Movement to include mental health providers on health care teams is coming into its own

When Neftali Serrano, PsyD, graduated from Wheaton College Graduate School in 2001, his first job was at a federally qualified health center on Chicago’s West Side. It served some 30,000 Medicaid recipients—primarily African American and Mexican immigrant patients who had few resources and had likely never seen the inside of a therapy office.

Serrano’s training had been in traditional psychotherapy: intensive, deep, one-on-one. And, as the clinic’s first and only mental health hire at the time, he assumed that was the type of care he would be providing.

That thought did not last long. “What I discovered challenged virtually all my assumptions as a psychologist,” said Serrano, now chief executive officer of the Collaborative Family Healthcare Associationopens in new window, a membership organization that promotes the practice of integrated care. For one thing, he was surprised to find that his schedule was rarely full, even though he had been hired to take on the large number of patients with mental health issues who were showing up for care but whom physicians felt ill-equipped to handle.

He decided to leave his therapy office and walk to areas down the hall where doctors were seeing patients. That simple outreach changed things dramatically: Soon, physicians began asking him to come into their exam rooms to talk with distraught patients. “I had people talking to me about some of the deepest personal things that were going on in their lives—marriages that were dissolving, abuse experiences, trauma,” Serrano said. Other surprises soon followed, like how easy it was to quickly establish rapport with patients when his training had taught him otherwise, and how even a very brief intervention could be helpful.

“I realized I had something to offer almost every person who walked into those exam rooms,” he said.

Serrano is one of many psychologists who have made the move into integrated care, meaning they work on-site with physicians and other health care practitioners to deliver mental and behavioral health interventions in a collaborative, team-based fashion. There are many locations where integrated care takes place—public and private medical settings, hospitals, rural clinics, academic medical centers, the Department of Defense, and Department of Veterans Affairs (VA), to name some. This form of practice is aligned with the concepts of whole-person care—treating patients as whole people with psychological, social, emotional, and spiritual needs—and value-based care, or reimbursing providers based on the quality and outcomes of the care they provide instead of on the volume of services delivered. And it is becoming more widespread.

“It’s taken a couple of decades to get to the point where integrated care is more widely understood, used, and accepted, but in the past 5 years it has really picked up steam,” although actions by the current administration are adding uncertainty to the picture, said Jeffrey T. Reiter, PhD, a leading expert and consultant on this mode of service and coauthor with Patricia J. Robinson, PhD, of Behavioral Consultation and Primary-Care: A Guide to Integrating Services (3rd ed.)opens in new window. Strides in the area are supported by research on the importance of adding psychologists and other mental health providers to medical care, along with growing recognition of the practice’s value by medical organizations like the American Medical Association and the American College of Cardiology, as well as by the federal government. And in March, bipartisan legislation called the Connecting Our Medical Providers with Links to Expand Tailored and Effective Care Actopens in new window, or COMPLETE Care Act (S. 931/H.R. 2509), was introduced in both the U.S. Senate and the House of Representatives that would help primary-care providers implement integrated care models in their practices—legislation that APA was instrumental in shaping and championing.

Psychologists in integrated care appreciate the opportunity to be part of a radically different form of care than private practice—one that promises to reach people who represent the diversity of society rather than only those who can best afford it.

“I love the opportunity to reach people I wouldn’t be able to reach in private practice,” said Reiter, who has helped numerous health systems develop integrated care programs. “There is a lot of reward in doing this work.”

Integrated care got its start in federally qualified health centers in the 1970s, gradually gaining federal and research support and entering the range of health care systems in the United States. Versions of it are found in both primary-care and specialty care settings like oncology, chronic pain, and women’s health. There are two main models of integrated primary care, primary care behavioral health or PCBH, and the collaborative care model or CoCM, though there is overlap and collaboration between them.

Psychologists often work within the PCBH model, developed in the 1990s by psychologists Kirk Strosahl, PhD, and Patricia Robinson, PhD, who also cofounded acceptance and commitment therapy (ACT). As the name implies, PCBH was designed for work in the primary-care setting.

In the most comprehensive version of the PCBH model, psychologists act in a role called behavioral health consultant. They are full members of the primary-care team, using their training to assess and treat psychological and behavioral issues in medical patients who have co-occurring mental health conditions. On a given day, they may address behaviors that undermine patients’ efforts to get healthier, such as smoking; treat distress related to having a chronic health condition; or support behavior change to improve patients’ overall health.

