives us a way to identify patients with behavioral health concerns,” says Tacoma South Clinic Chief Tania Posa, MD. “It shows us right away what their greatest needs are—so we can do something about it in the moment. It’s very timely and patient centered.”

Teamwork helps "normalize the conversation"

Members of the BHI implementation team at Kaiser Permanente’s Tacoma South clinic (left to right): Medical Assistant Devin Monteith, MA; Physician Assistant Noelle Egge, PA; and Patient Access Representative Jessie Chavez.

From patient access representatives (PARs) to flow staff (MAs and LPNs) to primary care providers, social workers, and nurses—everyone has an important role to play in BHI.

The process starts as soon as a patient walks in the door: Anyone who is due for annual screening receives a form from the PAR who checks them in. The form asks questions about mental health and alcohol and other substance use.

“The way we present the form is important,” explains Jessie Chavez, who oversees the PARs at Tacoma South. “We use a script to explain that everyone gets screened once a year—so it’s clear from the start that we’re not singling them out.”

“It also helps normalize the conversation,” says Egge. “Understanding that behavioral health is a standard part of care helps ease the stigma many patients feel.”

The next step appears equally routine to patients. During the rooming process, flow staff enter screening results into the computer while chatting with patients and taking their vital signs.

“It only takes about two minutes—if that,” says Devin Monteith, an MA who works with Egge. “And it helps me set the visit up for success—because I can tell right away when a call to the social worker might be needed and let Noelle know what’s going on before she sees the patient.”

“I think the most profound thing I’ve seen is that it makes people stop and think,” adds Egge. “Sometimes I’ll walk in and a patient will say, ‘I think I’m depressed and I didn’t know it,’ or ‘I’m drinking a lot more than I should.’ And I haven’t even said anything yet. It’s like they just couldn’t put words to it before.”

“It’s all about access”

What truly takes BHI to the next level for patients, however, is access to an onsite social worker for immediate planning and support around depression and alcohol or other substance use. In urgent situations, a registered nurse will step in if the social worker isn’t available.

“It’s all about access,” says longtime social worker Lisa Berendts, LICSW, who was working at Tacoma South when BHI launched.

“Research has shown that most people start with their primary care providers when they need mental health care,” she says. “Before BHI, that meant referring them to a specialist across town. But now they don’t even have to leave the building. And that makes them very happy.”

“Talking to an onsite social worker doesn’t seem as scary as getting counseling outside of primary care,” adds Egge. “They don’t seem to feel the stigma that many people feel. It removes a huge barrier to care.”

Another way BHI has made a difference is increasing access to medications that can help people stop drinking or cut down.

“Our providers weren’t comfortable with prescribing these medications,” explains Dr. Posa. “So we brought in Dr. Ryan Caldeiro, the chief of Chemical Dependency Services. He clarified the process and helped boost the overall comfort level.”

“Learning about the medications gave me a new way to provide practical assistance,” says Egge. “I have a patient who says he doesn’t crave alcohol anymore since starting the medicine. Before, he wasn’t ready to quit. But now he’s like, ‘I have the medicine, and Lisa is going to call me next week. I can do this!’ It just seems like everybody working together makes him know that we care.”

* Grant awarded by the Agency for Healthcare Research and quality (AHRQ 1R18HS023173: Sustained Implementation of Patient-Centered Care for Alcohol Misuse). The lead researchers are:

• Katharine Bradley, MD, MPH
  Senior Investigator, KPWHRI
  Physician, Washington Permanente Medical Group
• Paula Lozano, MD, MPH
  Senior Investigator, KPWHRI
  Associate Medical Director for Research and Translation, Washington Permanente Medical Group

by Jessica Ridpath