Feature

Sixteen-year-old Kyle* and his mother visited the Geisinger Health System primary-care clinic in Pottsville, Pennsylvania, last winter in search of treatment for Kyle's chronic acne. Toward the end of the visit, Kyle's mother told the doctor, William Gianfagna, MD, that Kyle seemed sad of late and uninterested in some of his favorite activities. Gianfagna spoke with Kyle for a few minutes and discovered he was depressed and even having suicidal thoughts.

"In the past, I honestly would have tried to bail and sent him to the emergency room," Gianfagna says.

But times have changed at the clinic, one of more than 50 Geisinger community practice sites serving 2.6 million patients in central and northeastern Pennsylvania. That's because Geisinger is now focused on integrated care. Three years ago, the facility was one of three pediatric community centers selected to pilot an integrated-care program in which primary-care physicians, psychologists, nurses and other medical professionals work together to diagnose and treat physical and psychological health problems.

Gianfagna and other physicians learned how to screen for depression, anxiety, attention deficit hyperactivity disorder and several other mental health conditions, and now have a full-time psychologist and several psychology residents down the hall available for one-on-one and group therapy or for consultations on a variety of mental and behavioral health conditions.

Armed with those skills, Gianfagna was able to spot the depression and get Kyle in to see a psychologist that night. "When I called the next morning, they already had a pretty good plan in place to treat him," Gianfagna says.

His eagerness and comfort level with using this mental health screening is one of several signs that Geisinger's integrated approach is working, says Tawnya Meadows, PhD, a pediatric psychologist at Geisinger's primary-care clinic in Selinsgrove, Pennsylvania.

"Anecdotal reports show that our physicians are feeling less stressed and more prepared because they have the screening instruments they need and our guidance," she says.

This spring, APA’s Dr. Randy Phelps met with Geisinger psychologists and physician leaders, and leaders of the Geisinger Health Plan. Back row standing, from left to right, are Eric Hill, Dr. Chris Chew, Dr. Tawnya Meadows, Dr. Laura Campbell, Dr. Erica Walles, Ed Madalis, Richard Bitting, Dr. Thomas Graf, Dr. Cathy Schuman, Dr. Fred Bloom and Mark Basinger. Front row sitting, from left to right, are Dr. Paul Kettlewell, Dr. Charlotte Collins, Dr. Randy Phelps, Dr. Shelley Hosterman, Dr. Heather Hoover and Dr. Nicole Quinlan.Preliminary data indicate that the approach is also reducing health-care costs and improving patient care, says Paul Kettlewell, PhD, Geisinger's chief pediatric psychologist. The system's health insurance company, Geisinger Health Plan, reports a statistically significant reduction in total pharmacy expenses for children in the integrated-care pediatric primary-care settings compared with non-interventions sites.In addition, the average length of treatment is shorter in integrated care: approximately 4.5 sessions, compared with 19 sessions at Geisinger's traditional behavioral health outpatient clinic.

Perhaps most important, the program is increasing access to behavioral health services, says Shelley Hosterman, PhD, a pediatric psychologist at the Pottsville clinic.

"I see families who have been referred by their primary-care physician to outpatient behavioral health clinics four, five, six times and they have never gotten in touch with services because there's just too many barriers — distance, travel, making the scheduling calls — it just involves all this extra work," Hosterman says. "Now, those families who really need care are just passed down the hall to us and they start getting quality services right away."

A reputation for excellence

Geisinger Health System serves mostly rural Pennsylvanians, providing health-care services ranging from primary care to complex medical subspecialties such as pediatric endocrinology and urogynecology. Geisinger also uses a state-of-the-art electronic medical records system to track patients throughout its 1,000-member multi-specialty group practice, seven hospital campuses, two research centers and dozens of community practice locations.

Psychologists are part of many medical teams throughout the system, says Charlotte Collins, PhD, chief of behavioral medicine and adult psychology at Geisinger. They work with many different medical populations, including those undergoing bariatric surgery, diabetics in need of help managing their medical regimen, cancer patients and those experiencing chronic pain, she says.

"From the very beginning, Geisinger was a collaborative group practice where the staff cooperated for the good of the patient, and psychologists have always been ranked as part of the professional staff," Collins says.

It also helps that psychologists are part of the system's psychiatry division, and the two groups support and celebrate each other's successes, Collins says. Maintaining a cooperative relationship with psychiatry is part of why Geisinger's psychologists are so well-respected, says Randy Phelps, PhD, director of APA's Office for Health Care Financing.

"Geisinger doesn't have psychiatry versus psychology turf issues," Phelps says. "They respect each other there, and if health care is really moving toward integrated, team-based care, that's absolutely essential."

Geisinger is the only hospital in the state in which psychologists have hospital privileges. That shows the system values them at the same level as their medical colleagues, Kettlewell says. But getting there took a lot of small steps by psychologists to show their worth, including offering to provide a mental health consult in the emergency room, and then taking the steps needed to make more systematic changes such as getting added to the on-call schedule for after-hours ER coverage, where decisions on hospital admission were needed.

"We're now in the process of using this same small wins strategy to try to change our culture so that psychologists and other behavioral health providers are an integral part of all of our primary care clinics," Kettlewell says.

A natural fit

Geisinger has also reduced its pharmacy expenses, according to data from the pediatric primary-care pilot study. Kettlewell believes the reduction is due in part to the fact that pediatricians now have more tools in their toolbox than medication alone.

"Primary-care physicians feel lots of pressure to take action when a parent or patient makes a request for help," he says."Referring the parent to a psychologist for further discussion and assessment represents a wise action-step, and results in a more thorough assessment so that the right children get medication."

Geisinger is now piloting integrating psychologists and psychology residents into adult primary care at four community sites, Collins says. If the data show Geisinger is successful, the hope is that other medical centers recognize the benefits of putting psychologists on site in primary care and follow suit, which would help improve the health of Americans nationwide, says APA's CEO Norman B. Anderson, PhD.

"Research clearly shows that psychological, behavioral and social factors are key drivers of health problems seen in the primary-care settings," Anderson says. "Incorporating psychologists directly into these settings can help ensure that health professionals are working together to treat the whole person."

The bottom line, Kettlewell says, is that as America attempts to redesign health care, behavioral health services should be expected to demonstrate cost savings, and the possibility exists when integrated care models like the one that Geisinger has implemented are put in place. He notes, however, that behavioral health services continue to be an underfunded area of health-care, and shouldn't only be considered valuable if adding these services into a health-care model demonstrates total cost-offset.

"Nobody providing comprehensive behavioral health services has a healthy return-on-investment using the fee-for-service model," Kettlewell says. "But there are profound consequences to society, including added legal, educational and unemployment expenses, because we are not adequately addressing serious behavioral health needs." Gianfagna also notes that working in tandem with behavioral health experts has helped him be a better physician. Knowing he has a partner who is keeping up with a child's behavioral health needs keeps him focused on the rest of the patient's care.

"It allows me to do what I do best, rather than playing part pediatrician, part psychologist, part social worker, part information gatherer, part research assistant," he says. "Incorporating psychology into primary care is just a natural fit."

*Pseudonym used to protect patient privacy.

Amy Novotney is a journalist in Chicago.