In hospital settings with a wide range of specialty departments, psychologists perform similar functions as consultation-liaison, or CL, psychologists. In this role, they provide comprehensive services including assessment and evaluation, diagnosis clarification, intervention, case conceptualization, treatment planning, and recommendations, sometimes specifically related to hospital stays, said Kelly Gilrain, PhD, chief psychologist at Cooper University Health Care in Camden, New Jersey, who has spearheaded a robust medical inpatient psychology team there. Gilrain, herself a CL psychologist, oversees a team of 10 other CL psychologists who work in a range of hospital departments, including trauma surgery, critical care, emergency medicine, hematology/oncology, and obstetrics/gynecology.

The other main integrated care model, CoCM, was developed at the University of Washington’s Advancing Integrated Mental Health Solutions (AIMS) Center and draws on a psychiatric framework. Here, patients with severe mental health conditions, most often major depression, receive most of their care from a primary-care provider and a case manager who checks in regularly to make sure they are well adjusted to their medications and to provide brief psychoeducation or problem-solving skills training as needed. The team is supported by a consulting psychiatrist, often located off-site, who counsels the primary-care provider on medication management but does not see patients or share in the responsibility for their care.

There is strong research backing for both models. In terms of PCBH, a 2018 systematic review of 36 studies led by Kyle Possemato, PhD, of the VISN 2 Center for Integrated Healthcare in Syracuse, New York, found that patients receiving PCBH treatment had shorter wait times for treatment and engaged more in treatment than those referred to specialty care. From the beginning to the end of treatment they also showed improved social, occupational, and psychological functioning as well as reductions in depression and anxiety (General Hospital Psychiatry, Vol. 53, 2018opens in new window).

PCBH has also been shown to improve patient and provider management of chronic conditions like diabetes and chronic pain. In one rural primary-care setting, a PCBH program tailored for patients with Type 2 diabetes not only helped patients better control their blood sugar but also addressed depressive symptoms and the emotional distress that can come with managing a chronic condition. And compared with patients who received usual care, PCBH patients were more likely to stick to their medication schedules and maintain lifestyle changes that supported their overall health (Cummings, D. M., et al., Diabetes Care, Vol. 42, No. 5, 2019opens in new window).

The PCBH model can also reduce treatment costs, research is finding. In a study conducted in a large Kansas City primary-care practice, integrating a psychologist into the team using a PCBH model was associated with a savings of $860 per member per year in overall treatment costs (Ross, K. M., et al., Journal of Clinical Psychology in Medical Settings, Vol. 26, 2019opens in new window).

In terms of the collaborative care model, an analysis of 79 randomized controlled trials found that CoCM patients with depression or anxiety had better short-term and long-term outcomes than patients who received care as usual (Archer, J., et al., Cochrane Database of Systemic Reviews, 2012opens in new window). Other research found that CoCM is more cost-effective than usual care, resulting in fewer emergency room or psychiatric inpatient visits (Verughese, J., et al., American Journal of Preventive Medicine, Vol. 42, No. 5, 2012opens in new window). Increasingly, many primary-care settings are adopting hybrid models that combine both PCBH and CoCM, a blended approach that allows systems to leverage the strengths of both approaches, noted Erin F. Swedish, PhD, APA’s director of health integration.

While integrated care is not and should not be for all psychologists, several factors make it a compelling alternative to traditional practice, say psychologists who work in these settings. One potential plus is working within the medical system—the active nature of the setting itself, as well as the opportunity to be a full team member with colleagues from other health care disciplines.

Reiter, for example, loves discussing cases with other providers. When there is the opportunity to join in team meetings, “I want to be there; I want to be in the middle of that,” he said. “There’s so much spontaneous teamwork that happens when you’re sitting there between patient visits.”

He also likes seeing patients in exam rooms rather than in a traditional therapy office. Providing care in this way gives patients the assurance that mental and behavioral health providers are a regular part of health care, in the same way they might see a nurse to learn about a new medication right after the doctor leaves the room.

“It helps patients feel that mental health care isn’t stigmatized but is rather a routine part of their primary-care visit,” he said.

Psychologists working in these settings also enjoy the opportunity to be generalists rather than specialists—to apply their skills in varied ways. On a given day, they may see patients who have chronic pain, newly diagnosed cancer, postpartum depression, or difficulty adhering to a diabetes regimen. As a result, interventions can range from psychoeducation to motivational interviewing to behavioral or cognitive interventions to referrals for longer-term therapy.

“The range of issues . . . is much bigger than what you’d imagine if you are just working at a specialty level and curating your own practice,” said Serrano.

As one example, clinical health psychologist Lindsey Bloor, PhD, provides broad-ranging clinical services to veterans with cancer at the VA Ann Arbor Healthcare System in Michigan, where she established a health psychology section and served as the section’s first program manager. Her interventions include helping veterans set health behavior goals that facilitate treatment—for example, cutting down on tobacco use and remaining physically active—and helping them follow through by building trust with the medical team and addressing internal resistance and other barriers.

She also uses cognitive behavioral therapy (CBT) and ACT interventions to help patients accept the realities of their condition and develop a good quality of life. “I switch back and forth a lot between those approaches, depending on what a veteran seems to respond to better,” she said. She also regularly employs CBT-CP and CBT-I, the evidence-based behavioral treatments for chronic pain and insomnia, to help oncology patients with co-occurring conditions, and she works with the VA’s social work, nutrition, and chaplain services to help veterans engage with an interdisciplinary team and discuss what is meaningful to them.

“We really offer a broad range of direct patient care services across all phases of a veteran’s cancer journey,” she said.

Integrated care psychologists also say they appreciate constantly learning about many dimensions of physical health and disease they were not familiar with before. They also enjoy the reverse: teaching medical providers about mental and behavioral health.

“It has become the role of psychologists working in integrated care settings to educate medical teams about how to utilize us”—to understand that psychologists’ skills go beyond therapy to intervening in any situation where there is medical distress or need, for example, Gilrain said. “It requires a good deal of continued education, and when it works, it works really, really well.”

Psychologists also like the opportunity to support medical providers so they can focus mainly on patients’ medical needs, said Michelle B. Moore, PsyD, an associate professor of clinical psychiatry and section chief for psychology at Louisiana State University Health Sciences Center in New Orleans.

“A lot of times people just want to tell their story—they just want to feel heard and give their narrative, especially if they’ve just experienced a medical trauma,” she said. “It reduces physicians’ burden when we take on the role of talking with patients about these things.”

Although integrated care has made important strides in the past several years, there is much to be done to make it a more universal part of health care, leaders in the area agree.

One of the biggest obstacles is payment. Medicare and other payers are just beginning to reimburse psychologists in integrated care settings, in a more limited fashion than is provided for other medical providers, including psychiatrists. As a result, psychologists must often resort to using diagnostic codes for traditional therapy or simply not bill for certain services because they are not sure how to do so.

“The fee-for-service approach works very well when you’re talking about a one-on-one encounter,” said Serrano. “But it doesn’t work well when you’re talking about a team caring for an individual, especially a team caring for an individual across a life span.” The medical system is also geared toward paying much more for interventionist services like surgery than for normal patient care, he said. What is more, reimbursement concerns impact primary-care practices’ willingness to adopt integrated care, said Scott Barstow, APA’s senior director of congressional and federal relations and its practice lead, adding that the U.S. health care system underinvests in primary-care compared with other developed countries.

“Switching to an integrated care model of practice requires not just a willingness by primary-care practices to take on new team members and to change operating procedures,” he said, “but also to adopt new billing and coding practices.”

Another obstacle is simply a dearth of qualified mental health practitioners to fill these roles, including psychologists, said Avshalom Caspi, PhD, a professor of psychology and neuroscience at Duke University, and author of a recent study highlighting the preponderance of mental health issues in primary-care (see sidebar page 62). “There is a lot of emphasis in integrated care about how to deliver the care,” he said, “but less about who should be delivering the care.” Major efforts are needed to train more clinical psychologists to work in primary-care and physician assistants in how to help provide mental health care, he believes.

Finally, there is the uncertain nature of the times politically. For example, community mental health centers—the birthplace and original soul of integrated care—receive much of their funding from federal grants. How this issue plays out politically and practically remains to be seen.

Despite these obstacles, some progress is being made. Although learning new codes requires education on the part of psychologists and health care systems, in 2023 the Centers for Medicare & Medicaid Services began to reimburse new Current Procedural Terminology, or CPT, codes that psychologists can use to bill general behavioral health integration services and interprofessional consultation services. Those codes include the general behavioral health integration (BHI) code (G0323), interprofessional consultation codes (G0546–G0551), health behavior assessment and intervention codes (96156, 96158, 96159, 96164, 96165, 96167, and 96168), and others, said Barstow.

Meanwhile, Swedish and her colleagues are working on ways to expand procedure codes to better represent psychologists’ roles in integrated care settings. That includes making existing codes more available to psychologists and exploring the possibility of developing new codes—a long-term but potentially important solution to the reimbursement problem. Supporting these efforts are two APA work groups she leads, the Integrated Primary-Care Advisory Groupopens in new window and the Integrated Specialty Care Advisory Group. These groups are discussing ways to successfully integrate psychologists into both kinds of settings through better payment structures and more.

While challenges remain, psychologists working in these systems firmly believe that integrated care is the wave of the future.

“The need in the population is just much broader than what I think most folks in [traditional practice] settings can imagine,” said Serrano. “We have an opportunity to connect ourselves into the physical health system and begin to champion causes that are larger than us, than our guilds. Because no one cares about our guilds except us.”